Developing an Aboriginal Health Plan for NSW: the consultation process

Business and human endeavours are systems…we tend to focus on snapshots of isolated parts of the system, and wonder why our deepest problems never get solved. Peter Senge¹

The New South Wales (NSW) Government made election commitments to closing the gap in Aboriginal health outcomes. Central to this commitment is the development of a 10-year Aboriginal Health Plan. The last NSW Aboriginal health policy and strategy, Ensuring Progress in Aboriginal Health: A Policy for the NSW Health System, and NSW Aboriginal Health Strategic Plan: Better Health Good Health Care, were published in 1999.² There is currently no strategic framework to guide action to improve health outcomes of Aboriginal people in NSW and to address the unacceptable discrepancy in life expectancy between Aboriginal and non-Aboriginal people.

The need for systemic change to improve health outcomes of Aboriginal people is reflected in a number of recent reports such as the NSW Ombudsman’s Addressing Aboriginal disadvantage: the need to do things differently³ and the Australian Government’s Strategic Review of Indigenous Expenditure.⁴ Historic responses have been unsuccessful in closing the gap in health outcomes for Aboriginal people. Rather than duplicating current action the NSW Ministry of Health is considering how to both work together differently and find new ways to address the causes of disadvantage. This paper describes the first phase of the development of a 10-year Aboriginal Health Plan for NSW.

The development of the Plan acknowledged the need to ensure genuine engagement and empowerment of Aboriginal people throughout the process. Stuart Rees, Director of the Sydney Peace Foundation and former member of the NSW Reconciliation Committee, states that this engagement should go beyond the ‘rhetoric of empowerment, which may merely disguise maintenance of a disempowering status quo’ and ‘seek out the people whose views are seldom heard.’⁵ This approach recognises that consultation processes have not always considered the needs of Aboriginal people adequately,^6–8 and reflects the significant issues raised in the NSW Ombudsman’s report which noted that ‘government needs to adopt a very different way of doing business with Aboriginal communities’.³

In designing the consultation and engagement process, the NSW Ministry of Health partnered with the Aboriginal Health and Medical Research Council of NSW (AH&MRC) representing the Aboriginal community controlled health sector, to ensure that the views of Aboriginal people were heard throughout the entire process. The Ministry involved the AH&MRC as partners in decision making in relation to the design and delivery of the consultations. To assist in the consultation, the Ministry engaged Reos Partners, an international organisation that builds capacity for innovative change in complex social systems.

The consultation process was conducted in three stages:

• interviews with stakeholders

• regional workshops and a forum

• written consultation.

Each stage explored the question: How can we together transform the way we work and collaborate to significantly improve health outcomes of Aboriginal people across NSW over the next 10 years?

Individual stakeholder interviews were conducted between 13 and 21 October 2011 by Reos Partners. Thirty people were interviewed from the public health system and Aboriginal community controlled health sector. The public health sector participants included a vertical cross-section of the health system from Local Health District Chief Executives and Chairs of Boards, Senior Executive in the Ministry, to program coordinators and front-line workers. Aboriginal community controlled health sector participants included the AH&MRC’s 12 community-elected Regional Board Directors.

Approximately half the interviews were with the Aboriginal community controlled health sector, and approximately 70% of those interviewed were Aboriginal people. This representation ensured that Aboriginal people were the dominant voice at the centre of the consultation process, providing input at its earliest stages. This process supported genuine consultation with the Aboriginal community and helped shift the power dynamic from a power-over⁹ to a collaborative partnership approach. This shift in emphasis was recognised during the interview process, as participants acknowledged:

When you look at how things have been done in the past and how things have been forced on people, you realise you must have consultation. Be up-front and honest with people in telling them what’s happening.

Interviews like this and the forums that are going to take place after this and getting Aboriginal people throughout the state having their voice heard and being involved in the whole process – is what we need.

The following themes emerged from the interviews:

• connection (relationships, consultation, linking up, trust)

• respect (acknowledgement, equality, safety, attitudes and understanding)

• time

• funding

• workforce (supply, pathways, education, capability)

• leadership

• measurement and reporting

• accountability

• delivery models (holistic health or medical problem, access and cultural safety, prevention and cure, health system delivery)

• outcomes.

The interviews and emerging themes informed eight regional consultation workshops held in Dubbo, Wagga Wagga, Tamworth, Broken Hill, Nowra, Coffs Harbour and Sydney between 3 and 15 November 2011. Over 200 health professionals and community members attended the workshops convened by the Ministry of Health and the AH&MRC, with attendees equally distributed between representatives of the Aboriginal community controlled health sector and the public health system. To ensure Aboriginal views and perspectives were in the majority, over half the attendees at each workshop were Aboriginal people. This aspect of the consultation workshops was noted by participants:

I think we all talk about real partnership, we’ve had a practical demonstration of what real partnership starts to be in this room. But you do have to put some rigour in real partnerships.

