PN1

DEPUTY PRESIDENT GOSTENCNIK: Good morning. Ms Steele, you're seeking permission to appear for the National Aboriginal and Torres Strait Islander Health Worker Association?

PN2

MS J STEELE: Yes, I seek leave, Deputy President, and for my junior Mr Nathan Avery‑Williams.

PN3

DEPUTY PRESIDENT GOSTENCNIK: Yes. Thank you, Ms Steele. Mr Svendsen, you're appearing for the Health Services Union?

PN4

MS L SVENDSEN: Yes. Thank you, Deputy President.

PN5

DEPUTY PRESIDENT GOSTENCNIK: I have received notice from the Australian Federation of Employers and Industries indicating that they were unlikely to attend the hearing, although they have filed some submissions. I have also received notice from the New South Wales Business Chamber and Australian Business Industrial that it does not intend to further participate in the proceedings. Mr Svendsen, is there any objection to permission being granted to the association?

PN6

MS SVENDSEN: No, Deputy President.

PN7

DEPUTY PRESIDENT GOSTENCNIK: Ms Steele, presumably you'll tell us, having regard to the complexity of the matter, that the matter will be dealt with more efficiently if we were to grant permission?

PN8

MS STEELE: Yes, Deputy President.

PN9

DEPUTY PRESIDENT GOSTENCNIK: Yes. All right. Permission is granted, Ms Steele. Yes, Ms Steele.

PN10

MS STEELE: NATSIHWA is the peak body for Aboriginal and Torres Strait Islander health workers and practitioners who constitute a unique - - -

PN11

DEPUTY PRESIDENT GOSTENCNIK: Just excuse me for a moment, Ms Steele.

PN12

MS STEELE: Yes.

PN13

DEPUTY PRESIDENT GOSTENCNIK: I just was having trouble seeing you over the top of my associate's hair.

PN14

MS STEELE: Thank you, Deputy President. The Aboriginal and Torres Strait Islander health workers constitute a unique and critical health profession because of the work that they perform in Aboriginal and Torres Strait Islander communities. The work that they perform plays a central role in the Federal Government's national imperative to close the health gap for Aboriginal and Torres Strait Islander Australians.

PN15

The health practitioners and health workers have never had an opportunity or a voice to make any submissions or representations as to the award provisions that affect them, because at the time that the Aboriginal Community Controlled Health Services Award was made NATSIHWA did not exist. The substantive changes sought by NATSIHWA are designed to ensure that the award ensures a minimum safety net of terms and conditions, as well as reflects the important work that the Aboriginal and Torres Strait Islander health workers and practitioners perform often in remote and difficult conditions.

PN16

In summary, to give an overview of the changes that NATSIHWA seeks, they seek firstly to expand coverage to cover Aboriginal and Torres Strait Islander health workers and health practitioners in private practice, because the practitioners and health workers in private practice are currently not covered by any modern award. Secondly, they seek to insert progression, recognition of prior service and evidence of qualification clauses.

PN17

DEPUTY PRESIDENT GOSTENCNIK: Just on that first point, your client's contention is that the Health Professionals and Support Services Award is not an award that's capable of covering - on its present terms - the health worker classifications that you seek inserted?

PN18

MS STEELE: Yes, it is, Deputy President. That's because of the very unique nature of the work that is performed by the Aboriginal and Torres Strait Islander health practitioners and I'll make some detailed submissions on that going forward.

PN19

DEPUTY PRESIDENT GOSTENCNIK: Yes.

PN20

MS STEELE: Thirdly, broadly speaking, NATSIHWA seeks to insert a new classification structure to reflect the work that's actually performed by the Aboriginal and Torres Strait Islander health workers and health practitioners, and also to provide a career path in order to incentivise the profession. Fourthly, NATSIHWA seeks to advance a limited work value case in respect of two classifications only. Fifthly, NATSIHWA seeks to insert some allowances and, finally, NATSIHWA wishes to clarify the existing award provisions that relate to ceremonial leave.

PN21

Now, in terms of the evidence NATSIHWA relies on the lay evidence of 32 witnesses who are principally Aboriginal and Torres Strait Islander health workers and health practitioners, and two experts. NATSIHWA has prepared a court book which has been handed up by your associate and, Deputy Presidents, Commissioner, you should find the five‑volume white court book - - -

PN22

DEPUTY PRESIDENT GOSTENCNIK: Yes.

PN23

MS STEELE: In addition to that, NATSIHWA also relies upon a further witness statement of Mr Briscoe, dated 24 July 2019. If I may hand that up. The original one is the first one. They are two copies.

PN24

DEPUTY PRESIDENT GOSTENCNIK: I take it, given the absence of any employer representation here today and given at least the position of the HSU, that witnesses are not required for cross‑examination?

PN25

MS STEELE: Yes. We wrote to both of those organisations and they said that witnesses were not required for cross‑examination.

PN26

DEPUTY PRESIDENT GOSTENCNIK: Yes.

PN27

MS STEELE: For the Commission's benefit I do have in court NATSIHWA principal lay witness Mr Briscoe and also the two experts, Associate Professor Lovett and Ms Wright, in case the Commission has any questions.

PN28

DEPUTY PRESIDENT GOSTENCNIK: Yes.

PN29

MS STEELE: NATSIHWA also thought it might be helpful for the Commission if NATSIHWA's two experts were at any appropriate time in NATSIHWA's submissions to give an opening and to speak to their report, and to explain some of the particular circumstances affecting this particular profession, if that was convenient to the Commission.

PN30

DEPUTY PRESIDENT GOSTENCNIK: Yes, well, we're certainly content to hear from them.

PN31

MS STEELE: Yes.

PN32

DEPUTY PRESIDENT GOSTENCNIK: We will leave it to you to determine the appropriate time in the course of your submissions to call that evidence. In the meantime, I'm just wondering whether you want the individual lay witness statements marked individually as exhibits or are you content for us to simply mark the court book as one document?

PN33

MS STEELE: It may be more convenient to mark the court book as one document for ease.

PN34

DEPUTY PRESIDENT GOSTENCNIK: I think so.

PN35

MS STEELE: Having said that, Deputy President, if I could ask the Commission to look at the index.

PN36

DEPUTY PRESIDENT GOSTENCNIK: Yes.

PN37

MS STEELE: That is at the first page of any of the volumes, but I'm looking at volume 1.

PN38

DEPUTY PRESIDENT GOSTENCNIK: Yes.

PN39

MS STEELE: You will see that behind tab 1 is the current award. It's just there for ease of reference. Tab 2 is the submissions, tabs 3 and 4 are the determinations.

PN40

DEPUTY PRESIDENT GOSTENCNIK: Yes.

PN41

MS STEELE: The evidence starts from tab 5.

PN42

DEPUTY PRESIDENT GOSTENCNIK: Tab 5, yes.

PN43

MS STEELE: There were two witnesses; Ms Evelyn Wilson, of which you will see there is an unexecuted statement at tab 39, and at tab 40 there is an unexecuted statement of Robert Dann. We were unable to get executed statements due to the illness of those health workers and them having been in hospital.

PN44

DEPUTY PRESIDENT GOSTENCNIK: Yes.

PN45

MS STEELE: We do not rely upon those statements, so I would not seek to tender the unexecuted statements behind tab 39 and behind tab 40.

PN46

DEPUTY PRESIDENT GOSTENCNIK: Yes, all right. In that case what we might do is mark the witness statements commencing at tab 5 of the court book through to tab 38, not including tabs 39 and 40, but including 41, as exhibit 1.

EXHIBIT #1 WITNESS STATEMENTS IN COURT BOOK - TABS 5 TO 38 AND TAB 41

PN47

DEPUTY PRESIDENT GOSTENCNIK: The statement that was handed up this morning of Mr Karl John Briscoe, comprising seven paragraphs together with annexures, can be marked as exhibit 2.

EXHIBIT #2 WITNESS STATEMENT OF KARL JOHN BRISCOE PLUS ANNEXURES

PN48

MS STEELE: There is one further exhibit, Deputy President.

PN49

DEPUTY PRESIDENT GOSTENCNIK: Yes.

PN50

MS STEELE: You'll see behind you there is a series of black folders, in the top row.

PN51

DEPUTY PRESIDENT GOSTENCNIK: Yes.

PN52

MS STEELE: They are the exhibit to Mr Briscoe's statement.

PN53

DEPUTY PRESIDENT GOSTENCNIK: Yes.

PN54

MS STEELE: Mr Briscoe, as I explained, is the principal witness for NATSIHWA. His statement is at number 7 or commencing at page 588 of exhibit 1. Those five volumes comprise the exhibit to that statement.

PN55

DEPUTY PRESIDENT GOSTENCNIK: Yes, all right. We'll note for the purpose of Mr Briscoe's statement, appearing behind tab 7, that they contain five volumes of annexures.

PN56

MS STEELE: To be clear, Deputy President, the five volumes of annexures to Mr Briscoe's statement will be part of exhibit 1.

