4. The NTER Child Health Check Initiative
Flawed reasoning and justification behind the CHC initiative
Notwithstanding the fact that the NTER CHC initiative has accelerated the rate of primary health care checks of Aboriginal children in the NT based on a pre-existing evidence-based template, it has been an ineffective measure for addressing child sexual abuse in NT Aboriginal communities. This is because standard child health checks are not designed to identify sexual abuse but rather belong within ongoing primary health care.
The focus on CHCs as an "emergency" response to child sexual abuse derived from the original flawed purpose of the initiative. Indigenous Affairs Minister, Mal Brough's media release on the package of measures that would constitute the Australian Government's Emergency Response, described the health check measure as:
"Introducing compulsory health checks for all Aboriginal children to identify and treat health problems and any effects of abuse."17
The announcement prompted an outcry from health professionals that the proposal was unworkable on ethical, legal and medical grounds. Amongst a plethora of concerns, it was pointed out that health screening was an inappropriate tool for identifying sexual abuse. Forensic examination for identifying sexual abuse requires specialist practitioners and is, of itself, inconclusive. To carry out forensic examinations on a compulsory basis would constitute, in the views of medical experts, the "further abuse" of Aboriginal children.
Having proposed an inappropriate and unworkable measure, the Minister was reluctantly forced to abandon the idea of compulsory sexual abuse checks18 and the measure was scaled back to the already-existing Medicare Item 708 Aboriginal and Torres Strait Islander Child Health Check (Item 708 CHC). These checks were already being carried out by Aboriginal medical services in the NT with over 1000 having been completed prior to the NTER. Although not designed to identify sexual abuse, the Item 708 CHCs are effective at identifying children suffering from neglect, which is a common co-condition of children suffering sexual abuse, if undertaken by practitioners experienced in remote indigenous PHC working within a multidisciplinary team. This team should include Aboriginal Health Workers who provide much of the community and cultural knowledge required to effectively engage with children and their families. However, the Australian Government glossed over the pre-existence of Item 708 CHCs performed within existing multidisciplinary community based Primary Health Care, and proceeded to organise a separate "emergency" process of Australian Government Child Health Check (AG CHC) teams utilising ‘volunteer' doctors and nurses recruited for the purpose. In AMSANT's opinion this was, for a number of reasons, a critical error:
- There was no valid research purpose in conducting a separate screening process as the health status of Aboriginal children was already well known from existing research;
- The CHCs were not designed to, and have not uncovered cases of child sexual abuse and therefore we know no more about the prevalence of it that than we did before the checks were carried out;
- The implementation of the AG CHCs involved a waste of resources through the duplication of delivery of CHCs via temporary and expensive AG CHC teams, and the burdening of Aboriginal medical services (AMSs)19 with additional, overly-complex administrative and clinical demands in coordinating with the AG CHC process and follow up;
- The use of AG CHC teams meant the loss of an opportunity to expand the long-term capacity of AMSs by providing them with additional resources to conduct the CHCs and provide the necessary follow-up.
- The AG CHC team practitioners who provided the CHCs were usually inexperienced in Indigenous health and remote health delivery. They did not have the necessary community knowledge and trust to be optimally effective.
In other words, if the Australian Government's primary objective was "the short term protection, coupled with the long term wellbeing, of these Australian kids"20, then the AG CHC initiative was misplaced. Indeed, by organising the CHCs as part of the "emergency response" rather placing it in its correct context of part of ongoing PHC delivery, the AG CHC initiative was designed to not increase the capacity of AMSs to improve long-term comprehensive PHC service delivery to Aboriginal children.
The need for increased capacity for AMSs is illustrated by the fact the majority of Item 708 CHCs completed prior to the NTER were carried out by the larger, better-resourced ACCHSs which are able to provide more comprehensive PHC services.
Flawed implementation of the AG CHC Initiative (Phase 1)
Notwithstanding the critical flaws in the conception of the AG CHC initiative, its implementation has been beset by a plethora of entirely preventable problems.
Significant problems emerged from the outset. The lapse of time between the announcement of the problematic compulsory CHCs and the revised approach of communities being provided with access to voluntary CHCs created unnecessary distress and alarm amongst community members - not a good way to kick off a culturally-sensitive initiative.
The roll-out of the CHC initiative was not adequately coordinated by the Taskforce. Tying the roll-out to the NTER Taskforce's military-planned, secretive community visit schedule and processes meant that communities and local health services had virtually no notice and little ability to prepare resources and notify community members. And when the Taskforce arrived in communities, all of which have limited accommodation, it was a veritable road show. For example, at one community 28 visitors were counted, including the CHC team, and personnel from the ADF, Centrelink, Mission Australia and CRS.
