Andrew White

1. Name Qualifications and Experience
Andrew White MBBS FRACP MPHTM

Contact Details

Work
Address: JCU Clinical School, The Townsville Hospital,
PO Box IMB52, Douglas, Qld, 4811
Phone: 07 47961776
Fax: 07 47961773

E-mail: Andrew.White@jcu.edu.au

I am a paediatrician and have 12 years of experience working in the Northern Territory. I worked in 1995 and 1997 in Alice Springs Hospital as a paediatric registrar. From 1998-mid 2000 I worked with Menzies School of Health Research in Darwin and was involved in child health research projects in remote communities mostly in the Tiwi Islands. From mid 2000 until April 2008 I worked as a Community Paediatrician providing Paediatric outreach services and working in public health projects and child health projects in remote communities in Central Australia. I worked very closely and extensively with primary health care programs in both NT government clinics and AMS clinics in Central Australia, and developed strong relationships with many Aboriginal families. I am the current coordinator of the child health section of the CARPA standard treatment manual used in the NT, and have been involved in almost every child health initiative in remote NT communities in the last 10 years.

I met many of the visiting health providers who gave short term service to do child health checks, visited many of the orientation sessions, followed up most of the children referred to a paediatric service in the communities I visited, as well as very many children not referred, and read many of the child health check data sheets. I was aware of and observed the way the Australian Government and NT Government Health departments implemented the child health components of the interventions.

I am limiting my comments to the child health component of the intervention. My comment include direct effects and indirect effects and as such sometimes it is difficult to separate effects of the way the AG managed the intervention and effects of the way DHCS managed things. I do have some concerns about other aspects of the intervention such as community consultation in general, encouragement of negative stereotyping of Aboriginal people and lack of concern about human rights and think that some things such as improved police services have been well received and have provided benefits, but will not comment further about these things. I have confined my comments to child health aspects of the AGI the area in which I have some expertise and experience.

Please accept my thoughts about the child health component of the intervention. They are my own personal opinions. I have commented in short point form, and have not provided references for all comments I have made, but have included a reference list below which covers many of the points I make. There is evidence in the literature which could guide health services in improving the health of Aboriginal children in the NT. Unfortunately this evidence base was not considered or followed. There has been much research published in the last 10 years about the importance of the early years (age in-utero to 5 years ) for child development and future health. Ref 1 provides a good summary of early years evidence. References 2 is a review of international research showing evidence about factors which can be ameliorated and would make a difference for the development (and health) of children in developing countries. A number of these factors apply to remote Australia. The review 3 shows there is little evidence for screening growth. Reference 4 shows interventions which have worked. Zlotkin ref 5 has developed community acceptable formulations to prevent iron deficiency anaemia. Ref 6 and 7 discuss interventions and risk factors for child abuse and neglect – without any suggestion of a screening program. Reference 8 discusses the internationally accepted criteria for an ethical and useful screening program – the AGI child health check failed dismally.

The Long Reach of Childhood” In McCain, MN, Mustard, JF and Shanker, S (2007) Early Years Study 2: Putting Science Into Action, Council for Early Child Development, Toronto, Canada. Pp 17-56. Full report available at www.founders.net
Walker SP, Wachs TD, Gardner JM, Lozoff B, Wasserman GA, Pollitt E, et al. Child development: risk factors for adverse outcomes in developing countries. Lancet 2007;369(9556):145-57.
Panpanich R GP. Growth monitoring in children. Cochrane Database of Systematic Reviews, 1999.
Bhutta ZA, Ahmed T, Black RE, Cousens S, Dewey K, Giugliani E, et al. What works? Interventions for maternal and child undernutrition and survival. Lancet 2008;371(9610):417-40.
Zlotkin SH, Schauer C, Christofides A, Sharieff W, Tondeur MC, Hyder SM. Micronutrient sprinkles to control childhood anaemia. PLoS Med 2005;2(1):e1.
Hindley N, Ramchandani PG, Jones DP. Risk factors for recurrence of maltreatment: a systematic review. Arch Dis Child 2006;91(9):744-52.
Scott DA. Towards a public health model of child protection in Australia. Communities, Families and Children Australia 2006;1(1):9-16.
Andermann A, Blancquaert I, Beauchamp S, Dery V. Revisiting Wilson and Jungner in the genomic age: a review of screening criteria over the past 40 years. Bull World Health Organ 2008;86(4):317-9.

