The institute for urban indigenous health: The role of psychiatry in reducing health inequality

The disparities in health status between Indigenous and non-Indigenous Australians have been well documented, with mental and substance use disorders being the leading cause of health loss among Indigenous Australians (see www.indigenoushpf.gov.au). Indigenous people also have lower than expected access to mental health services and professionals. In 2012–2013 across Australia, the most common Closing the Gap service deficits reported by Aboriginal community controlled health organisations related to mental health and social and emotional well-being services. Although mental disorders and access to services are significant challenges in across all geographic areas, unlike other contributors to the health gap, mental disorders are disproportionally over-represented in non-rural areas compared with rural areas (Queensland Health, 2017). As the majority (79%) of Indigenous people live in urban areas, most of the health gap occurs among those living in non-rural areas despite the proximity to mainstream healthcare services (Turner et al., 2019). As the rate of urban Indigenous population growth outpaces rural areas, challenges associated with delivery of culturally capable care and achieving equity of access will also increase in urban areas. Furthermore, mental disorders are debilitating in themselves but also have significant impact on physical health, social and economic outcomes for Indigenous people. Combined, mental disorders experienced by Indigenous people in urban areas represent one of the most important drivers of health inequality and inequity in Australia. If we do not focus on improving mental health outcomes, we will not be successful in achieving health equality.

Regional health ecosystem

The Institute for Urban Indigenous Health (IUIH) is the largest Indigenous community–controlled health service in Australia (Turner et al., 2019). It was established in 2009 to provide a coordinated and integrated approach to the planning, development and delivery of comprehensive primary healthcare services to the Indigenous population within the South East Queensland (SEQ) region. Using a novel systematised model of care approach – a regional health ‘ecosystem’ called the IUIH system of care – IUIH has grown from five primary care clinics caring for 8000 patients in 2009 to a network of 19 primary care clinics caring for 33,300 patients in 2019 (Turner et al., 2019). In brief, the IUIH system of care promotes integrated health solutions and operations among the IUIH Network, as well as influencing mainstream policy and strengthening linkages with mainstream services. As an example, the Birthing in Our Community (BiOC) service illustrates the effectiveness of this care provision model (Kildea et al., 2021). To address the maternal and infant health outcome gap, IUIH partnered with the local tertiary hospital to design and implement the BiOC service. Underpinned by Birthing on Country principles, the BiOC service allowed the participants to access (1) midwifery services 24 hours a day and 7 days a week; (2) frontline staff who are working within IUIH’s cultural safety framework, including with regular clinical and cultural supervision, orientation and cultural training and (3) holistic wrap-around services delivered from a community-based hub that provides transport, psychosocial support and child therapy services (including perinatal mental healthcare) integrated into the BiOC Model of Care. The longitudinal evaluation of the service showed that compared with Indigenous women who received standard care, women in the BiOC service were more likely to have had greater than five antenatal visits and to be exclusively breastfeeding at discharge from hospital, as well as having a significantly reduced risk of preterm birth (Kildea et al., 2021). In sum, the BiOC model, underpinned by an Indigenous practice framework and a partnership with a tertiary hospital, was able to close the gap against several perinatal health measures.

IUIH senior psychiatrist role

The IUIH model of care aims to embed frontline clinical care into the broader regional ‘ecosystem’ which promotes integration at, and between, every level of the IUIH Network operations and connects this with a range of public health services. A key development in systematising IUIH’s mental health service offerings and connecting them with public mental health services has been the establishment of an IUIH Senior Psychiatrist position in 2021. The main aims of the role are to (1) expand access to high-quality specialist mental health assessment and care (i.e. a one-stop shop model where patients can access a specialist service within a primary healthcare setting, as has been successfully implemented for other specialities such as otolaryngology), (2) strengthen systems for safety and quality of services, (3) support continuous quality improvement of mental health and related services within IUIH, (4) contribute to policy and advocacy in the area of mental health and related services and (5) build opportunities for training and professional development pathways for psychiatry trainees through such initiatives as Psychiatry Workforce and Specialist Training Programs, as well as supporting the broader social health workforce and primary care providers. Of particular significance, the IUIH senior psychiatrist position brings psychiatry to Indigenous health – to the system of care with proven effectiveness for Indigenous people. One of the most striking findings from the My Life My Lead consultation report was that although at times necessary and even lifesaving, psychiatric inpatient care and specialist services are often seen as the least culturally safe settings for many Indigenous people (Commonwealth of Australia, 2017). It is hoped that by strengthening the relationship between IUIH and mainstream mental health services, such unintentional iatrogenic events can be minimised.

The collaboration is not limited to clinical care. IUIH is currently engaged in a partnership with the Queensland Centre for Mental Health Research on two research projects to better quantify the magnitude of health inequality. First, the Queensland Urban Indigenous Mental Health Survey is currently underway to determine the prevalence of mental disorders among Indigenous people living in SEQ (https://qcmhr.org/research/research-streams/policy-and-epidemiology-research-stream/epidemiology-and-burden-of-disease/queensland-urban-indigenous-mental-health-survey/staying-deadly/). This will be complemented by the second project, the Indigenous –SEQ National Mental Health Service Planning Framework Project, which will estimate population-based needs for the same cohort.

Advocacy and collaboration

Whiteford (2014) argued that advocacy in the mental health sector should not require a crisis to occur before action is taken. Rather, advocacy can be effective when those making the case identify a coalescence of three things: (1) a significant problem, (2) a potential solution to that problem and (3) an environment where action is politically expedient. In Indigenous mental health, we have a significant problem. Fifteen years after the launch of the Closing the Gap campaign, the mental health gap remains unaddressed. However, there is a reason to be optimistic. IUIH has shown that solutions to what appeared to be intractable problems can be developed. The success of the BiOC services intervention in perinatal care has demonstrated that there is a solution in the area of Indigenous health (Kildea et al., 2021). For mental health, an Indigenous-governed strategy with a strong partnership with mainstream mental health services, underpinned by Indigenous principles (e.g. the Gayaa Dhuwi [Proud Spirit] Declaration) and an Indigenous-led practice framework, is most likely to lead to the improvement of key mental health outcomes. In implementing such an intervention, strong advocacy, commitment, contribution and collaboration from psychiatry, from within IUIH, mainstream mental health services and at the national and state policy levels, are of upmost importance.