AUSTRALIA IS REGULATING AGAINST RACISM IN HEALTHCARE

Jayde Fuller, National Director, Australian Health Practitioner Regulation Agency (Ahpra)

Globally, there’s been an escalation of white supremacy culture which seeks to silence dialogue and discredit thought leadership around racism, diversity, equity and inclusion.

This serves to maintain the status quo by upholding power within non-Indigenous structures, systems and stakeholders. White supremacy culture poses a threat to our regulatory remit of protecting the public, by selecting which communities are worthy of protection and safety and ignoring or failing to take action to protect or redress harm to those who aren’t.

I work at the Australian Health Practitioner Regulation Agency (Ahpra) in partnership with the National Boards and accreditation authorities, and we’ve gone against the tide of white supremacy culture by remaining committed to eliminating racism from healthcare for Aboriginal and Torres Strait Islander Peoples.

The Australian context

Australia has a total population of 25.69 million people, with the total Indigenous population accounting for 3.8%, just under 1 million people, drawn from 500 separate nations with different languages and histories.

There are two distinctly separate First Nations groups in Australia, Aboriginal people who inhabit the mainland and Torres Strait Islander people who are custodians of the chain of islands in the Torres Strait region which is positioned between the state of Queensland and Papua New Guinea.

We have occupied Australia for 65,000 years, and have one of the longest, continuing cultures in the world. The country was colonised by the English 254 years ago.

Colonisation in Australia was justified by the false legal status of ‘terra nullius’ meaning ‘nobody’s land’ in Latin justifying claims that territory may be acquired by a state's occupation. The history of colonisation included seizure of land, massacres, removal of children from their families, displacement from tribal lands onto reservations, unpaid labour known today as Stolen Wages of which many hospitals and health infrastructure was built from, assimilation, and more recently reconciliation.

Aboriginal men and women live on average 10 years less than the non-Indigenous population, have higher suicide rates and are impacted by a higher burden of disease in relation to mental health, cardiac-related and chronic disease. The population is largely a younger one with a significant proportion being under 29 years old.

On October 14th 2023, we had a referendum in Australia seeking to establish an Indigenous voice to Parliament to be enshrined into our constitution, a mechanism that would allow Indigenous Peoples to advise the government on matters that affect us.

60% of Australians voted against this and the state I reside in of Queensland, had the highest ‘no’ vote of all the states and territories in the country.

Resulting in a resounding message to Aboriginal and Torres Strait Islander Peoples that we are not viewed by the majority of Australians as valuable citizens who should be able to have a say over decisions that impact our lives. Racism is inherently about power within society—wielded collectively by those who have it - against those who don’t.

Faced with these results, how could one not accept that Australia is indeed a racist country?

In 2020, we released the National Scheme’s Aboriginal and Torres Strait Islander Health and Cultural Safety Strategy 2020-2025 – which set the strategic and operational priorities to move us towards the elimination of racism.

"Although progressing cultural safety and anti-racism work is a challenging space to be in, you need to understand that this work is life-long and must be self-determined by us as Indigenous Peoples. " – Jayde Fuller

The most impactful actions in this strategy can be broadly categorised under the following verbs - define, legislate, educate, participate and govern.

Define: language matters

In 2019, we standardized the definition of ‘cultural safety’ through a six-week community consultation which was decided upon by the Aboriginal and Torres Strait Islander Health Strategy Group and peak Indigenous body the National Health Leadership Forum.

Having a common, cross-profession (we regulate 16 health professions), definition aligned with our core purpose as a regulator of patient safety and asserts that cultural safety is self-determined by Aboriginal and Torres Strait Islander Peoples, families and communities.

Working in partnership with our National Boards and accreditation authorities, it allowed us to change practitioner’s codes of conduct and accreditation standards at scale and pace, driving accountability around cultural safety to measure performance using a number of regulatory mechanisms.

Legislate: landmark decision

Leveraging off the definition, in October 2022, we passed the expectation of it into law in relation to service provision, access and workforce capability. This time explicitly mentioning through the guiding principle that the workforce needs to ‘contribute to the elimination of racism.’ It was the first time the word ‘racism’ has been featured in healthcare legislation in Australia. We’re now able to hold practitioner’s accountable at tribunal for the most serious misconduct relating to racism against Indigenous health consumers and practitioners. This includes practitioners experiencing racism from other practitioners.

Medical Board of Australia vs CDA –landmark decision

Last year, we had a landmark tribunal decision on anti-Indigenous racism made in the medical profession - resulting in a non-Indigenous doctor’s behaviour being constituted as professional misconduct. He was prohibited from providing any health service and cannot apply for registration for 12 months.