The effect of the presence of the Army on communities was also not considered by the NTER Taskforce and has proved to be counter-productive in some communities. For example, the very first community visited, Santa Teresa, has its origins in the forced removal of Aboriginal people from their original community by the army in 1942 – the memory of which remains strong. This is why a third of the population vacated the area when the NTER team rolled in.21 Similar responses from concerned and confused community members have continued to occur as the CHCs have been rolled out into new communities,22 indicating that the problem has not been effectively addressed by the NT Emergency Coordination Centre (NTECC).
The AG CHCs were unnecessarily arduous - for small children and elderly carers in particular. Despite warnings from local operatives, the Canberra-based NTECC insisted on planning deployments into Central Australia in the winter and into the Top End in the Wet. A CHC takes 40 minutes, which is a long time for a child to be examined in a tent in winter or on a verandah in the Wet.
Due to the Wet and road/air strip restrictions, some Top End outstations were not visited by CHC teams.
As this suggests, with no detailed, prior planning for the CHCs, planning was done on the run, creating, at times, minor chaos. In other respects planning of the CHCs created processes that were unnecessary, impractical and inflexible, or that introduced avoidable burdens on local health services.
The insistence on using a custom-designed paper form for the CHCs23 created additional problems and work to modify the computerised patient records (PIRS) systems used by most Aboriginal health clinics and manually input the data from the paper forms.
Some health services wanted the AG CHC team to backfill in their clinics so that their own staff, who were already known by the community, could do the CHCs. Initially this was not permitted with the reason being given that the "volunteer" doctors and nurses were expecting the "front line" experience of doing the health checks.
As a result of this some ACCHSs missed out on revenue from Medicare bulk billing24 because the AG CHC Team doctors were employed by the Commonwealth and not the local health service. These doctors could have been employed as locums and issued with a Medicare provider number attached to the clinic they were deployed to. The NT office of Medicare Australia confirmed that provider numbers can be issued in 24 hours, and that the Australian Government did not claim Medicare via the single provider number that AG CHC teams were directed to use.
The AG CHC teams ‘volunteers' were also mainly inexperienced practitioners in the context of remote Indigenous health without the necessary community links and knowledge and therefore not optimally effective. Some health services sought to ameliorate this by supplying Aboriginal Health Workers (AHWs) to work with the teams.
Some AG CHC teams had a negative impact on local staff who worked with them. For example, one remote health service recruited a long-term nurse, two AHWs and local drivers to assist the AG CHC team, thus enabling the process to achieve good compliance. By the end, the AHWs were fatigued, mistrustful and burnt-out. They were aware that the AG CHC team "volunteers" were being paid considerably more and they reported feeling used and abused as the process could not have been done without them. They also felt they had been put in the position of pressuring and manipulating families to come in and do the checks.
Other examples of criticisms of some of the AG CHC Teams were that they were rude, alienated staff, were poorly organised and had poor understanding of the health systems in which they were working.
Interstate recruits had difficulty adjusting to local conditions through lack of community awareness, unfamiliarity with working with Aboriginal people, or though being adversely affected by hot and humid conditions. A few team members were extracted due to topless sunbathing, taking liquor into communities, mental abuse towards other team members, and lacking adequate team skills.
Teams weren't trained to detect and did not have the right equipment to screen for trachoma or to do tympanograms, audiology and dental testing.
Interstate doctors were not familiar with heart problems in children and unnecessarily referred children for suspected heart murmurs. The NT Department of Health and Families (NT DHF) has been slow to follow up with echocardiograms, so the extent of children with actual heart conditions is unknown, and could be much lower than flagged by the data collected.
In addition to these problems with the deployment of the AG CHC teams, the organisation of the NTER "volunteers" through the NTECC workforce pool did not contribute to ongoing workforce needs as most of the "volunteers" were not interested in being employed by AMSs in Phase 2 (the health check follow-up), as the AMSs were unable to match the over-generous Phase 1 "volunteer" packages provided by the Australian Government.
The kinds of problems outlined here are broadly representative of those experienced by our member services during the Phase 1 CHCs and bring into question the decision to conduct a separate "emergency" process for the child health checks.
While many of these may have been unintended consequences, they were very much predictable and avoidable. Over the course of Phase 1, some health services were able negotiate variations in the service model for the CHCs which helped reduce the negative impacts of the CHCs on communities and health clinics.25 AMSANT also worked cooperatively with OATSIH and other government agencies to address difficulties and problems associated with the initiative.