2. What is Working
There have been many committed practitioners providing primary health care to children in NT communities for many years (medical nursing. allied health, AHW’s, community workers, social service workers etc ). Unfortunately these services have been fragmented and poorly coordinated, with some services from AMS clinics and some from the NT dept of health. The NT health department centralised and silo’ed all services several years ago leading to a frustrating level of fragmentation and huge distance (geographically and philosophically between workers and bureaucratic management located in Darwin). However in Central Australia we had made considerable progress in developing teamwork across these disparate services, and were attempting to develop services further and enhance care provided to children. We had also been advocating for many years for an increase in resources especially in areas such as ear health services, child and parent mental health services, community based child health programs and enhanced paediatric outreach including provision of training positions.

So in short, the positive of the Australian Government Intervention is that the AG committed to improving services and has provided increase in funding. It is also a positive that Government has made some strong statements about “closing the gap” etc as Government can now and must now be held accountable for results.

3. What is not working
Unfortunately the implementation of enhanced services for children has been introduced in an extremely amateurish manor, respect for individual children and their families has been lacking, consent and confidentiality not ensured, existing services have been damaged and the actual child health checks and new follow up services have provided very little benefit. (Despite glowing reports promulgated by the AGI in the media).

Specific concerns that I have about the child health checks performed include:

There is little evidence from national or international studies to suggest that child health checks lead to an improvement in health, while there is evidence for other activities – such as primary health care programs.
Child health screening does not conform to accepted criteria for screening, thus it is unethical.
Importance of relationships. Where-ever I have seen child health services working well, one of the keys to success is strong respectful relationships between individual staff and clients. This cannot occur with programs which are provided by health staff on short secondments. This sort of program gets reduced to ticking off boxes on a form and actually provides very little benefit for children.
The program was unethical in the way it dealt with referrals. Secondary services provided (ENT/ Dental in particular) were provided only for children referred by the AGI doctors ignoring children who had been on existing waiting lists for a long period of time and had actually been assessed and referred with much greater care than occurred from the AGI checks. I believe this was unethical and also that it caused great distress to existing health staff and significantly damaged good will and existing services. It also was discriminatory in that it provided services based on factors other than need. This may have been somewhat rectified towards the end of the year.
Unethical nature of data and medical information management. I understand that data from checks and also from all subsequent referrals including for example detailed letters following paediatric consultations – (including my own), have been sent to Canberra for data purposes. Consent was never obtained from parents or guardians or from the clinicians (I was one) and the clinical information in these letters should have been treated as medical confidential material (unless specifically consented to by the patients).
Lack of continuity with existing and long term programs.
Lack of involvement of expertise in planning. There was no involvement of people with either expertise in child health programs, remote communities, or staff who had been working in the region.
Lack of any community involvement in planning and implementation.
Child health checks of very poor quality. In my work as outreach paediatrician until April 2008, I read the data sheets from AGI checks from many children. Standards did vary but on the whole were extremely poor. Health staff very often (and understandably because they were only given very short orientation) did not understand the conditions they were looking for or treating. Training and experience in Southern Australia does not prepare doctors for work in remote Central and Northern Australia. Many of the conditions seen had probably not been encountered by the doctors previously (eg scabies, suppurative ear disease, undernutrition, rheumatic heart disease etc) also the health staff obviously struggled to obtain history or communicate with the parents of children seen (again understandable – and foreseen by those of us who knew something but were never asked)
Orientation and training was short and inadequate (because you cannot do it in a day or 2 – most staff coming to Central Australia need mentoring in the workplace by more experienced staff and are not really very effective for months)
Lack of cultural safety, and cultural understanding. This was especially a problem by some of the bureaucrats.
Practitioners often did not follow standard treatment protocols. In the NT, primary health services have developed and follow the CARPA guidelines which are evidence based protocols for treatment of commonly seen conditions in primary health services. Although the visiting doctors were instructed to always follow these protocols and received some orientation in this – many did not follow them and used individual management. Sometimes this resulted in inadequate treatment, and sometimes in acceptable alternatives but in this type of service following protocols is extremely important as the person providing the treatment may not be the person following the child.
Members of teams sent into communities very often conflicted with each other. I heard stories of conflict within the teams over and over again. This made the teams less effective and sometimes counterproductive as they also damaged existing and vital services. I guess this issue was expected with adhoc teams, little orientation, poor training and lack of appropriate leadership or management.
Conflict between AGI teams and local services was not uncommon.
Doctors and Nurses employed by AGI were paid more than existing long term staff. This caused significant ill feeling from existing staff.
Poor management. I was aware of several cases of “volunteer staff” who previously had worked in Central Australia, had relationships with families in some communities, and in one case even spoke an Aboriginal language. However despite these advantages and the importance of personal relationships these individuals were sent to communities they had not worked in, where they did not have any relationships and did not know the language.