A racially offensive email was sent to Prof Rallah-Baker, former Australian Indigenous Doctors Association and highly respected, Yuggera, Warangoo and Wiradjuri ophthalmologist. The Tribunal found that he was treated less favourably than other persons because of his racial background and had the potential to bring the medical profession into disrepute.

The Chair of the National Medical Board, Dr Anne Tonkin said, ‘this ruling is a clear message that racist and culturally unsafe practice and behaviour is unlawful and carries substantive penalties, including disqualification from registration.’

Educate: how to practice cultural safety

Between 2021 and 2023, an Indigenous owned consultancy PricewaterhouseCoopers Indigenous Consulting delivered Moongmoong-gak cultural safety training to almost 1,800 Board, committee and staff members. This education program was the first of its kind globally for health regulators and aimed to really plant the seeds of what culturally safe practice means for regulatory administrators – the start of a lifelong commitment.

It sets an important precedent that we’re willing and able of practicing what we preach in requiring ongoing learning in culturally safe practice for Aboriginal and Torres Strait Islander Peoples. In the near future, it’s very likely we will expect all practitioners to commit to learning on cultural safety throughout their learning and practice years.

Importantly, it also begins the unlearning process, challenging the lies and preconceptions of who we are as Indigenous Peoples – the ideologies developed and reinforced through the colonial project. This directly impacts how we’re treated.

Participate: representation matters

Having an Indigenous employment strategy has been critical for us and has increased the level of participation of Aboriginal and Torres Strait Islander Peoples in Ahpra. However, more work needs to done with the agency still needing to improve its understanding of what attracts us to work in regulation, the nuance of Indigenous recruitment, how to retain us and address unsafe con- duct or racism in the workplace.

In 2021, we established the Aboriginal and Torres Strait Islander Health Strategy Unit (HSU) and it’s 100% Indigenous led and staffed.

We also established an Aboriginal & Torres Strait Islander Support and Engagement Team (Indigenous registrations) who assist Indigenous practitioners with registration and broader workforce issues. They’re a front door to Ahpra, often the first contact. They help to redirect practitioners to the right place in the agency in a responsive way.

Importantly, we've increased our representation on Boards and committees.

Govern: selfdetermination in action

Culturally safe regulatory decisionmaking

Changes to governance structures that places us at the centre, in a self-determining way is most evident in the larger reform project deliverables of the Culturally Safe Notifications Project and the Culturally Safe Accreditation and Continuing Professional Development Project. Both projects are informed by working groups comprised of Aboriginal and Torres Strait Islander health practitioners, leaders and community members.

We’ve successfully established a medical and nursing and midwifery regulatory decision-making committees comprised of Aboriginal and Torres Strait Islander Peoples who decide on whether to take regulatory action on all matters that involve an Indigenous person.

Another key project milestone has been the recruitment of the Aboriginal and Torres Strait Islander Peoples to support Indigenous complainants through the process and to provide cultural advice to investigators.

We know that collecting data is important for quality improvement and measuring cultural safety effectiveness – we engaged Yardhura Walani an Indigenous led and governed research centre at the Australian National University to undertake focus groups with Aboriginal and Torres Strait Islander Peoples who've gone through our complaints process.

Cultural Safety Accreditation and Continuing Professional Development Project

In regulation, ideally we’d like to prevent harm from occurring. In taking a preventative lens, we've committed to develop a sector-wide national cultural safety and accreditation framework and strategy for all the practitioners we regulate.

We hired Weenthunga Health Network to deliver the project milestones, a Victorian based Aboriginal and Torres Strait Islander owned and run organisation, that supports the upholding of health sovereignty and progressing health justice.

It's a big paradigm shift for non-Indigenous allies to give up power in regulatory spaces, and accept that just because it's their way of doing business, it's not the only way of doing business, and to trust we are fully capable of achieving meaningful change if we're supported to lead.

Although progressing cultural safety and anti-racism work is a challenging space to be in, you need to understand that this work is life-long and must be self-determined by us as Indigenous Peoples. We’ve had enough of being told by non-Indigenous Peoples how we can be ‘fixed.’ I urge you to appreciate that trust and relationship building with Indigenous Peoples will take time and you’ll inevitably get it wrong, but if you respond with humility and you take the time to critically self-reflect on your discomfort, this will set you up for success as you embark on your anti-racism regulatory journey.

Click here to find out more about the National Scheme’s Aboriginal and Torres Strait Islander Health and Cultural Safety Strategy.

This article is a contribution from Jayde Fuller, National Director, Aboriginal and Torres Strait Islander Health Strategy Unit Strategy, Policy and Health Workforce from the Australian Health Practitioner Regulation Agency (Ahpra)