*** Aboriginal and Torres Strait Islander readers are advised that this article contains names and details of people who have passed ***
Introduction by Croakey: A national review is about to make recommendations for improving healthcare for First Nations people in prisons.
The review is not yet released but sets important context for a #CroakeyLIVE online webinar next Tuesday, 28 May (please register here to join, from 5pm-6pm AEST). We thank and acknowledge the webinar sponsor: Girra Maa Indigenous Health Discipline at the UTS Faculty of Health.
Below, Alison Barrett previews some of the key calls to action.
Alison Barrett writes:
Financially supporting Aboriginal Community Controlled Health Organisations (ACCHOs) to provide culturally safe care for First Nations people in prisons should be a priority, according to Aboriginal health leaders and organisations.
This is a key recommendation they want to see prioritised by the Department of Health and Aged Care’s review of First Nations healthcare in adult prisons and youth detention facilities across Australia.
Nous consultancy group is undertaking the review – led by Maria Jolly, Nous Principal, and Craig Ritchie, Nous Associate and Chairperson of Winnunga Nimmityjah Aboriginal Health and Community Services – through a series of roundtables and discussions with key stakeholders and organisations, including state/territory and justice health departments, and Aboriginal community controlled organisations.
The review is examining the current state of healthcare delivery in custodial settings and aims to deliver recommendations to the Australian Government on how it can be improved.
It is also exploring barriers to culturally safe healthcare for First Nations people in prison and youth detention, according to a spokesperson from the Department of Health and Aged care.
“It is hoped the review will identify opportunities for systemic reform that will lead to improvements in health outcomes for First Nations people in prison and youth detention and a reduction in deaths in custody,” the spokesperson said.
The final report is expected to be submitted to the Department in June.
Funding matters
The National Association of Aboriginal and Torres Strait Islander Health Workers and Practitioners (NAATSIHWP), Winnunga Nimmityjah Aboriginal Health and Community Services in the ACT, and Queensland Aboriginal and Islander Health Council (QAIHC) told Croakey they want implemented a key recommendation from the 1991 Royal Commission into Aboriginal Deaths in Custody (RCIADC).
This is that Aboriginal health services be involved in the provision of health and medical advice, assistance and care for Aboriginal and Torres Strait Islander people in custody.
“We need adequate funding to provide culturally safe, comprehensive services,” said Julie Tongs OAM, CEO of Winnunga.
“The majority of ACCHOs are not provided with funding to deliver primary healthcare and support to prisons,” said Associate Professor Sophia Couzos, QAIHC Public Health Medical Director.
Couzos told Croakey that the current prison healthcare model is “based on acute healthcare treatment” and prevents people in prison from “accessing holistic, long-term, preventative care”.
Improving access to mental healthcare, allied health, telehealth, and to the Medicare Benefits Schedule and Pharmaceutical Benefit Scheme are other recommendations made by health and justice experts who spoke to Croakey for this story.
Because prison health is delivered by state and territory governments, people in prisons generally are not eligible for Commonwealth-delivered Medicare and the PBS.
However, enabling people in prisons to have access to Medicare is “not as simple as it may seem”, Tongs said. Doctors can’t just go into prisons and do a consult – they need to go through training and to undergo a custodial security process prior to seeing clients inside.
QAIHC says State and Commonwealth government negotiations are needed to “enable access to the MBS and the PBS for the delivery of prison healthcare services in custodial settings”, together with local negotiations with ACCHOs to “enhance the quality of prison healthcare being delivered to those in custody”.
Couzos told Croakey that involving ACCHOs in prison care will help meet Targets 10 and 11 of the National Agreement on Closing the Gap – to reduce the rate of Aboriginal and Torres Strait Islander adults and young people in the criminal justice system.
Wiradjuri Professor Megan Williams, who has contributed to coronial investigations and reviews of prison health services, said Closing the Gap implementation plans clearly outline the need for reforming the way governments do business – Priority Reform 4.
Williams pointed to the Productivity Commission’s review of Closing the Gap and the overwhelming failure to make progress, “including about the holistic understanding of health – that seems near impossible for most government organisations to achieve, but not for ACCHOs”.