Follow up program so far

ENT - The program appeared to just want to perform operations. I assume because this would give the most favourable coverage in the media. This is despite the fact that surgery although important in some individuals is often too late to improve educational outcomes and disability due to hearing impairment during critical times for learning and language development. (including auditory processing development). Later ENT surgeons were sent to communities to provide assessment and services – however they were not well orientated or supported, often did not want to be there and only assessed children for surgery where they should have also been supporting primary care ENT interventions and helping to train primary care staff , visiting schools and advocating for public health programs for ear health. Of course these doctors also were probably poorly orientated. Visiting audiologists likewise just checked hearing and reported but were not involved in primary health care intervention as they could and should be. They need proper, extensive orientation to do this and need to be integrated into the PHC services not just come in do a task and leave.
Dental – What was needed was an enhanced dental service – not sending doctors and nurses who didn’t have any idea how to assess dental disease. The outreach dental service in CA was very good – it just needed to be expanded and supported, and needed some increase in theatre time in Alice Springs.
Paediatric services. Paediatric referrals were made but of in general of very low quality. (ie the fly in doctors provided extremely little information and showed little understanding of the issues both medical and social related to the specific referrals made). This I guess is related to inability of many of the providers to obtain history of people from a different culture from their own, the fact that they did not have time to develop relationships with individual patients or families and that they often had not had any experience with some of the medical conditions encountered. Extra paediatric funding was provided or promised to ASH, however this has never been spent as the hospital was unable to find an appropriate paediatrician. However if the funding had been provided to the paediatric outreach service (located in the central Australian remote health service of DHCS) we would have been able to recruit 2 excellent paediatricians experienced in outreach paediatric work in Central Australia (several months for each individual).
Resources – Many of the additional resources have been given to Alice Springs Hospital while they should have been given to community services. I suspect this occurred because the NT health department saw the AGI as a opportunity to obtain funding. Examples of resources provided which were either of dubious value or should have been funded by existing hospital funding streams include equipment such as paediatric bronchoscope, hospital based positions such as paediatric speech therapist and nutritionist (needed in ASH – but the AGI should have placed these positions in the community). There are many more examples of resources being placed in the wrong places. This results from the hospital focus of many people in government and also in health services (some with vested interests) but is not supported by available evidence.

4. Other unintended consequences
Medical service to remote health services are currently in crisis in Central Australia. (at least the services provided by DHCS) with extreme lack of staff. The lack of morale, inability to retain and recruit appropriate general practitioner doctors is partly the result of the AGI. This in my understanding has occurred because of 1. Poor morale due to lack of involvement in any planning or implementation of the AGI. 2. Lack of recognition of the hard work people have put in and the services that existed in communities prior to the AGI. 3. Management in DHCS became preoccupied with aspects of the AGI and support of people already working became problematic. 4. There was significant conflict (and still is) between staff about the way the AGI was implemented and the way DHCS has and is implementing followup programs etc. 6. Unfortunately some new appointments made with AGI funding (phase 2 or 3) were (in my opinion) rushed and references etc not well checked and so inappropriate people who lacked appropriate skills were appointed.