PN57

DEPUTY PRESIDENT GOSTENCNIK: Yes. Exhibit 1, yes.

PN58

MS STEELE: That is the evidence for NATSIHWA. As I was explaining, NATSIHWA relies upon the two experts. The first expert is research fellow Alyson Wright and in exhibit 1 at page - court book 197 - - -

PN59

DEPUTY PRESIDENT GOSTENCNIK: Yes.

PN60

MS STEELE: Sorry, 195. You will see Ms Wright's report and you will see in paragraph 1 that she has over 17 years' experience working in research with Indigenous Australians, including through her research roles with the two large Aboriginals organisations in Central Australia and that she currently works as a research associate at the Australian National University on longitudinal studies of Aboriginal and Torres Strait Islander wellbeing.

PN61

The other expert is Associate Professor Lovett and his CV is at page 580 of exhibit 1. He is the current chair of the Medicare Benefit Schedule Review of the Aboriginal and Torres Strait Islander Reference Group. He lectures at ANU for the Masters of Public Health on screening and provision of Aboriginal and Torres Strait health.

PN62

The other key witness for NATSIHWA is Mr Karl Briscoe and his evidence is in volume 2 of exhibit 1 at page 588. Mr Briscoe belongs to the Kuku Yalanji people. He is from the Mossman and the Daintree area of Far North Queensland. He has extensive qualifications in Aboriginal health. He was an Aboriginal health worker himself and he commenced as a trainee Aboriginal health worker in 2008 before moving into significant positions of health policy, including being the principal policy officer in rural and remote health.

PN63

As you pointed out, Deputy President, the substantive changes by NATSIHWA were supported by all the interested parties in the consultation process, apart from AFEI and ABI. AFEI have filed some submissions in the proceedings, but they're not appearing. NATSIHWA has filed some very detailed written submissions and we rely upon those. NATSIHWA has also prepared and aide‑memoire - if I could hand this up - to try to simplify the changes to work through them.

PN64

DEPUTY PRESIDENT GOSTENCNIK: Yes. Thank you.

PN65

MS STEELE: What I propose to do, if it's convenient to the Commission, is to start with each change that is sought by NATSIHWA, then to go to the relevant evidence concerning that change.

PN66

DEPUTY PRESIDENT GOSTENCNIK: Yes.

PN67

MS STEELE: Then to go through NATSIHWA's submissions and the legal argument as to why it meets the modern award's objective.

PN68

DEPUTY PRESIDENT GOSTENCNIK: Yes.

PN69

MS STEELE: Before I do that, if it's convenient I might just give the Commission some background information on NATSIHWA. If I could ask you, please, to look at Mr Briscoe's exhibit, so volume 2 of the exhibit to Mr Briscoe.

PN70

DEPUTY PRESIDENT GOSTENCNIK: Yes.

PN71

MS STEELE: I'm sorry, I will get the exhibits correct. What I would ask you actually to look at is Mr Briscoe's statement, which is in the second volume of the white volume as opposed to the black volume of the exhibit.

PN72

DEPUTY PRESIDENT GOSTENCNIK: Yes, all right.

PN73

MS STEELE: Starting at paragraph 8 at the top of page 590, you'll see that:

PN74

NATSIHWA is a national organisation that was incorporated pursuant to the Corporations Act on 7 August 2009.

PN75

It was established following the Australian Government's announcement of increased funding as part of "Closing the Gap". At paragraph 10, that its role is focusing on achieving health outcomes and that its objects pursuant to its constitution - which are taken from the exhibit to Mr Briscoe's statement in tab 1 - are to:

PN76

Promote the prevention and control of disease in Aboriginal and/or Torres Strait Islander communities; improve health outcomes for Aboriginal and Torres Strait Islander people in pursuit of the objectives to "Close the Gap" in life expectancy; address the impacts of disadvantage on the health of Aboriginal and Torres Strait Islander people; assist Aboriginal and/or Torres Strait Islander health workers health practitioners in delivering holistic primary health care within Aboriginal and Torres Strait Islander communities in order to improve health outcomes for Aboriginal and Torres Strait Islander people; do all such lawful things as may be incidental or conducive to the attainment of the above objectives.

PN77

You will see in paragraph 12 what NATSIHWA does; it provides programs and resources to support health workers and health practitioners. At paragraph 13, NATSIHWA is an organisation that supports the health workers and health practitioners -

PN78

regardless of whether they are employed in an Aboriginal Community Controlled Health Organisation -

PN79

which is sometimes called an Aboriginal Medical Service -

PN80

a mainstream health service or private practice.

PN81

Now, that is an important concept because there are approximately 141 Aboriginal Community Controlled Health Organisations and they're the organisation that is the subject of the current award. That is where most of the Aboriginal and Torres Strait Islander health workers and health practitioners are employed, in these community controlled health organisations, but there are also health workers and health practitioners who are employed in private practice.

PN82

At the time of the formation of the current modern award, NACCHO - who is the National Association of Community Controlled Health Organisations and who represents these Aboriginal community controlled organisations - was the principal proponent of that award. As I mentioned, at that time NATSIHWA was not formed or was in its infancy and there wasn't any opportunity at the time of the formation of the current modern award for Aboriginal and Torres Strait Islander health workers or health practitioners to have any input into any aspect of the award.

PN83

Significantly - and I will come back to this - at tabs 86 and 87 of Mr Briscoe's exhibit, which is in volume 4, you will see that the two principal employers who employ Aboriginal and Torres Strait Islander health workers are obviously the National Association of Community Controlled Health Organisations, or NACCHO for short, but also the Australian Indigenous Doctors' Association, AIDA.

PN84

At tabs 86 and 87 the Commission can see that there are letters there from both of those principal employers of the health workers - from both the Australian Indigenous Doctors' Association and also from the National Aboriginal Community Controlled Health Organisation - supporting the changes that are sought by NATSIHWA to this award.

PN85

The Australian Indigenous Doctors' Association, they say at tab 86 that they're the national body representing Aboriginal and Torres Strait Islander doctors and medical students, and at they're committed to supporting improvements to experiences of health care for Indigenous peoples in Australia; that they work to ensure that the health system is culturally safe, high quality, reflective of need and respective and inclusive of Aboriginal and Torres Strait Islander values.

PN86

This concept of "culturally safe health care" is a concept that I will be returning to as a theme and as a reality as to why this health profession is outside of the mainstream of the health profession and is not covered by any other award, and is one of the reasons why it is unique and one of the key and important reasons why the Commonwealth recognises this particular health profession as really making a difference in closing the gap. I will come to all the evidence about the cultural sensitivities and why that aspect of providing a culturally safe health care really differentiates this profession from any other health profession.

PN87

You'll see that paragraph 2 that the Australian Indigenous Doctors' Association is supportive of NATSIHWA's intention to seek expansion of the existing award to include coverage to health practitioners and health workers. They acknowledge that including private practice employees would offer equitable rates and allowances.

PN88

They also note the inherent inconsistency and inequality of the current environment and that, if coverage is extended, that would be an opportunity to strengthen the health system by taking steps to include the Aboriginal and Torres Strait Islander health workers in private practice; that that will be able to ensure Indigenous engagement with the health system both as employees and as patients continues to improve, and they offer their support to expand the award.

PN89

Likewise, with the main employer of the Aboriginal and Torres Strait Islander health workers, NACCHO - you'll see behind tab 87 there is a letter there from the chief executive officer to the chief executive officer of NATSIHWA supporting NATSIHWA's submission to expand the modern award.

PN90

DEPUTY PRESIDENT GOSTENCNIK: Behind tab 87, did you say?

PN91

MS STEELE: Yes.

PN92

DEPUTY PRESIDENT GOSTENCNIK: Of volume 4?

PN93

MS STEELE: Yes, volume 4.

PN94

DEPUTY PRESIDENT GOSTENCNIK: I don't appear to have a document behind my - - -

PN95

MS STEELE: We can hand up a copy, Deputy President. I apologise for that. We have another copy here. I apologise for that, Deputy President.

PN96

DEPUTY PRESIDENT GOSTENCNIK: No, that's all right. Thank you very much.

PN97

MS STEELE: There have been so many documents. We've done our best to try and - - -

PN98

DEPUTY PRESIDENT GOSTENCNIK: I understand, that's all right. I'm not being critical.

PN99

MS STEELE: Yes. But it is a key document in the proceedings.

PN100

DEPUTY PRESIDENT GOSTENCNIK: I have it now.

PN101

MS STEELE: Yes. So you'll see there that they are the national body representing these art shows and again that they're committed to supporting improvements to the experience of health care for Aboriginal and Torres Strait Islander people in Australia, and again that they work to ensure that the health services are culturally safe and high quality, and this culturally safe as I said is very important. You'll see that they're supportive of their intention - of NATSIHWA's intention to seek expansion to improve coverage and they also offer their support to expand the award and wish to acknowledge the exceptional work undertaken today and leadership of NATSIHWA in this important matter.