Williams reflected on findings of coronial investigations that reveal countless times prison-based healthcare staff have not had available the resources they require to deliver safe care, nor culturally safe care.
She said investigations “have shown multiple layers of interpersonal, institutional and systemic racism occurring together”.
Williams added that increasing financial support for ACCHOs to deliver healthcare to people in the community could “prevent people with health issues going to prison, or remaining in prison”.
Structural context
In a powerful article in Overland earlier this year, ‘Prison healthcare as punishment – the killing of Veronica Nelson’, lawyer Sarah Schwartz investigated the many ways that inadequate healthcare in prisons “is an extension of the logic of prisons – its own distinct form of punishment”.
“The structures that govern prison healthcare, and the ways in which the prison health system is kept separate from the public healthcare system, largely immune from scrutiny and accountability, further entrench punitive models of care”, Schwartz wrote.
While medical issues are the most common cause of deaths in custody, First Nations people who die in custody are three times more likely to not receive all required medical care prior to passing, according to data cited by Schwartz. For First Nations women, the result is even worse – less than half receive required medical care prior to death.
The way in which health services are delivered varies from jurisdiction to jurisdiction, with some being delivered by state or territory justice or corrections departments and others by health departments, or private contractors.
In 2021, approximately 43,000 people – mostly men (92 percent) – were in Australian prisons. Aboriginal and Torres Strait Islander people are overrepresented in the criminal justice system – accounting for 30 percent of people in prison.
The Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability found that people with disability, particularly First Nations people with disability, are also overrepresented in the criminal justice system.
Almost 40 percent of people entering prison report a disability or long-term health condition, compared to 18 percent in the general community.
Common health conditions reported by people entering prison include asthma (27 percent of people), back pain (27 percent) and cardiovascular disease. According to the Australian Institute of Health and Welfare (AIHW), many people entering prison may be unaware of existing health conditions due to not accessing health services previously.
Just over half of people entering prison have been told they had a mental health condition at some stage in their lives, according to the AIHW. Harmful alcohol consumption and illicit drug use are also common among people entering prison.
In other words, people in prison are more likely than other Australians to be in poor health and in need of comprehensive, effective and safe healthcare – but are less likely to have access.
Workforce matters
Karl Briscoe, CEO of NAATSIHWP, and Couzos both told Croakey that ACCHOs can provide comprehensive, holistic and culturally safe healthcare that address critical cultural and social determinants of health, as well as physical aspects of health.
Briscoe, proud Kuku Yalanji man from the Mossman-Daintree area of Far North Queensland, said that if the review makes a recommendation for ACCHOs to go into prisons, NAATSIHWP will continue to provide professional development for its members to work in prison healthcare, as well as recommend that healthcare is delivered via a multidisciplinary team.
Prisons tend to be “culturally unsafe environments” for Aboriginal Health Workers, he said.
Prison staff have limited understanding of the cultural nuances, protocols and practices of Aboriginal and Torres Strait Islander people in custody that enable their wellbeing to be addressed, he said.
There are no systems in place such as the Australian Health Practitioner Regulation Agency guidelines for health professionals that can be applied to hold security guards to account, for example.
Further, Williams said, “prison officer training and roles do not match prisons having so many people with multiple and compounding health issues and poor determinants of health”.
Couzos said that QAIHC recommends all prison staff undergo “compulsory and comprehensive cultural awareness and trauma-informed training”.
However, neither the recent Victorian Ombudsman investigation into healthcare provision for Aboriginal people in Victorian prisons, nor the Victorian Government’s cultural review of prisons found adequate training resources or processes available.
Tongs said from her experience as CEO of the only standalone ACCHO providing a government-funded full-time clinic in an Australian adult custody setting – Winnunga Health and Wellbeing Centre in the Alexander Maconochie Centre – it is a challenging environment to work in, due to issues around power, control and punitive behaviour.
Her message for other ACCHOs is to be strong and resilient. You “have to have a lot of guts to stand up for what you believe in”, she said.