5. Some suggestions for the future

Only use short term "fly-in" health staff where long term staff cannot be found. Never again pay short term visitor staff at significantly higher rates than longer term staff. "Fly in" visitor staff need to always leave the continuing health service in better shape than before they arrived. Fly in staff even if experts will have little impact except by improving continuing services.
In delivery of health services to children, parents, families and communities two things are important. Firstly having the right program which has evidence behind it, is well organised, has the right resources and infrastructure to implement it. Secondly staff who have the right skills and can develop relationships with their patients / families. Unless both are in place a program will fail. Developing staff who can develop relationships, operate in cultural safety and work as a team is as important as having a check list of things they can do. Investment in people is very important and should be a priority. Invest in improving the skills and providing care for existing health staff, who already have been orientated and have developed relationships with families.
Investment in and training of primary health managers. They need to have people skills, bring the team together and facilitate collaboration and quality services. There primary care should be for their staff and for their patients and not reporting to an uncaring bureaucracy. Managers should have some understanding of public health and should use expertise in their teams and not pretend they know what they are doing when they do not. The health system should invest in training and retraining health managers (in my opinion from manager of a community health service to regional and state managers). This is one of the biggest problems. In the NT in remote health services there are good clinicians in all disciplines, there are people who are committed and passionate about their jobs. They are often working in difficult situations and in isolation. Many of these people have left because they have not been provided with the responsive and proactive management required. The Commonwealth should invest in change management – ie a change in management culture in remote health services. (this includes all sectors – Australian government / NTDHCS / division of GP’s / AMS sector).
Improve the structure of management. DHCS has a very hierarchical system. Senior managers do not respond to issues raised even by their senior staff (I am writing from personal experience). This type of management must be addressed. Also the centralisation which took place in the NT DHCS several years ago has been a disaster for Central Australia primary health care and should be changed. (these are issues specific to DHCS but I think the principles are important. To create good health services for children and families we need a responsive management system which can engage all staff and must be local or regional not delivered from 1000’s of km away. (ie not based in Darwin or Canberra).
All the elements of the health services for children need to be brought together within a region. So in Central Australia this would include clinic staff based in communities and other services including Allied Health / child development/ rehabilitation, mental health, audiology and secondary ear health services, nutrition, health promotion, community paediatrics, visiting child health nursing, social work etc. A current impediment to delivery of comprehensive excellent care is the fragmentation of services as well as the lack of service. Services and disciplines working as one will also assist in retention and management of staff.
Sponser local community based child health programs which are well supported by people who have appropriate skills and experience, eg in areas such as nutrition, ear health, skin health. Employing local Aboriginal people to work on programs is good, but will fail if not adequately supported. You should not expect an untrained person to be able to run (for example) a primary ear program on a community without very extensive mentoring and support. I believe that there is data that suggests that for 3 or 4 community workers you need 1 professional full to provide support.
Develop and promote quality early child services and provide support programs for parents and families of young children. This is a preventative approach which has sound evidence. See reference above by Fraser Mustard.
Make all classrooms acoustically appropriate, install soundfield systems and assist teachers in use of the systems. This is a part of a population approach to dealing with ear health and hearing issues. The current view appears to be that we can identify children with poor hearing, operate on them and fix them. While better ENT services are certainly needed this approach is extremely naïve. Minimising the effects of hearing loss on children’s education, working very hard to try to prevent initial ear infections and ear damage in young children and medical management of early chronic ear disease are the most important factors. ENT specialists should be involved in these aspects as well as in providing operations.
Provide sustainable and adequate visiting specialist services to communities including dental, paediatric, ear health and mental health.
Build up a sustainable and functional child protection system, which focuses not just on getting convictions, but can also provide services to families in preventing abuse and early intervention.
Invest in establishing and supporting training positions based or visiting remote communities in all relevant health disciplines. In medicine these type of positions should not have to rely on medicare for funding, as they might in Sydney. Every more senior practitioner should be mentoring and assisting in the training of junior staff for remote work. Established staff need support / time / development to be involved in training.
Support development of senior clinical staff who develop experience and expertise and can mentor junior staff.

I hope you find these comments useful. I thank you for considering them. I would be happy to provide more information if it would be useful to you. Please contact me if you need clarification etc.

I have been quite frank in my criticisms of the way the program was implemented and also about deficiencies of the current health system. I have done this not to attack individual people as I have respect for many of the individuals involved, but with the hope that you might provide fearless advice about improving the system. The managers of the program (AGI and DHCS) often had little control over the program because of political imperatives, and I think that almost without exception the “volunteers” who came to do the checks were committed and striving to make the program work, and hoped to help to improve the health of Aboriginal Children living in these communities.

Andrew White

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