PN102

DEPUTY PRESIDENT GOSTENCNIK: Ms Steele, does the Australian Indigenous Doctors Association represent practitioners who conduct private clinics who would employ the classification of worker you now seek?

PN103

MS STEELE: Yes, it does and that's why it's significant, Deputy President, that both of the principal employers for these workers support the changes and endorse the changes.

PN104

DEPUTY PRESIDENT GOSTENCNIK: Are there other health service - private sector health service providers who might engage such workers, who are not represented by the Australian Indigenous Doctors Association. For example, does the AMA represent any doctors who conduct or who operate clinics who might employ such persons?

PN105

MS STEELE: Theoretically that may be possible but as a matter of evidence of what we've been able to determine, we don't have any evidence that that is the case. The evidence that we have on private practice is that it's generally indigenous doctors who are conducting indigenous practice who employ indigenous workers as part of that health process.

PN106

DEPUTY PRESIDENT GOSTENCNIK: Yes.

PN107

MS STEELE: But as a matter of theoretical possibility, it's possible for anyone to employ a - I couldn't rule that out.

PN108

DEPUTY PRESIDENT GOSTENCNIK: Yes. In any event, it doesn't appear that the AMA have expressed any interest in being involved in those proceedings.

PN109

MS STEELE: No, they haven't, Deputy President.

PN110

DEPUTY PRESIDENT GOSTENCNIK: Yes.

PN111

MS STEELE: So going back to Mr Briscoe's statement which is at page 591 of exhibit 1, you'll see at paragraph 14 he sets out what NATSIHWA does, which is through our members' work, contributing significantly to closing the gap in health outcomes between indigenous and non-indigenous Australians, which is of direct and immediate benefit to Aboriginal communities across Australia and also a significant national priority for Australia.

PN112

Apologies, Commission.

PN113

DEPUTY PRESIDENT GOSTENCNIK: All right.

PN114

MS STEELE: And again it sets out the support that NATSIHWA provides to the Aboriginal and Torres Strait Islander health workers. Paragraphs 16 to 20 of Mr Briscoe's statement on page 592 deal with the members of NATSIHWA. There's three levels of members but significantly when we come to the section on private practice you'll know that paragraph 20, that the membership database does not automatically divide the members between where they work, such as whether they work in private practice or whether they work in an art show, or whether they work in the public sector. That's one of the reasons why it's so difficult to be more precise about how many members there are in the private practice or there are in art shows, but I'll take the Commission to that evidence going forward.

PN115

If I could ask on the subject of NATSIHWA the Commission finally to look at tab 2 in the first bundle of Mr Briscoe's - you'll see there at page 48 to Mr Briscoe's exhibit that there's confirmation that NATSIHWA's establishment in 2009, it's funded by the Department of Health and it was established in 2009 as part of the Closing the Gap initiative. Division of NATSIHWA is behind tab 3. I've already taken you to the evidence of that in Mr Briscoe's affidavit.

PN116

Flipping over at tab 4 you'll see there's further evidence of what NATSIHWA does and behind tab 5 there's the Aboriginal and Torres Strait Islander Health Work Association Annual Report for 2018 and at page 58 it confirms it's the peak professional body and at page 63 on organisation, you'll see that NATSIHWA has been funded by the Australian Government Department of Health since its establishment in 2009 in order to promote support and increase recognition for the vital roles that the Aboriginal and Torres Strait Islander health workers and health practitioners play.

PN117

That's the background to who NATSIHWA is. I'd now like to talk about the first substantive change sought by NATSIHWA which is to expand coverage and to consequently change the title of the award to reflect occupational coverage. So perhaps the best place to start is to look at the existing award, which is behind tab 1 of exhibit 1. The Commission can see page 4 there's the definitions and at clause 3.1 there's the definition of what an Aboriginal community controlled health service is, and they're incorporated Aboriginal organisations initiated and based on Aboriginal community. Then there's a definition of health worker which includes:

PN118

A person who is registered with a national state or territory registration body where registration is required in a state or territory where the person is employed.

PN119

I'll come back to this later when it's more relevant but it is important for the Commission to understand that at the time that this award was made there was no requirement for national registration of health practitioners, and that there was only one state, which was the Northern Territory, where Aboriginal health workers were required to be registered. You can see that in the last three lines of the note, Commission, that it's intended that a national registration system will be implemented and variations will be sought once that registration system is established.

PN120

So it was known that there was likely to be a national registration which occurred as part of the Closing the Gap initiative but it hadn't occurred at the time of this award. Then you will see that there's Aboriginal knowledge and cultural skills which are defined and that there's three levels of cultural skills. Clause 4 deals with coverage and the Commission can see at 4.1 that the current award is limited to employers throughout Australia in the Aboriginal Community Controlled Health Services Industry and their employees in the classification system in clause 14, which include relevantly Aboriginal and Torres Strait Islander health workers and health practitioners, but also other employees who are employed in the Community Controlled Health Services.

PN121

What is sought - the change that is sought by NATSIHWA is at page 130 of exhibit 1 and you'll see there the two clauses that are sought as part of the draft determination and 2(a) reflects the current award. The changes in (b) to employers throughout Australia with respect to their employees engaged as an Aboriginal and/or Torres Strait Islander health worker, and that's the change to - that NATSIHWA seeks to cover health workers and health practitioners in private practice. Then clause 3 of the draft determination is also relevant to coverage and sought to include that the award doesn't cover an employee excluded from the award coverage by the Act, employers covered by the following awards; the nurses awards and the medical practitioners award.

PN122

Now there are four key propositions that NATSIHWA advances in relation to coverage and expanded coverage, and so if it's convenient I'll briefly state those four propositions and then I'll work through the evidence and the submissions supporting those propositions.

PN123

The first one is that the Aboriginal and Torres Straight Islander health workers and health practitioners are not covered by any award because the profession is unique. The workers must firstly identify as either Aboriginal and/or Torres Strait Islander. They must secondly provide health care in a culturally safe manner and thirdly they must have specific qualifications that have been developed by Aboriginal and Torres Strait Islander people for the Aboriginal and Torres Strait Islander people. So they are unique from other health professionals because in order to be a health worker or health practitioner, apart from anything else, you need to have those three things, which are different from any other profession.

PN124

Secondly, the second proposition that I wish to develop - - -

PN125

DEPUTY PRESIDENT GOSTENCNIK: Does it follow that the person who is covered by, for example, the nurses award and I note the exclusion, but that a registered nurse may also have the qualifications necessary to be a relevant health worker?

PN126

MS STEELE: They might have those qualifications, Deputy President, but then some nurses have the qualifications to be a health worker but then they're employed as a nurse under the nurses award. Is that the question that you're asking?

PN127

DEPUTY PRESIDENT GOSTENCNIK: Well, that's what I'm trying to understand. When would the classification be engaged? Do you say it would only be engaged not because the person has a classification for carrying out another profession. It would only be engaged if a person has the qualifications for the classification and is engaged in that classification.

PN128

MS STEELE: That's correct.

PN129

DEPUTY PRESIDENT GOSTENCNIK: Yes.

PN130

MS STEELE: In order to do that they would have to identify as Aboriginal or Torres Strait Islander, provide health care in a culturally safe manner and have the relevant qualification and be engaged to be an Aboriginal and Torres Strait Islander health worker or health practitioner.

PN131

DEPUTY PRESIDENT GOSTENCNIK: Yes.

PN132

MS STEELE: The second proposition is that whilst NATSIHWA is unable to provide the precise numbers of health workers and health practitioners who work in private practice, there is evidence that clearly shows that there are Aboriginal and Torres Strait Islander health workers and health practitioners who are employed in private practice and that that number is growing and is likely to increase because of the changes, the upcoming changes to Medicare items which will allow for those health workers and health practitioners to be able to bill Medicare items in private practice.

PN133

The third proposition is that when the award was made in 2010 the Full Bench was not asked to make any award with respect to the Aboriginal/Torres Strait Islander health practitioners or health workers and in our submission that was for three reasons. Firstly, the evidence is that in 2010 it was highly unusual if at all that any health workers or health practitioners were employed in private practice. Secondly, as I've mentioned the major proponent of the art show of the award was NACCHO and they were obviously concerned with the main employment of the health workers in the community controlled health centres, and there was no representation by any of the Aboriginal/Torres Strait Islander health workers or health practitioners in 2009, with respect to the award. That's assuming that there were any health workers or health practitioners in private practice at the time of the creation of the award.

PN134

The final proposition that I'll seek to make good is that it is appropriate to extend coverage, to provide a minimum safety net of terms and conditions for these Aboriginal and Torres Strait Islander health workers and health practitioners, who aren't currently covered by any modern award. Apart from the section 134 factors which we've identified in our submissions, the commonwealth and state governments have acknowledged the criticality of the role that these health workers play in Closing the Gap and providing culturally safe health services for Aboriginal and Torres Strait Islander health people. So that it would be appropriate, in my submission, to expand coverage for that reason.

