Ellen Phiddian
Cosmos science journalist
Unstable workforces plague healthcare in remote areas. Aboriginal communities are particularly vulnerable to the revolving door of healthcare staff.
But according to researchers, training local Aboriginal practitioners is one of the most effective ways to stabilise the workforce – and in the Northern Territory (NT), a new venture is underway to do more.
A recent study led by the Menzies School of Health Research has found extremely high staff turnover rates in remote NT and West Australian healthcare clinics run by and for Aboriginal communities.
The study, which is published in Human Resources for Health, found staff turnover in Aboriginal Community Controlled Health Services (ACCHSs) had an annual average of 151%.
ACCHS (also called ACCHOs, Aboriginal Community Controlled Health Organisations) are services run by local Aboriginal communities to deliver healthcare for those communities.
Clinics run by ACCHSs can provide culturally sensitive and holistic care for the communities they serve. They aim to employ local Aboriginal people as well, and in 2021-22, 52% of the staff in ACCHSs were Aboriginal.
But many ACCHS clinics struggle to retain staff.
According to Dr Prabhakar Veginadu, a research fellow at Menzies, the high turnover from the 2017-19 data in the study he just published is part of an unfortunately consistent pattern.
“We are constantly having these conversations with these health services and understanding what has changed,” he tells Cosmos.
In terms of staff turnover, for the last decade the answer is “not much”.
“We did a similar study back in 2017 when we looked at the turnover of staff in Northern Territory Government-run primary health care clinics. That looked at the payroll data from 2013-2015, and the trends have been similar since then,” says Veginadu.
In work yet to be published, the team has found post-pandemic data from 2021 tells a similar story.
This turnover has direct and indirect effects on the quality of care.
“It takes a lot of time to build trusting relationships between the healthcare professional and their patients,” says Veginadu.
“If staff leave, [patients] would have to start all over again in terms of understanding, opening up with sensitive issues to the new health staff who have walked into the clinic.”
Veginadu says that qualitative research the team has done, talking to members of communities serviced by ACCHSs, has shown this has a negative effect.
“It discourages people from accessing care, because they feel unsafe reaching out to this absolutely new person who’s in the clinic,” he says.
“There is a very high burden of chronic diseases among Aboriginal people in remote communities, and that means that they need regular access to primary health care to keep everything under check.”
There are also indirect impacts – high staff turnover is expensive for the clinics, which run on limited funds.
“There’s a considerable amount of resources that these health services are needing to invest towards recruiting and orienting new staff, and this is money that should have been used directly in providing healthcare,” says Veginadu.
In this study, Veginadu and colleagues examined payroll data for 22 regional and remote clinics, managed by 11 ACCHSs.
These clinics had an average of 7 staff at any given point – 5 health workers like doctors, nurses and allied health professionals, and 2 in non-health roles such as administration or cleaning.
Annual turnover was 151% for individual clinics and 81% for organisations as a whole. In the “client-facing” (healthcare) roles, turnover was 164% per clinic, while for non-client-facing (non-healthcare) it was 120%.
This means that staff leave and are replaced an average of more than once per year at each clinic.
Veginadu says that a “multitude of factors” are contributing to this turnover, including safety, adequate housing, and very high workloads.
“Currently we are working with the staff in the health services as well as the executives, to try and understand what strategies could be implemented to improve retention among the staff,” he says.
But there is a hopeful statistic in the data: turnover rate among Aboriginal staff was half that of non-Aboriginal staff. Clinics saw 81% turnover for Aboriginal staff compared to 162% for non-Aboriginal staff.
The researchers believe that greater employment of local Aboriginal people would help to stabilise the workforce, both in clinical and non-clinical roles.
In non-clinical roles, Veginadu says that support and targeted training for Aboriginal school graduates could help to improve their employment.
“For example, being a medical receptionist is a highly taxing job. It might seem simple, but it needs a lot of skill,” he says.
“We could develop a support system for them, consisting of elderly Aboriginal people within the health service that are able to train them, mentor them, support them… that would help them to not only cope with the with the with the stress of the work in the clinic, but also develop a career path within the health service that will retain the workforce.”
Then, there’s clinical roles: Aboriginal nurses, doctors, and other healthcare practitioners.
“We need more on-Country training and locally contextualised courses that are targeted towards Aboriginal people,” says Veginadu.
Next year, Charles Darwin University, which is partnered with Menzies, is aiming to supply one of these courses with a medical program for training doctors.
The university was initially planning to start operating the program in 2026, with a $24.5 million injection from the federal government, but it’s recently received permission to accelerate the start to 2025.
The first year of the program will have 20 students, and the intake is expected to be 40 from 2026.
“We want to train local students,” says Ian Lee, the First Nations lead on the medical program.
“They’re used to the hot weather, the buildup, and all of the things that come with living in the Territory.”
Lee cites research done by James Cook University which finds that local people trained as doctors in northern Australia tend to remain there to practise.
The program will have preferential admission for First Nations students and NT residents.
Lee says First Nations students from the NT will represent a minimum of 40% of the students in the program, and NT residents in general will represent a further 40%. There will be smaller quotas in the remaining 20% for non-NT First Nations students, and non-Indigenous residents of rural and remote areas in other Australian states.
The program, which was purchased from Western Sydney University, is also being modified to focus more on Aboriginal health.
“In the first two years, we’ll be teaching a lot First Nations culture and health,” says Lee.
This will include things like Welcome to Country and Acknowledgements of Country, and how these will differ in different parts of the Territory.
“Then we’ll talk about communications – using an Aboriginal interpreter, how to communicate with Aboriginal people, things that might help them to start off that rapport,” says Lee.
“We’ll teach them about well-known Aboriginal names in the Territory … so if they get a patient in that’s a Yunupingu, they can say, ‘Oh, you’re from Nhulunbuy way’. And they might not live there, but they’ll have connections there.”
ACCHSs are going to be involved in the program, to tell the students about their areas and the health concerns in their communities, as will other Aboriginal health organisations like IPEPA.
“In the third, fourth and fifth years, when they’re doing a placement out in one of the remote or regional Aboriginal health organisations, they’ll have that understanding,” says Lee.
Lee’s team is also preparing to support First Nations students, financially and socially, as they undertake the program.
“We’ll have tutors, we’ll have mentors, we’ll be looking into scholarships,” he says.
The program is being split from year-long courses into semester-long, to make it easier for students to repeat or catch-up classes if they need to take long absences. This is particularly useful for First Nations students who may need to leave for sorry business or other family requirements.
“If they’re unable to complete one of the units one of the semesters, then we’ve got rules on how they can come back and redo it,” says Lee.
“That’s one of the advantages of starting a new medical program: we can set things up for everything that we can think of. Whereas a lot of the older medical programs, they’re set and they’re rigid in their way, and it’s a lot of work to change it.”
The team also plans to keep supporting Aboriginal students once they graduate and begin work as doctors.
“We’re looking forward to getting the students in,” says Lee.
Note, 10 September 2024: An earlier version of this article contained an error in the numbers for CDU’s medical program quotas. We have updated the article with the correct quotas.
