Aboriginal and Torres Strait Islander people are more likely than other Australians to leave a healthcare service before receiving care or against medical advice, putting them at increased risk of treatment delay and hospital readmission.
The issue was explored in a recent report by the Australian Commission for Safety and Quality in Health Care.
In the article below, Julieann Coombes and Keziah Bennett-Brook of the George Institute for Global Health, who contributed to the review, say that leave events can be due to ongoing impacts from colonisation, including systemic racism in healthcare. They also outline the potential solutions.
Julieann Coombes and Keziah Bennett-Brook write:
Aboriginal and Torres Strait Islander people have an inherent right to receive culturally safe and quality healthcare. By better understanding why Aboriginal and Torres Strait Islander patients leave health services in higher numbers, health organisations can be better informed on how to improve healthcare for Aboriginal and Torres Strait Islander patients.
Leave events lead to delays in receiving the correct medical treatment and are associated with increased readmissions to hospital. This affects ongoing medical care and is associated with increased morbidity and mortality for Aboriginal and Torres Strait Islander people.
A leave event is broadly understood as an instance of a person leaving a health service before being seen by a health professional or leaving against medical advice.
A recent review looking into leave events from health services found that Aboriginal and Torres Strait Islander people are at higher risk of leave events than other Australians.
The review highlighted that it is especially important to understand that for Aboriginal and Torres Strait Islander peoples, leave events can be due to ongoing impacts from colonisation, including systemic racism within the healthcare system, and issues surrounding trust and power, which other Australians do not experience.
There are very real experiences of power imbalances between Aboriginal and Torres Strait Islander people and healthcare providers. Healthcare providers need to understand that experiences of shame and disempowerment, fear of child removal, cultural misunderstandings and stereotyping must be considered within the patient and clinician relationship.
Inequitable power structures
Health service organisation policies have predominantly been developed within a western framework that continues to reinforce power imbalances that do not take account of Aboriginal and Torres Strait Islander people and culture.
A change in service policies to balance these inequitable power structures is urgently needed and genuine engagement of Aboriginal and Torres Strait Islander communities is paramount to improve the policy structures that support change.
The United Nations Declaration on the Rights of Indigenous Peoples clearly states that First Nations people globally have the right to best practice healthcare and access to health services free from discrimination.
Within Australia, The National Aboriginal and Torres Strait Islander Health Plan 2013-2023 has a vision that the Australian health system is free of racism and inequality. The review found these were key drivers of higher leave events among Aboriginal and Torres Strait Islander patients.
The National Plan also states that all Aboriginal and Torres Strait Islander people should have access to effective, high quality, appropriate, and affordable health services.
While attempts have been made to understand the causes of leave events, most current research efforts are focused on studies that lack an exploration of experiences from the perspective of Aboriginal and Torres Strait Islander patients. The review highlighted the need for effective cultural capability training among health professionals and culturally appropriate holistic models of healthcare to be embedded into everyday practice.
There are various terms that are currently used within the Australian healthcare system to document leave events. These terms are often framed as if patients have a choice of whether to stay or leave, rather than understanding the broader issues that impact upon whether a patient is able to receive the care they need.
Although these terms are widely used, they can be stigmatising to Aboriginal and Torres Strait Islander people who may leave a health service due to factors that are currently not understood or acknowledged by the health system. There are a variety factors associated with leave events including but not limited to loneliness, waiting too long, experiences of racism, distrust of the health system, a lack of culturally safe services, miscommunication, remoteness of community, family and cultural obligations.
The Aboriginal Health Policy Directorate 2018 from the Department of Health WA identified a number of preventive measures to reduce leave events. One was the need for health systems to be approachable through effective cultural safety including cultural training of hospital staff on connection to country, kinship and family obligations. For this to be effective, training must be mandatory and ongoing rather than being just a ‘tick a box’ exercise. Cultural training models need to be developed for individual settings according to local communities’ priorities.
Aboriginal and Torres Strait Islander community-controlled health services need to be involved in developing resource information about hospital processes and what patients can expect when they attend the healthcare service.
Healthcare services must also establish partnerships with Aboriginal and Torres Strait Islander community-controlled health services to improve coordination and continuity of care. This supports two-way communication between Aboriginal and Torres Strait Islander community-controlled health services and mainstream healthcare services.
Policy makers in our healthcare systems could start by rewording the stigmatising terms used to define leave events from healthcare services across all states and territories within Australia.
Improving healthcare providers’ understanding of power imbalances and building a more culturally capable workforce would reduce experiences of racism and stigmatisation. These actions are essential in order to decrease the number of leave events from health services and move towards improving health outcomes for Aboriginal and Torres Strait Islander people.
Julieann Coombes is a Gumbaynggirr woman through her grandmother and has connections to Gamilaraay country where she grew. She is a Research Fellow at the Aboriginal and Torres Strait Islander Program, George Institute for Global Health.