PN135

As to the first proposition that the health workers and the health practitioners are a unique profession, I'm going to firstly define and delineate the difference between a health worker and a health practitioner. Then I'm going to outline and explain to the best of my ability some of the intrinsic cultural knowledge that's unique to this profession and why it is that this cultural knowledge is unique and different to any other health services provided by any other professionals. Then I'm going to take the Commission through the specific qualifications that are required now in order to be an Aboriginal and Torres Strait Islander health worker, and then I'm going to go to the evidence about the Aboriginal and Torres Strait Islander health workers and health practitioners in private practice, because ultimately as you have anticipated, Deputy President, I will be asking the Commission to accept that these health workers and health practitioners are a unique profession and that the workers who are employed in private practice aren't covered by private or any modern award.

PN136

So dealing first with what is a health worker and what is an Aboriginal and Torres Strait Islander health practitioner, if I could ask you to please return to Mr Briscoe's affidavit at page 592 of exhibit 1 in volume 2.

PN137

DEPUTY PRESIDENT GOSTENCNIK: Yes.

PN138

MS STEELE: At paragraph 21, page 592 Mr Briscoe says that:

PN139

An Aboriginal and Torres Strait Islander health worker -

PN140

And that's what that abbreviation means throughout that evidence -

PN141

is a person who is of Aboriginal and Torres Strait Islander heritage and who holds any of the following qualifications.

PN142

These are the principal qualifications that are held by health workers and health practitioners. There's a Certificate II in Primary Health Care or if they're training to get a - to hold a Certificate II, if they're a trainee health worker. Then there's a Certificate III which is the next level qualification in care, and then a Certificate IV in care, or they might hold a diploma in care or an advanced diploma in care.

PN143

At 23 he gives evidence that:

PN144

Their role is to provide holistic health care, which is consistent with the Aboriginal and Torres Strait Islander broader notion of health, which extends beyond physical health.

PN145

At 24, that:

PN146

In order to perform that role they need to have the appropriate clinical skills and training, community connections and cultural knowledge to provide a bridge between mainstream health services and the Aboriginal and Torres Strait Islander people.

PN147

At 25, Mr Briscoe sets out the range of tasks that are performed by the health worker and that includes at (a) being the first point of contact for clients, gather medical data and information which might have been otherwise obscured by cultural factors.

PN148

Health workers often perform a yearly check for their clients and they check up on client's care and then formulate a care plan and that's one of the other unique things about this health work course is that they not only treat people who are sick, they aim to try and prevent disease from occurring in the first place, which is obviously significant in circumstances where the health outcomes for Aboriginal and Torres Strait Islander health people are significantly behind other members of the Australian community.

PN149

At (b) they treat disease or injuries. (c) They attend medical appointments with Aboriginal and Torres Strait Islander people. They act in those medical appointments as communicator and advocate, sometimes a translator between the mainstream health professional and the Aboriginal and Torres Strait Islander person. There are some Aboriginal and Torres Strait Islander people for whom English is their fourth or fifth language and who would not have access to health services without having a health worker or health practitioner to act in that role of communicator and advocate.

PN150

They provide clarification to Aboriginal and Torres Strait Islander clients and ensure they've understood the medical advice they've received. They take part in case management and following up on clients. They advocate with the mainstream health workers to over the historical distrust of the mainstream workforce, and they also provide educational to Aboriginal and Torres Strait Islander communities regarding the health conditions and the health services available to them. They provide input into planning, development, implementation and evaluation of programs in the community and they inform and help non-indigenous health care workers to provide health services in a culturally sensitive manner.

PN151

So you'll see that in looking at that list of jobs that are performed by health workers that there's a range of medical skills, administrative skills, educators, interpreters, advocates, all undertaken in a culturally sensitive manner to help to overcome the historical mistrust often felt by Aboriginal and Torres Strait Islander people about mainstream health services.

PN152

The distinction between the health workers and health practitioners, if I can summarise it before taking you to Mr Briscoe's evidence is that they do a specific qualification in practice, which is a Certificate IV but they are registered, and that is the significant change that has occurred in this profession since the last or since the formation of the modern award for the Aboriginal Community Controlled Health Services. That is, there is a national system and I will take the Commission to the evidence of what registration means in going through the work value case that's sought to be met, but there's been a change to increase the units for the Certificate IV. There's now 500 hours of clinical care that needs to care to be done to become a health practitioner, and there's code of conduct and - - -

PN153

DEPUTY PRESIDENT MASSON: Ms Steele are those changes you're referring to in relation to the additional hours, is that as a consequence of the now require legislation?

PN154

MS STEELE: Yes, it is, Deputy President. So there's been a significant change which I'll go through but that is the differences that they are - and in terms of their functionality, they perform a much more clinical role than in care, and we'll go through that but they have a much more - some of their duties are more akin to nurses, which is different to the health workers who don't have that clinical focus and they don't have that registration focus. That's the difference between the health workers and the health practitioners.

PN155

Mr Briscoe says at 30 when he sets out what a health practitioner is again it's Aboriginal and Torres Strait Islander heritage, then you've got the Certificate IV and then you have to comply with the reporting and registration requirements under the National Registration and Accreditation Scheme which is administered by the ATSI Health Practice Board of Australia, and this is another important point. Depending upon the location where these health practitioners practice they also have to comply with the relevant state legislation about the handling, possession and administration of medicine.

PN156

So in very remote areas and I will go through the legislation in more detail area but in very remote areas of Queensland and in Western Australia and in the Northern Territory, as a result of the national registration scheme health workers are actually able to dispense medication and immunisation - health practitioners, health practitioners.

PN157

At paragraph 32, Mr Briscoe says that these practitioners tend to work as independent practitioners alongside other medical professionals such as doctors, nurses and mainstream health professionals. That is another important point about practitioners is that they are able to work autonomously. Then at paragraph 33, Mr Briscoe sets out the different duties that might be performed by a health practitioner and you'll see that they have a much more clinical focus than the health worker because they include assessing, diagnosing and treating clients but also undertaking clinical care duties, such as taking blood, dressing wounds, suturing and taking client observations.

PN158

Also, supplying and administering medication subject to state legislation. Being the first point of contact, treating diseases or injuries and maintaining health records and then some of these are analogous obviously to the health worker attending medical appointments and acting as communicator, advocate and/or translator. Providing clarification to Aboriginal and Torres Strait Islander clients and ensuring that they have actually understood the medical advice that they've received. Taking part in case management. Following up on their clients, either independently or with other health care providers, advocating for clients with mainstream health workers to overcome the historical distrust of mainstream workforces.

PN159

Again, providing education to the community, which is a big part of Closing the Gap to educate the Aboriginal and Torres Strait Islander health workers about the particular medical conditions that impact upon them particularly. Then providing input into planning, development, implementation, monitoring and evaluation of all health programs in the community and informing non-indigenous health care workers to provide health services in a culturally sensitive manner.

PN160

These practitioners may be generalist or they may specialist in areas such as mental health, sexual health or drug and alcohol health. So Mr Briscoe then goes on to deal with the registration requirements which I'll come back to because it's relevant to the work value case. I'd like to just show the Commission some of the exhibits to Mr Briscoe's affidavit dealing with health workers.

PN161

In the first volume to Mr Briscoe's exhibit at tab 6.

PN162

DEPUTY PRESIDENT GOSTENCNIK: Yes.

PN163

MS STEELE: At page 105, you'll see that's NATSIHWA's information as to why Aboriginal and/or Torres Strait Island health workers and practitioners are needed, and they're needed to provide Aboriginal and Torres Strait Islander people - I'm reading, Commission, from the first paragraph under "Frequently asked questions".

PN164

To provide culturally safe preventative health care and treatment services to experience health equity. We are unique in that we have not only clinical skills but can respond to the social and cultural needs and contexts of the Aboriginal and Torres Strait Islander families and communities.

PN165

You'll see on the next page at page 106 under "We provide a range of health services", there's set out the different services that might be provided by Aboriginal and Torres Strait Islander health workers as part of their practice. At tab 7, this is the flowchart which deals with the Medicare health items that flow from the adult health check which is item 715 on the Medicare system which is available to Aboriginal and Torres Strait Islander people every nine months, and the development of this Medicare item for health check - for Aboriginal and Torres Strait Islander health people is probably one of the key reasons why there's been an increase in health workers in private practice. Because there's now a specific Medicare item that health practitioners are able to perform under the Medicare system.

PN166

Before I move onto the cultural factors, now might be a convenient time to show part of a video that is referred to by Mr Briscoe at paragraph 29, and this is a video about the work that is performed by Aboriginal and Torres Strait Islander health workers and health practitioners in the Aboriginal Community Controlled Health Services. The whole video is 30 minutes and I don't intend to play the whole video. I intend to play part of the video starting from minute 18 for approximately seven minutes, if that's convenient for the Commission.