Expert advice
Professor Stuart Kinner, Head of the Justice Health Group at Curtin University and Murdoch Children’s Research Institute, said it appears the review is being done as a matter of urgency.
Kinner told Croakey that he would like to see “all reasonable steps” taken to improve the scope, quality, and cultural capability of health services in prisons, including independent oversight.
Additionally, supporting in-reach for ACCHOs is a “good idea”, he said. Making changes to grant ACCHOs an exemption to the exclusion from billing for Medicare item 715 is “one important step” but “no means a panacea”.
Medicare item 715 is for a “professional attendance by a general practitioner at consulting rooms or in another place other than a hospital or residential aged care facility, including custodial settings, for a health assessment of a patient who is of Aboriginal or Torres Strait Islander descent”.
According to Kinner, genuine discussions are needed to determine how Medicare item 715 is implemented on the ground, including but not limited to matters about funding co-payments, providing appropriate security inductions for all people providing in-reach care and ensuring that suitable facilities are available for external healthcare providers.
Kinner emphasised the importance of distinguishing between whether to end the exclusion of people in custody from Medicare, and how to make it happen.
“There’s a whole lot of genuinely important issues to work through”, which he characterised as implementation challenges. But these are “not a reason not to go ahead”, he said.
Kinner told Croakey that he and colleagues have recently completed a project based on publicly available data estimating the cost of making item 715 available for all people in prisons. While the results are not yet public, he said the cost is “very small…a drop in the ocean” in terms of the federal health budget.
He also said that improving access to federally-subsidised mental health services is worth considering.
Mental healthcare
For Damien Linnane, a Māori person with lived experience of incarceration in Australia, the limited access to mental healthcare in prisons came as a shock.
Linnane, who is doing a PhD exploring what issues have been raised by people in prison in prison literature, acknowledged that different jurisdictions and prisons have different rules, but from his experience, “therapy and rehabilitation stop at the door”.
Prior to entering prison in 2015, Linnane was on a mental healthcare plan that was helping to make a significant difference to his health and wellbeing.
Upon asking for therapy once in prison, a psychologist told him “everyone in here would benefit from therapy, but there’s no funding for it”.
The psychologist told Linnane her job was to assess whether people are dangerous or at risk from suicide or self-harm. After that, Linnane realised that psychologists are not in prison to help people – “they’re there to write reports for probation and parole”.
Linnane’s mental health deteriorated in prison, “but they still have a duty of care to make sure you don’t self-harm”. When he alerted prison staff to his mental health concerns, he was put in solitary confinement – removed from sunlight, ability to exercise or call family and friends.
According to Linnane, there is no confidentiality or privacy in prison – staff may sit in on health appointments and gain information which could be used against clients.
The inquests of Aboriginal people Veronica Nelson, Kevin Bugmy and Ivan Goolagong – that Williams worked on – highlight this array of issues, and the “additional agony that Aboriginal families and services have tried to visit, to in-reach and to advocate, but are literally locked out”.
Services provided by Winnunga
Since January 2019, Winnunga Nimmityjah Aboriginal Health and Community Services has provided a standalone prison health service at the relatively new Alexander Maconochie Centre, funded by the ACT Government, Tongs told Croakey.
Winnunga AMC Health and Wellbeing service is staffed by nurses every day of the year, has an Aboriginal cultural support officer 9am-5pm Monday through Friday, GPs and nurses five afternoons a week and a clinical psychologist one day a week.
An optometrist visits once a month, and clients requiring psychiatric care reviews are done via telehealth with psychiatrist and social health teams.
Tongs said that increased harm reduction strategies are required in prisons, such as the needle and syringe program. She said the recent tobacco ban in the Alexander Maconochie Centre is problematic as it may push more people to illegal substances, which “run freely” in prison.
“Tobacco is not good for your health, but neither is drugs, and neither is alcohol,” she said.
Winnunga has “always been passionate about prison health,” Tongs said, and they are seeing results. In the last 18 months, they haven’t had one client self-harm in the Alexander Maconochie Centre.
The Winnunga service also provides a justice reinvestment program – intensive support for clients who are at risk of being detained, as well as continuity of care after release from prison – that is linked to Alexander Maconochie Centre, Tongs said.
