New approaches to health care are constantly needed in rural and remote Australia – to build on existing strengths, fill gaps and ensure access and quality. Such approaches need to be applied in situations with high patient needs, constant staff turnover and limited resources. These factors end up being drivers of innovation, and many “new models” can later be more widely applied in a range of settings, urban as well as rural, in Australia and overseas.
However, it is one thing to come up with effective and efficient approaches in research and pilot programs and quite another to scale them up and sustain them over time, and across large jurisdictions and whole health systems. It is the continuous in continuous quality improvement that is the hardest bit.
The Northern Territory has long been a place where health research and health policy applicable to Aboriginal and Torres Strait Islander populations have been developed and trialled. This carries a historic legacy, both good and bad. Part of the positive legacy is a modern-day commitment to proper ethical partnerships between communities and researchers, and between government services and Aboriginal community controlled health organisations.
The work described in this volume is notable for its direct relevance to primary health care (PHC), its rigour and (frankly) its longevity over decades and through various institutional arrangements. It started with the Audit and Best Practice in Chronic Disease (ABCD) program in the early 2000s, which linked with the Northern Territory Preventable Chronic Disease Strategy (PCDS) that began a few years earlier in the late 1990s and continues to this day. The basic architecture of the strategy remains intact but has been modified and improved over time, as a result of a commitment to ongoing research and evaluation and an attention to meaningful partnerships. These are the same principles that underpin the continuous quality improvement work in primary health care, which has now been expanded nationally and extended in scope to cover a range of chronic conditions, preventive as well as clinical care, and mental health.
So, if you are looking to enhance your knowledge of continous quality improvement (CQI) or PHC, or build some health architecture to stand the test of time, there will be many useful lessons and practical tools to be found in this volume. The gains may be modest initially, but such hard-won improvements sustained over time and built into a new base of primary care practice will be worthwhile in the long run for a large number of patients.
The public health dimension of PHC is also writ large – we might start with individual risk factors for chronic disease, but we very soon see the absolute need to link such care to a broader risk environment (social and economic) at the family, community and population health level. And anyone reading, writing or thinking about Aboriginal health in Australia will quickly realise that the “culture” word should first be applied to the organisation of health services, and to the broader society, before it is used to “blame and explain” unacceptable gaps in health outcomes.
There are many people, some of whom are longstanding personal friends and colleagues, who have contributed substantively to the success of this program of work. All have been motivated by a passion for equity and a desire to improve health care and health outcomes. They have been willing to work together as a team, to learn together by sharing information, data, perspectives and insights, and to sustain collaborations over the long term. The leadership and co-mentoring provided by people in a range of roles and levels within the collaboration have been essential ingredients in building trusted research-policy-practice partnerships, unique in Australia and relevant everywhere.
Tarun Weeramanthri is a public health physician and President of the Public Health Association of Australia. He lived and worked in the Northern Territory for 17 years, as a researcher with the Menzies School of Health Research in Darwin (1991–95), as Community Physician with the Northern Territory Centre for Disease Control (1996–2003) and as the Northern Territory Chief Health Officer (2004–07). He was Chief Health Officer in Western Australia from 2008 to 2018. His awards include the Sidney Sax Medal by the Public Health Association of Australia for his contribution to public health in Australia.
One of the earliest jobs in my career was working at an Aboriginal community controlled health service. These services were created from the 1970s through Aboriginal and Torres Strait Islander activism to address our people’s poor access to health care, and the racism they experienced when seeking care. I began to work as an Aboriginal health worker over the summer of 1986 at the Victorian Aboriginal Health Service when I was still a medical student at university. After my graduation, I worked as a general practitioner and as the chief executive officer at the same service. These early work experiences convinced me of the importance of providing quality primary health care to improve Indigenous health outcomes more generally.
Later in my career, as a health services researcher, I became aware of the broader body of research that investigated the relationship between coordinated and integrated primary health care and population health outcomes. In Indigenous health there are important questions that arise from this. For example, does both the routine screening of chronic disease risks and the integration of prevention activity with clinical interventions improve chronic disease outcomes for Aboriginal and Torres Strait Islander peoples? The answers to such questions have important implications for clinical operations, primary care services and policymakers.
From 2003 onwards, the Cooperative Research Centre for Aboriginal Health (and its later iterations) developed both a primary healthcare research program and a connected program in health systems research. Within this context we fostered a research focus on continuous quality improvement in Aboriginal and Torres Strait Islander primary healthcare services. This was a key stimulus for some of the research work outlined in this volume. It also had an influence on Indigenous health policy thinking, such as the health investment program associated with the Council of Australian Governments’ Closing the Gap initiatives that has been active since 2008.
It is exciting to see the ongoing evolution of this field of work, described in detail in this book, as it continues to impact and improve health services’ practice, thereby contributing to better health outcomes for Aboriginal and Torres Strait Islander peoples.
Professor Ian Anderson, Order of Australia, is a Palawa man and the Deputy Vice-Chancellor at the University of Tasmania. He was previously the Foundation Chair, Indigenous Higher Education; Pro Vice-Chancellor (Engagement), the Foundation Chair of Indigenous Health at the University of Melbourne and Deputy Vice-Chancellor at the Australian National University. His academic, policy and practice roles in Indigenous health include Director of Research for the Lowitja Institute and related Cooperative Research Centre for Aboriginal Health and Chair of the National Indigenous Health Equality Council.