PN167

DEPUTY PRESIDENT GOSTENCNIK: We'll try and muddle through that.

PN168

MS STEELE: It might make sense of some of the - - -

PN169

DEPUTY PRESIDENT GOSTENCNIK: No, it's our technology, it's not you.

DVD PLAYBACK [11.02 AM]

PN170

DEPUTY PRESIDENT GOSTENCNIK: Yes, thank you, Ms Steele.

PN171

MS STEELE: Sorry it was hard to hear but hopefully you were able to hear parts of it.

PN172

DEPUTY PRESIDENT GOSTENCNIK: That's all right, I did, yes.

PN173

MS STEELE: So I thought I'd now just move on to explain some of the cultural factors that are necessary to be an Aboriginal health worker or health practitioner, and going back to Mr Briscoe's affidavit, which is in volume 2 of exhibit 1, behind tab 7 at paragraph 52. Mr Briscoe outlines some of the broader notions of health which for Aboriginal and Torres Strait Islander people is much broader than physical health in that it encompasses the physical, spirit, emotional and cultural wellbeing of the individual and therefore health care for Aboriginal and Torres Strait Islander people requires care for more than just their physical health.

PN174

In around 2019, HealthInfoNet, and I'm reading from paragraph 53, published a report titled "Summary of Aboriginal and Torres Strait Islander health status 2019", and in that report it identifies some of the cultural, historical, social and political factors that have influenced the health of Aboriginal and Torres Strait Islander people. Those factors, which are at tab 25, and at page 200 of Mr Briscoe's exhibit, volume 1, at the top of the page sets out:

PN175

The historical, social and political factors starting from colonisation -

PN176

This is in the second paragraph on the left-hand column -

PN177

colonisation of Australia occurred around 1788 and led to many negative impacts on the health and wellbeing of Aboriginal and Torres Strait Islander people. Some of those impacts are still present today, including racism, discrimination, forced removal of children, loss of identity, language, culture and land.

PN178

Then on the second paragraph in the right-hand column:

PN179

Factors known as the social and cultural determinants of health which are impacting the health and wellbeing of Aboriginal and Torres Strait Islander people include early life employment, education and connection to family and friends.

PN180

This report provides a snapshot of a summary of the Aboriginal and Torres Strait Islander health status in 2018. You'll see at page 202 that in 2018 there was estimated to be 778,064 Aboriginal and Torres Strait Islander people living in Australia and that the population makes up about 3 per cent of the total Australian population. You'll see page 203 that in 2006 more than a third of the Aboriginal and Torres Strait Islander people lived in a major city and a fifth lived in remote or in very remote areas. The age structure of this population is also different to the general population in that one third of - reading from page 203 - one third of the Aboriginal and Torres Strait Islander people are less than 15 years old. Then this report goes through to set out in stark terms some of the disparities between Aboriginal and Torres Strait Islander people and the broader community, such at page 204, 12 per cent of babies were of low birth rate. At page 205, the life expectancy gap and you'll see that there's a 8.6 year gap for males and seven to eight year gap for females.

PN181

Then on the next page, hospital admissions that Aboriginal and Torres Strait Islander people are admitted to hospital 2.6 times more than non-indigenous people. Hospitalised at higher rates across all age groups and at page 207, cardiovascular health is a real issue for Aboriginal and Torres Strait Islander communities and page 208, acute rheumatic fever and rheumatic heart disease which are preventable health problems, which are much higher for Aboriginal and Torres Strait Islander people.

PN182

Go back to Mr Briscoe's affidavit and the cultural beliefs. At page 599 of exhibit 1, Mr Briscoe sets out that certain Aboriginal and Torres Strait Islander cultural beliefs can alter the manner in which health care needs to be provided to Aboriginal and Torres Strait Islander people. A key example is their beliefs around death which can have significant ramifications about how health care is provided to Aboriginal and Torres Strait Islander people and how medical personnel should communicate with family members of an Aboriginal and Torres Strait Islander person who's dying.

PN183

The New South Wales Northern Sydney Local Health District has published a framework on death and dying in Aboriginal and Torres Strait Islander culture or Sorry Business, which illustrates a number of these issues and that is behind tab 26 of volume 2 to Mr Briscoe's statement, and this provides some of the guidance that's been given by the New South Wales government on dealing with cultural issues and death. You'll see at page 241 under the section at the top of the page, "Culture versus health care" that:

PN184

Aboriginal and Torres Strait Islander and non Aboriginal and Torres Strait Islander people have contrasting views. Non Aboriginal and Torres Strait Islander people usually interpret hospitals as a place of healing, rehabilitation and security for improved health. For Aboriginal and Torres Strait Islander people the hospital is a place where people go when they're suffering and more likely a place of death.

PN185

That as a health professional working with patients it is essential that all care is responsible to the unique needs. Then you'll see there's a whole section on effective communications and that there's a section on body language and verbal communication and then at 10.3:

PN186

Points that may assist on rapport building such as that Aboriginal and Torres Strait Islander people may be more likely to respond to indirect questions. Personal questions may make Aboriginal and Torres Strait Islander people suspicious. Singling Aboriginal and Torres Strait Islander people out for criticism or praise is not recommended as it could cause severe shame. The need to use simple terminology when explaining procedures although not to act in a patronising or paternalistic fashion. The fact that Aboriginal and Torres Strait Islander people speak more than one language and some experience difficult with English let alone medical terminology and that some Aboriginal and Torres Strait Islander prefer to talk about what's happening now rather than talking about what's happening in the future or the past.

PN187

On page 242 on the right-hand side of the page in the second paragraph:

PN188

The opportunity for an Aboriginal and Torres Strait Islander person facing death to return to country if possible should be considered as a high priority. It is important for the person to pass away on the land on which they were born, as the connection is profound and holds a strong spiritual significance.

PN189

Then they give a case study of Aboriginal elders. At page 244 there's some information provided about the Aboriginal and Torres Strait Islander health worker at 15.3 at the bottom of the left-hand column, and it says:

PN190

An Aboriginal health worker may be able to help translate the expectations that present as cultural barriers. They can also contact the patient's family for support, make clarifications on any medical history. Often towards the end of life some Aboriginal and Torres Strait Islander people would prefer to be at home. If that's medically possible the health worker would arrange that.

PN191

Again:

PN192

They play a key role in the relationship between the health care profession and the patient and often speaking with the health worker is the most productive method of source information and communicating with the patient.

PN193

On the right-hand column, the second paragraph:

PN194

If an Aboriginal and Torres Strait Islander patient is close to death it is important that they don't die alone. Family presence is culturally critical at this time.

PN195

At page 246 "when death is approaching", it sets out some of the culturally significant factors, which is that:

PN196

Large gatherings at the hospital may take place to support and show respect for the family member who's close to death. Some Aboriginal and Torres Strait Islander people believe that the gathering helps prepare the person for the next stage of life on their journey. This also benefits the people who will mourn the death of the patient by allowing quality time to prepare for the loss and grief that will follow when the patient passes. If an elder of a community has died or their health is deteriorating, many community members will gather and there will be ceremonies to reflect the respect and honour that the community held for the elder.

PN197

Then there's "cultural expectations for Aboriginal and Torres Strait Islander following death", which I'll take the Commission to in more detail when I come to the amendment on ceremonial leave. As you can see there are significant cultural differences in the way that Aboriginal and Torres Strait Islanders perceive health and perceive information that's given to them by - in the conventional hospital setting and the Aboriginal - by having that culturally safe framework and having health workers and health practitioners who are there and able to explain what's happening in terms of any language barriers or distrust about the medical profession. Some of these people have come from very remote communities and haven't even been - you know, haven't seen tall buildings. It's a significant and intrinsic factor of this profession that's unique.

PN198

The next unique - I should just take the Commission to paragraphs 55 and following in Mr Briscoe's statement because apart from death he explains that the concept of family and kinship is much broader than for non indigenous people, and that fear and shame can provide practical barriers to Aboriginal and Torres Strait Islander people in accessing health care from mainstream services. Then there's the lack of understanding. At paragraph 75(a) they may not understand the terminology, they may seek health support but not actually understand the medical advice that they receive.

PN199

If some of that advice may be that they won't be able to implement it until certain lifestyle changes are required, in some circumstances that lack of understanding can be dangerous for the client because such as if the Aboriginal and Torres Strait Islander client does not understand that certain medications conflict with other medications and are not to be take at the same time. Lacking - not understanding the medical advice may also mean that the Aboriginal and Torres Strait Islander person is unable to advocate for their own needs, and that the medical support - and to get the medical support that they actually require for their own circumstances.

PN200

Another key cultural barrier at paragraph 58 is the need to built trust between - and a strong relationship between the Aboriginal and Torres Strait Islander client and the health worker or health practitioner, and where there's that trust then the Aboriginal and Torres Strait Islander people will seek their support and assistance and will believe that advice, which is very important. The need for deep trust and a respectful relationship can have practical ramifications on how health workers and health practitioners perform their roles.