The approach used in the workshops had been developed over twenty years by Adam Kahane¹⁰ and the team at Reos Partners and others including Otto Scharmer and Peter Senge.¹ Participants were involved in three different components of the workshop:

1. exploring what’s currently happening in the health system

2. stepping back from the detail to reflect on the current situation and what is needed

3. identifying new ways of working to create a changed system. Participants focused on addressing opportunities for change, and identified initiatives for positive results in the future.

The workshops were introduced with participants stating where they were from to provide a context for their life beyond work, and to emphasise an Aboriginal way of relating to people through their connection to land and country. Workshop leaders challenged participants to consider new ways of talking and listening that could lead to genuine inquiry and to understanding different perspectives. One participant commented that this method allowed those in the workshop to start to ‘see the same challenges through new eyes’.

Participants reflected:

I need to be more conscious of trying to engage better with Aboriginal people I work with. Listen more, engage more to be a better advocate and supporting Aboriginal people. Aboriginal health is so often left off the agenda. Taking more responsibility for that. Collaboration and engagement – genuinely respectful and partnering.

We need to keep listening to what Aboriginal people are telling us, especially the Elders who have been around a while.

In order to transform the health system to improve health outcomes of Aboriginal people, the workshop participants considered the current situation by examining the interconnections and relationships between the different parts of a system. This model presents a way to see what is happening based not only on observable events, but also on what has happened over time (patterns); it also identifies underlying structures (structures) and ways of thinking (mental models) that influence the system.

Participants agreed that a simple linear cause and effect relationship did not relate to the complex problem of Aboriginal health inequalities and that it would be more useful to consider multiple causes and multiple effects. Participants were encouraged to consider aspects of change required to shift the system and improve health outcomes of Aboriginal people. These ideas were grouped to provide directions for action.

From the workshop discussions to identify ideas and approaches that would make positive systemic change to Aboriginal health outcomes in NSW over the next 10 years, core themes emerged. These themes will provide the basis for the elements to be included in the 10-year Aboriginal Health Plan:

• Unified vision and definition of Aboriginal health

• Unified and integrated planning and funding framework

• Critical measures of transformation

• Outcome reviews/needs and gaps audits (state and local)

• Joined-up local strategy and action planning

• Workforce – attract, develop, sustain

• Making it happen – joined-up local action and service delivery

At the conclusion of the workshops, participants said:

This was more a spirit building exercise for me, I was hoping to look for something to empower me to move forward. It was more about seeing the experience of my community coming from different areas, I see the beauty of our culture coming from different areas, and even from non-Aboriginal people, the partnership. I saw that today, it rejuvenated the spirits. I want to leave the tiredness, the battles, and realised I don’t fight alone.

We need to maintain the shared vision we’ve experience today to work closely together. To continue to find ways to include the community in solution building.

I’d like to think that we see ourselves as part of a wider team, working together for the same purpose, if problems or issues, we need to discuss and I would like to see an integrated plan as we go forward. There seems to be silos, and never the twain shall meet. They need to be broken down.

The Minister for Healthy Lifestyles, the Honourable Kevin Humphries MP, and the AH&MRC co-hosted a health and wellbeing forum for senior health leaders in November 2011. The forum expanded the findings of the regional workshops and sought broad agreement regarding the themes for the future. The forum also elicited a number of underpinning principles to guide the development of the Plan. These principles are outlined in Consultation Paper 2.

Along with the workshops, a written consultation process was undertaken. Comments were sought around broad themes. A consultation website was launched which describes the consultation process, reports and data, and provides background information and mechanisms to provide feedback and submissions (see http://www.health.nsw.gov.au/publichealth/aboriginal/plan/index.asp).

Consultation paper 2 was released in March 2012, and detailed the findings from the interviews, workshops and health and wellbeing forum.¹¹ A discussion paper was released on National Close the Gap Day, 22 March 2012. This paper reflects the earlier consultations and proposes a vision, definition, goal and underpinning principles for how we work and identifies strategic directions to improve Aboriginal health outcomes. A further report synthesising the written submissions will complete phase 1 of the consultation process to develop the new 10-year Aboriginal Health Plan for NSW.

The feedback from the second phase of consultation informs the draft Aboriginal Health Plan. Details of phase 2 of the consultation process can be found online at:

http://www.health.nsw.gov.au/publichealth/aboriginal/plan/index.asp.

Submissions to the consultation process can be made on this website or by email to: aboriginalconsultation@doh.health.nsw.gov.au.