It also needs to be acknowledged that some of our members also reported positive experiences with the AG CHC Teams. The factors that appear to have been significant in such positive experience are mainly contextual: the presence on the AG CHC Teams of medical personnel with good understanding of the context of remote Aboriginal health delivery and/or with an interest in supporting and coordinating with the local health service; the capacity of health services to interact with the AG CHC Teams; the ability to utilise AG CHC Team members in a manner optimal to the local health service (eg, for back-filling in clinics while the CHCs were occurring); and the type of impacts on local health services of the CHC process.
Another positive aspect was that in a few later cases Phase 1 and Phase 2 occurred concurrently, avoiding unnecessary duplication of effort and long delays between the initial child health check and subsequent follow up. With better planning this model would have been the norm everywhere.
Cost and efficiency of the AG CHCs
A further concern with the design and implementation of the CHC initiative has been its considerable cost and the relative inefficiency of the AG CHCs in comparison to what would have been the case if existing health services had been used to do the work. The cost of the CHC initiative includes the time of bureaucrats to develop and plan a custom, one-off process which was not a long-term, sustainable program. In addition, the role of bureaucrats changed from overseeing funding of programs, to actually being the implementing body. This occurred as a result of not initially trusting the primary health care service delivery bodies (ACCHSs and NT government) to boost their current systems if additional funding had been supplied. In addition, the overall cost was markedly elevated by the costs of carrying out the CHCs using external CHC teams recruited and flown in from interstate and accommodated and remunerated at great cost.
In comparison, existing health services, while mostly not sufficiently resourced to do the checks as quickly as the AG CHC teams, could have completed the health checks at a fraction of the cost and with superior outcomes. As an example, one of our member services which did undertake to do the checks in local communities, budgeted $200,000 for the work and from that money completed 1100 health checks with a compliance rate of 93%. In comparison, approximately 9,000 AG CHCs26 have been completed since the CHC initiative began with an average compliance rate of 64%. Based on the example above, the 9,000 health checks would have cost approximately $1.6 million if they had been carried out by local ACCHSs.
Exact figures aren't publicly available for how much was spent by the Commonwealth. Originally, $72.7 million had been budgeted for the health checks. However it was revealed that in the first six months since the appropriations legislation was passed, $14.9 million had been spent on NTER "Improving child and family health" measures.27 The majority of this would have been expended on the health checks. If we further assume (conservatively) that only two thirds of this was spent on health checks and then double this to arrive at an approximate twelve month expenditure figure, then something in the order of at least $20 million has been spent on 9,000 health checks.
In other words, the Australian Government is likely to have spent over twelve times more to do the health checks than it would have cost had it used the existing health services and the Medicare Item 708 Health Checks, and has achieved sub-optimal outcomes.
If confirmed, this would represent a deeply-concerning, unnecessary and inefficient expenditure of public money which has significant implications for the broader evaluation of the NTER and lessons for future policy development. It is also an issue that Aboriginal communities and the broader public have a right to know about. AMSANT therefore strongly urges the Review Panel to investigate and compare the total cost and efficiency of the AG CHCs with the alternative of using local health services to do the checks; and to consider the opportunity cost of not using these funds towards increased recurrent investment in primary health care. [See Recommendation 5]
17. Media release, 21 June 2007, Minister for Families, Community Services and Indigenous Affairs.
18. Former Minister, Mal Brough, recently expressed regret that he had been prevented from proceeding with the compulsory sexual checks of children and identified it as one of the measures he would like to have completed (ABC Lateline, 20th June 2008).
19. The term AMS is used here to refer to both Aboriginal community-controlled health services (ACCHSs) and NT Government-run Aboriginal health services.
20. Media Release, 26 June 2008. Minister for Families, Community Services and Indigenous Affairs.
21. This could easily have been anticipated if basic prior consultation had occurred. The Taskforce might also have learnt that there were remote communities that had had recent positive experiences with the army through community infrastructure projects, and these would have been better places to visit initially.
22. For example, at Utopia in February this year when the NTER team arrived in the community.
23. Rather than the standard Medicare Item 708 ATSI Child Health Check form which is already integrated into the computerised record systems and reporting procedures of health services.
24. Medicare is an important revenue source for Aboriginal health services and is relied upon to provide for health staff wages and to fund health programs.
25. Out of 70 communities where the CHCs have so far been undertaken, in 23 the checks were carried out by ACCHSs and NT DHCS clinics and in 47 by the AG CHC Teams.
26. FaHCSIA website. Accessed August 2008.
27. From an answer to questions at Senate Estimates in February 2008.