PN201

There's evidence that these workers work extremely - or work longer hours than many other professionals because in Aboriginal and Torres Strait Islander culture if someone comes to you and asks for help and you don't give it because you're off duty, then that's perceived as being a person who's only interested in doing it for the money and in not helping their community and can have real negative connotations for those health workers and health practitioners. One of the things that health workers and health practitioners, as part of the culturally safe health care are trained to do is to engage with members of their community regardless of when and then to help bridge the cultural divide, NATSIHWA has made a number of publications around the importance of providing health care and they include the cultural safety framework which is at tab 27 and also there's a policy position statement regarding the centrality of culture to health.

PN202

Looking now at the specific qualifications for this particular profession, you'll see from paragraph 62 on, Mr Briscoe gives details of the training packages for health workers and health practitioners that have been designed by the Aboriginal and Torres Strait Islander people for their own people. The certificates are at tab 29 of the exhibit and following. The Certificate II which is at tab 29 and in volume 1 to Mr Briscoe's affidavit, that's the introductory basic course to become an Aboriginal health worker and you'll see that this is in care and I've explained that it's the practice stream that's for the practitioners. This is a good entry pathway because it's aimed at workers with lower levels of English, because as Mr Briscoe says at paragraph 63 of his affidavit:

PN203

Many ATSI people may have English as their second, third, four or even fifth language, particularly in remote or very remote areas.

PN204

The qualification description at page 270 of the exhibit, it's described as:

PN205

Reflecting the role of workers who undertake a range of tasks under direct supervision to support the provision of primary health care services to Aboriginal and Torres Strait Islander clients and communities. Such work will be performed as part of a health clinic, centre or service but no licensing, legislative or certification requirements apply to this qualification.

PN206

The next page 271 to the exhibit, there are seven core units for the Cert II and three elective units, and you'll see at page 272 that there is no equivalent qualification.

PN207

This certificate covers material such as how to work with Aboriginal and Torres Strait Islander clients and communities and how to support clients to obtain access to health services and to provide basic information to a client and to provide first aid, and to provide work, working within the primary health care context.

PN208

The next qualification is the Certificate III, which is behind tab 30 to the exhibit. This is the minimum qualification for an Aboriginal and Torres Strait Islander health worker to work under supervision, but without direct supervision, and you will see under the qualification description that it's described as: to reflect the role of Aboriginal and/or Torres Strait Island people working at the entry level of primary health care for Aboriginal and/or Torres Strait Islander clients that may be regarded by many jurisdictions as the minimum level for Aboriginal and/or Torres Strait Islander health work. However, in some jurisdictions individuals may started at the level 2, and when ready progress to level 3, and that the qualification structure supports both pathways, and at page 275 there's 12 core units and five elective units, and at paragraph 69 of Mr Briscoe's affidavit, he sets out that the certificate covers materials such as working in the A&TSI primary health care context, how to undertake basic health care assessments, assisting in the planning and implementation of basic health care, providing information about the social and/or emotional support, assisting with basic health screening, promotion, education services, and identifying community health issues, needs and strategies. That certificate takes approximately 12 months to complete, subject to how the RTO delivers the course.

PN209

The next certificate in care is behind tab 31, and that's a Certificate IV in Primary Health Care, and Mr Briscoe gives evidence about that at paragraph 71 and 72 of his affidavit. This is a much more advanced qualification than the Certificate III. At page 282 of the exhibit, it's described as reflecting the role of Aboriginal and/or Torres Strait Islander people working to provide a range of non‑clinical primary health care services to Aboriginal and/or Torres Strait Islander clients and communities, including specific health care programs. These workers can be expected to flexibly assume a variety of job roles and undertake a broad range of tasks, either individually or as a member of a multi‑disciplinary team. You will see Mr Briscoe describes the material that is covered by the Certificate IV in Care as opposed to the Practice stream at paragraph 72 of his affidavit, and again it covers subjects such as working in an A&TSI primary health care context, facilitating and advocating for the rights and needs of clients, assessing and supporting clients' social and emotional wellbeing, supporting the safe use of medications, planning, implementing and monitoring health care in a primary health care context, providing nutrition guidance, and delivering primary health care programs for A&TSI communities. That qualification, Mr Briscoe says, takes approximately 12 months to complete, again subject to how the RTO delivers the course.

PN210

At tab 32, there's the Diploma in Care.

PN211

DEPUTY PRESIDENT MASSON: Ms Steele, can you just remind me when the changes on introduction of the national accreditation took effect?

PN212

MS STEELE: July 2012.

PN213

DEPUTY PRESIDENT MASSON: Thank you. So the certificate requirements and the diploma requirements I think further to my earlier question faltered after the national accreditation?

PN214

MS STEELE: In relation to health practitioners?

PN215

DEPUTY PRESIDENT MASSON: Yes.

PN216

MS STEELE: There was a change in that there were more - and I will come to the evidence on that in that there were more electives were added into the course, plus 500 hours of clinical work. Supervision was required in order to get a Certificate IV post‑registration. Pre‑registration (indistinct) that.

PN217

DEPUTY PRESIDENT MASSON: So page 281, which is the Certificate IV where it refers to release 1 and there are references to increase in units, both core and elective, is that related to that change, or is that just an update to the previous certificate requirements?

PN218

MS STEELE: Deputy President, I believe that's an update, but that certificate, and it is to do with care, so the change wasn't on the Certificate IV for Care; it was on the Certificate IV for Practice.

PN219

DEPUTY PRESIDENT MASSON: Yes, I understand.

PN220

MS STEELE: So at the moment - it is confusing - at the moment I'm going through the Care qualifications, which - -

PN221

DEPUTY PRESIDENT MASSON: All right. No, I should hold my curiosity. Thank you.

PN222

MS STEELE: Yes, I'm not sure if I'll be able to answer the same question when we get to the Certificate IV of Practice.

PN223

DEPUTY PRESIDENT MASSON: You can tell me to hold my curiosity.

PN224

MS STEELE: Thank you. So the Certificate IV in Care - I think I've been through the criteria on that, and I'd moved on to the Diploma on Care, which is a much more advanced qualifications that enable health workers to operate at a management or program coordinator level, and at page 292 of the diploma, it's described as a qualification reflecting the role of Aboriginal and/or Torres Strait Islander people working to provide a range of primary health care services to Aboriginal and/or Torres Strait Islander clients. The Diploma of Primary Health Care defines the knowledge and skills for workers involved in Aboriginal and/or Torres Strait Islander primary health care and who work autonomously under the broad guidance of others, and it covers workers who have a basis of skills and knowledge in primary health care which they may apply in program delivery, management and policy or education functions. And I should say I'm taking some time to go through these qualifications because they will become relevant when I get to the classification about - yes, so that's why I'm taking some time to go through the different qualification.

PN225

And then you will see at page 293 on the diploma, in the exhibit, that there's 20 core units and 10 elective units, and that the types of units that are being offered at the diploma level include, in the last six points on page 293, advocating on behalf of the community, applying a strategic approach, engaging in community health, supervising the health care team, and on the next page, implementing and monitoring infection prevention. So there's a lot more management units in this course, and on page 299 courses such as, at about six down, leading and managing team effectiveness, leading team effectiveness, managing people performance, providing leadership, and planning assessment activities and processes. So it's designed to be a much more - a managerial course.

PN226

And then the next course behind tab 33 is the Advanced Diploma of Aboriginal and/or Torres Strait Islander Health Care, and this qualification reflects the role of senior Aboriginal and/or Torres Strait Islander health workers - this is at page 301 - working in primary health care positions to provide advanced primary health care skills or management of a health clinical service who have extensive experience in primary health care work and relevant qualifications, and the advanced diploma covers workers who integrate knowledge of Aboriginal and/or Torres Strait Islander primary health care into broader aspects of management and community development, contributing to policy‑making and decision‑making across the spectrum of service delivery. This qualification is important because under the current award, when we go through the classification structure, there is no classification for someone who has done an advanced diploma.

PN227

At the next tab, tab 34, Deputy President, this is the certificate that you were asking me about before. This is the Certificate IV in Practice, so this is the new qualification that's required post‑registration, and the description at page 310 is that it reflects the role of

PN228

Aboriginal and/or Torres Strait Islander people working to provide a range of clinical primary health services to Aboriginal and/or Torres Strait Islander clients and communities, including specific health care programs, advice on the systems with the administration of medication. These workers can be expected to flexibly assume a variety of job roles and undertake a broad range of tasks, either individually or as a member of a multi‑disciplinary team, and the qualification addresses the specific legislative responsibilities of Aboriginal and/or Torres Strait Islander health practitioners and is required for national registration with the Aboriginal and Torres Strait Islander Health Practice Board of Australia.