People in prison don’t “just have issues with incarceration”, Tong said – family breakdown, child protection and probation are all common issues they need support with, in addition to physical and mental healthcare.
Medication costs “are very high because people in prison don’t have access to PBS”, access to allied health professionals is limited, and Winnunga “can wait long periods of time for medical imaging and outpatient appointments at the Canberra Hospital”, Tongs told Croakey.
Clients’ access to healthcare can be impacted by correctional service staff and operations, including lock-ins, according to Tongs.
• Coming soon: an article on #ImprovingPrisonHealthcare, by Associate Professor Sophia Couzos, Public Health Medical Director of QAIHC.
Department of Health and Aged Care response
This statement was provided on 23 May in response to queries from Croakey:
The Australian Government is committed to improving health outcomes for First Nations people.
Numerous coronial inquiries have raised concerns about access, quality and cultural safety of custodial health services for First Nations prisoners.
In the October 2022 Aboriginal and Torres Strait Islander Health Roundtable, Health Ministers and First Nations stakeholders discussed the issue of custodial health for First Nations people, with Health Ministers agreeing to work collaboratively on this as a priority.
The Aboriginal and Torres Strait Islander Health Collaboration, which includes First Nations senior officials from the health agencies of each jurisdiction, commissioned the Review, to be led by the Commonwealth.
The Review is considering barriers to culturally safe health care for First Nations people in prison and youth detention.
The Review is being informed by targeted stakeholder consultation, including with state and territory governments, the Aboriginal Community Controlled Health Services sector, key experts and individuals with lived experience of incarceration.
A final report will be submitted to the Department of Health and Aged Care in June 2024.
It is hoped the Review will identify opportunities for systemic reform that will lead to improvements in health outcomes for First Nations people in prison and youth detention and a reduction in deaths in custody.
Crisis supports
Lifeline provides free suicide and mental health crisis support for all Australians.
Phone: 13 11 14
13YARN is a crisis support line for Aboriginal and Torres Strait Islander people. Available 24/7. No shame, no judgement, safe place to yarn.
Phone 13 92 76
Kids Helpline provides free, private and confidential 24/7 phone and online counselling service for young people between the ages of 5 and 25.
Phone: 1800 551 800
Beyond Blue provides free telephone and online counselling services 24/7 for everyone in Australia.
Phone: 1300 224 636
1800 RESPECT provides confidential sexual assault and family and domestic violence counselling via phone and webchat. Available 24 hours a day, seven days a week.
Phone: 1800 737 732
Further reading and viewing
Comprehensive Indigenous health care in prisons requires federal funding of community-controlled services, by Professor Megan Williams, The Conversation, 2021
Health of people in prison, AIHW, 2023
Prison healthcare as punishment — the killing of Veronica Nelson, by Sarah Schwartz, Overland, 2023/2024
Government reviews First Nations healthcare in prison, by Denham Sadler, 2024
Investigation of inadequate healthcare in prisons highlights importance of cultural safety and Aboriginal-led solutions, by Professor Megan Williams and Jack Bulman, 2024
Holistic primary health care for Aboriginal and Torres Strait Islander prisoners: exploring the role of Aboriginal Community Controlled Health Organisations by Simon Pettit, Megan Williams and colleagues, 2019
First Nations people in the NT receive just 16% of the Medicare funding of an average Australian, by Professor Stephen Duckett and colleagues, 2022
Governments urged to address determinants of incarceration, and provide safe healthcare in prisons, by Alison Barrett, 2023
Challenges for Medicare and universal health care in Australia since 2000, by Damien Linnane, Craig Cumming and Stuart A Kinner, 2024
‘How a healthy community should be’: how music in youth detention can create new futures by Alexis Anja Kallio, 2024
Paper chained: a journal of expression from behind bars, edited by Damien Linnane
Cultural Review of the Adult Custodial Corrections System. This Victorian Government review recommended a public health model for the delivery and oversight of health services across the adult custodial corrections system.
Watch this Victorian Aboriginal Legal Service prison healthcare webinar.