PN229

Going back to your question, Deputy President, I'll have to take that on notice and maybe over the lunchtime adjournment check the releases. I have evidence in the lay evidence from one of the health workers who runs the training program and also from Mr Briscoe about the increase in the subjects that were required as a result of registration, and also the additional 500 hours of clinical care, but I must confess I haven't gone back to check each of these releases - - -

PN230

DEPUTY PRESIDENT MASSON: I'm just trying to under the practical implications, apart from the requirement to maintain registration.

PN231

MS STEELE: Yes.

PN232

DEPUTY PRESIDENT MASSON: Whether it had any consequences in terms of the number of units that had to be complete, the additional clinical hours that had to be - - -

PN233

MS STEELE: Yes.

PN234

DEPUTY PRESIDENT MASSON: Yes.

PN235

MS STEELE: I have evidence from a trainer to say that the units increased from 13 to 21, and then there's the 500 clinical hours in Mr Briscoe's recent statement. But I will endeavour to track down these over the lunchtime.

PN236

DEPUTY PRESIDENT MASSON: That's fine. Thank you.

PN237

MS STEELE: So the Certificate IV includes as a core subject administering medication, which is about halfway down on page 311. There are 14 core units, seven elective units; it's now an 18‑month course to do a Certificate IV, and in reading through the subjects, the Commission will see that this is a much more clinically focussed role than the Certificate IV in Care, because this is the Practice, the Practice course. And Mr Briscoe says about the Certificate IV, he deals with that at paragraphs 81 and 82 of his affidavit, and he sets out the material that's covered there, including administering and supporting the safe use of medications, which is core units, and that it takes approximately 18 months to complete, subject to how the RTO delivers the course.

PN238

And then the final relevant qualification for this particular workforce is the Diploma in Practice, and a copy of the HLT50213 diploma is behind tab 35 of Mr Briscoe's exhibit, and again at page 319, there's a description of the qualification and the diploma defines the knowledge and skills for workers involved in Aboriginal and/or Torres Strait Islander primary health care and who work autonomously under the broad guidance of others. The diploma qualification covers workers who have a basis of skills and knowledge in primary health care practice, which they may apply in the clinical management or education functions, and again, there's no certification requirements that apply to that particular qualification. So they're all specific qualifications, designed specifically for this profession, and none of them, apart from the Certificate IV in Practice require national registration, and hence the difference between the health workers and the health practitioners.

PN239

Then paragraphs 87 to 91 of Mr Briscoe's affidavit, at page 605 of exhibit 1, Mr Briscoe also sets out, apart from the formal qualifications for the health workers and health practitioners, they may receive practical on‑the‑job training, including from elders and more experienced health workers and health practitioners, and Mr Briscoe gives his own example when he was working as a trainee health worker, how he had an aunty who took him under her wing and showed him how to actually perform his duties in a culturally respectful manner and how to engage with the community, and explains that Aunty Judy is not his relative but he calls her Aunty Judy because she's a respected elder, and that's relevant when I come to the changes that are requested with respect to ceremonial leave, this much broader concept of kinship and family.

PN240

And then Mr Briscoe says about how he taught health workers things such as you can't bring a nurse into someone's home without going in and asking that member if they're happy to have the nurse come in, and if the person says no then the health worker has to go in on their own and deliver the primary health care themselves, and then also the importance of not judging other people in the community, otherwise you're not welcome back and not able to perform your role. And then at paragraph 91, that health workers and health practitioners may also undertake training in phlebotomy, complex wound management, foot assessment, diabetes, brief intervention such as suicide, smoking, drug and alcohol, which are obviously very big problems in the Aboriginal and Torres Strait Islander communities, as well as the social and emotional wellbeing and intergenerational trauma.

PN241

So that concludes the evidence on the proposition that this is a unique workforce that isn't covered by any other award, and I'll make submissions on that. I'm now going to move on to the next section of the evidence, which is that whilst the precise numbers of health workers and health practitioners are not known, there are certainly Aboriginal and Torres Strait Islander health workers in private practice, and their numbers are likely to grow. So from paragraphs 92 onwards in Mr Briscoe's affidavit, he gives evidence as to the nature of the Aboriginal and Torres Strait Islander health workforce and health practitioner workforce, and he refers to a policy statement behind tab 36, and if I can ask the Commission to look at the exhibit behind tab 36, which is specifically at page 330 under the heading, "Workforce size." He says:

PN242

It's difficult to be sure of the members employed in the health system, but we need more to fill the constant vacancies and more young people preparing to join the Aboriginal and/or Torres Strait Islander health workers and health practitioners workforce for an expanding population. The ratio of one worker per 150 people has been suggested. Using 2011 data, the health practitioners' framework stated that 99 per cent of workers in these professionals are Aboriginal and/or Torres Strait Islanders and that the number employed in all services was 1256.

PN243

There will be expert evidence about the number of health workers that are employed, the shortages that there are, and why it is important to make the changes that are sought by NATSIHWA in this award in order to grow this critically important profession. Then at paragraph 3, it's suggested that there's 941 employed in the primary health care services, and that as at August 2017 that there were 608 health practitioners, mostly in the Northern Territory, 35 per cent in NSW, Western Australia and Queensland, and ACT with less than 1 per cent. At paragraph 93, Mr Briscoe says that there's 875 full members of NATSIHWA as at 31 May 2019, and he explains at 94 why it's difficult to accurately assess the numbers, because there is no single body that governs or regulates them, and because these health workers and health practitioners work across a number of different contexts. So they not only work in the community controlled health organisations, but they also work in private practice and in hospitals.

PN244

Then Mr Briscoe from 96 and following sets out his knowledge of practitioners in private practice. He says there are some working in private practice, but they're limited in numbers. He received contact in around 2018 or 2019 from a couple of health workers who were working in private practice in Cairns. He has had a discussion with a health worker called Haysie - and we've got a witness statement from that worker - who had been working in private practice on the Gold Coast for two years, but she told him because there was no warden there was no career - I think there's a mistake in that sentence.

PN245

DEPUTY PRESIDENT GOSTENCNIK: That's essentially your point in relation to the expansion of this class of worker to the private sector that it will facilitate growth.

PN246

MS STEELE: Yes. And then he says that in 2010 it was highly unusual to have anyone in private practice, that in May 2010 there was a review of that Medicare items, and I took you previously to that Medicare item, 715, which came into operation in October 2013, and at 102 there are currently seven Medicare items that are relevant to Aboriginal and Torres Strait Islander primary health care, and of those seven items, at the moment health practitioners can claim all seven items. The health workers can only claim three items. But there has been another review of the Medicare items and the report in relation to that review is at tab 38, which is the next volume of Mr Briscoe's statement - the exhibit, I mean.

PN247

DEPUTY PRESIDENT MASSON: Sorry, is that tab 38 of the exhibits?

PN248

MS STEELE: Yes, tab 38. So this is a report from the Aboriginal and Torres Strait Islander Reference Group as part of the Medicare Benefits Review Taskforce. The main things are at page 342 and following, and noting at page 344.9, one of the recommendations is to enable qualified Aboriginal and Torres Strait Islander health workers to claim for certain follow up items provided on behalf of a medical practitioner that are apparently allowed to be claimed by health practitioners, and then there's the items' numbers, and then under the longer term recommendations, 12 and 13, to invest in the growth and sustainability of the Aboriginal and Torres Strait Islander health worker and health practitioner workforce and to invest in a campaign explaining the role of these important practitioners, and then at page 368 at 5.2.1, you will see there the recommendation to add a new item for group service delivery of follow up services after a health assessment. So that will be a new item, and the example descriptor is, "Follow up service provided by a nurse, Aboriginal and Torres Strait Islander health practitioner or health worker for an Indigenous person who has received a health assessment if" - and this is envisaged to be a group service for groups of two to 10 participants for a minimum of 20 minutes, and the rationale for that is that these group services may offer increased cultural safety for Aboriginal and Torres Strait Islander patients and it may increase the likelihood of Aboriginal and Torres Strait Islander patients attending follow up services and promoting continuity of care. So that could be a completely new item that's currently not available on Medicare that would encourage doctors in private practice to engage health workers in order to be able to perform that service.

PN249

And then you will see at the top of page 371 that in 2016 to '17, 29 per cent of Aboriginal and Torres Strait Islander people received the health assessment - that's the health assessment that I took the Commission to before - and that the government has set a target increasing that to 65 per cent, and that's another reason or incentive for engaging these health workers and health practitioners in private practice. And then at the bottom of 372 there's another recommendation, recommendation 9, to enable qualified Aboriginal and Torres Strait Islander health workers to claim for certain follow up items, and at page 373, that recommendation is to enable qualified Aboriginal and Torres Strait Islander health workers to claim all the items that the health practitioners can currently claim, and there are four items there where those services fall within their scope of practice, as divined by the relevant state or territory, and also to amend the description to reflect the option to be provided by a health worker, and then they've set out example descriptors of these services.

PN250

So service 10987 is "Follow up services of up to 10 services after you've had the health assessment", and then there's item 10988, which is "Immunisation", which is currently provided by health practitioners but will shortly be provided by health workers, and then item 10989, "Treatment of a person's wound", and then 10997 on page 374 as well, "A service provided to a person with a chronic disease by a health practitioner or a health worker", and a maximum of five services in a calendar year. And you will see that the rationale, at page 374 under heading 5.4.2, is to improve the availability of services for Aboriginal and Torres Strait Islander people, and then it is stated that these health workers and health practitioners play an important role in providing high quality health care. In a recent series of focus groups, Aboriginal and Torres Strait Islander people stated a preference for culturally sensitive, in‑person support and information through face‑to‑face discussions, and that they're recognised as important in providing cultural safety and helping to alleviate concerns, and that face‑to‑face discussions are the preferred source of information for Aboriginal and Torres Strait Islander health workers.

PN251

Then on page 375 at the top, it says, "While there is an insufficient supply of health workers and health practitioners" - and that's one of the problems facing this workforce is that whilst the workforce is growing, it's not growing at the same rate as the Aboriginal and Torres Strait Islander people and so the number of health workers per population is decreasing. So it's noted that:

PN252

Adding health workers that have the skills, knowledge and ability to provide services for and on behalf of GPs would triple the number of available Aboriginal and Torres Strait Islander health professionals and bring Australia closer to closing the gap. There are only 641 registered Aboriginal and Torres Strait Islander health practitioners and 1256 health workers in Australia.

PN253

And then about the fourth point down:

PN254

Increasing patients' ability to claim rebates for basic medical services will support the growth of the Aboriginal and Torres Strait Islander health workforce, which has been limited over the previous two decades. In 1996, there were 19 Aboriginal and Torres Strait Islander health workers per 10,000. By 2011, this had only increased to 23 per 10,000 Australians.

PN255

And:

PN256

Increasing patients' access to services from Aboriginal and Torres Strait Islander health workers will improve the quality of care in rural and remote areas.

PN257

And then at page 378, there's a recommendation to invest in the growth and sustainability of the Aboriginal and Torres Strait Islander health worker, and recommendations to, at point (c), strengthen the career path for Aboriginal and Torres Strait Islander health workers and health practitioners, and at page 379, under the rationale, you will see that the taskforce said:

PN258

There is a shortage of qualified health professionals who can provide culturally and clinically appropriate care to Aboriginal and Torres Strait Islander people, and this is partly because Aboriginal and Torres Strait Islander are significantly under‑represented in the Australian health workforce.

PN259

And the second dot point, that:

PN260

Aboriginal and Torres Strait Islander people living in rural and remote communities suffer poor outcomes, partly because of their educational disadvantage and their remoteness.

PN261

And then at point three, that:

PN262

The practitioners and workers play an important role in providing culturally safe, comprehensive primary health services to Aboriginal and Torres Strait Islander people. They are also well‑distributed in rural and remote regions in Australia.

PN263

And then the next point on 1 August 2018 at the Council of Australian Governments Health Council, the Ministers agreed to develop a national Aboriginal and Torres Strait Islander health workforce plan and that that plan - the recommendations are of particular relevance in the context of that reform process, and there's agreement that supporting the growth of Aboriginal and Torres Strait Islander health workers and health practitioners would be:

PN264

an efficient way to increase culturally and clinically appropriate care for Aboriginal and Torres Strait Islander people at high risk of poor health outcomes. It would also be a major employment opportunity for Aboriginal people, as there are many unfilled positions for Aboriginal and Torres Strait Islander health practitioners with nurses currently meeting demand for those services.

PN265

The reference group agreed that recruitment and training needs to improve across Australia by providing access to training. The next dot point on page 380 which is relevant is:

PN266

Developing a clear training pathway to demonstrate options for progression within the health workforce and developing an approach to ensure clear and consistent recognition of prior learning.

PN267

Which is the second substantive change of recognising prior learning that NATSIHWA seeks in amending this modern award, and the training pathway and options for progression, that is one of the main reasons NATSIHWA seeks to amend the classification and to create a classification structure that really provides opportunities for people to have a career commensurate with other health professionals under other awards.

PN268

A summary of those recommendations is behind tab 39 to Mr Briscoe's exhibit, and you will see he sets out the key recommendations from the report that are relevant for Aboriginal and Torres Strait Islander health workers and health practitioners, which is bulk‑billing incentives, and enable all health services available to A&TSI people to be provided as group services. Then, 5) increase the number of allied health sessions available for A&TSI people; 6) create a new item for group service delivery of comprehensive follow up services, and then, as I took the Commission to, enable these qualified health workers to claim for the same Medicare items, 10987, 88, 989 and 997, that the health practitioners are currently able to claim for. And then at page 425, to invest in the growth and sustainability of the Aboriginal and Torres Strait Islander health worker and health practitioner workforce, and to invest in an awareness campaign to explain the roles and scopes of practice.

PN269

Going back to Mr Briscoe's affidavit, he also refers to his evidence of health workers and health practitioners in private practice being contacted, at paragraph 99, by Dr Stephanie Trust, who is an Aboriginal general practitioner working in Kununurra in Western Australia, who wanted to employ a health worker to work in her practice but she did not know what rates to pay the health worker. Dr Trust has provided a statement, which is at page 727 of exhibit 1, and that is behind tab 36 of exhibit 1, and Dr Trust gives evidence at paragraph 3 that she's a Kidja woman who was born and raised in the eastern Kimberley, and that she identifies as Aboriginal. She holds a Bachelor of Medicine. This is at tab 36.

PN270

DEPUTY PRESIDENT GOSTENCNIK: Yes. I have it, yes. Thank you.

PN271

MS STEELE: She holds a Bachelor of Medicine and a Bachelor of Surgery, and she completed her qualification as a general practitioner in around 2013, and before she was a doctor, Dr Trust was a health work - you see at paragraph 6. So she started off, in paragraph 7, as an enrolled nurse. She became a health worker in approximately 1992, and she worked as a health worker for the duration of her medical studies. She worked as a cadet - and she sets out how she got her medical qualifications in paragraph 7. She now works at Kununurra Medical, which at paragraph 8 she describes as a not‑for‑profit, private medical practice owned by Wunan, and Wunan is an Aboriginal development organisation, East Kimberley, which aims to drive long‑term socio‑economic change for Aboriginal people. So it not only provides medical services, but it also provides support for education, employment, accommodation, housing, welfare reform, leadership and health services, and she sets out at 9 how she is able to not only provide medical services, but also to refer patients to housing support if needed. She says that:

PN272

Aboriginal‑owned organisations have a leading role in rural and remote health care services, as they consider and address the link between health services and social determinants for health, such as housing, employment and education.

PN273

At 11:

PN274

They bulkbill their Australian and Torres Strait Islander patients.

PN275

And at 12 that:

PN276

Kununurra Medical currently employs one health worker. Our health worker initially began as a receptionist role, and while working as a receptionist she expressed interest to become -

PN277

in the clinical side, and so the medical centre supported that receptionist with her training and she is now employed in that medical service as a health worker once she completed her training in 2019. And in 2015, Dr Trust also says that there was at least one other health worker before this receptionist trained to become a health worker. She sets out at 15 the duties that the health worker performs, saying that she does much the same work as what our nurses do, including blood pressure checks, blood sugar level checks, ECG tests, drug and alcohol testing. That health worker has completed the Certificate IV in Practice, but there has been a delay in registration, so you will see that they have been unable to supplement her income with Medicare until she is registered as a practitioner, but that will obviously happen. The medical centre is a teaching practice, and at 18, that that medical centre is looking to move into a bigger site. They're currently in the process of seeking funding and that when that happens Dr Trust anticipates hiring another health worker once the health worker is sufficiently experienced so that they can focus on training the new health worker.

PN278

Then at paragraph 19, Dr Trust says that she found it difficult to work out what to pay the health worker when she started earlier this year, because she couldn't find any state health awards and awards for - she could find state health awards and she could find the award under consideration here, but there was nothing for the private general practice sector. Dr Trust telephoned NATSIHWA to see if there was anything there with a guide, and NATSIHWA advised her that there is no national award that applied. So Dr Trust had to use a hybrid system to work out what to pay the health worker and had to use her own judgment as to what to be equitable, taking into account what they offered nurses, and that she wants to pay her people appropriately.

PN279

DEPUTY PRESIDENT GOSTENCNIK: Is Dr Trust's practice incorporated? The reason I ask is that it's in Western Australia and so the scope of the Fair Work Act's coverage is limited, and unless her practice is a trading or financial corporation, or caught by some referral, then anything we do here is unlikely to assist her.

PN280

MS STEELE: Yes, it just says that it's a private medical practice.

PN281

DEPUTY PRESIDENT GOSTENCNIK: Yes, but I understand the gist of the evidence - yes, but if it wasn't readily available, an instrument from which you could determine the appropriate pay entitlements.

PN282

MS STEELE: Yes, and I will take that on notice, Deputy President, and see if I can speak to Dr Trust and have further information over the course of the hearing. And then paragraphs 21 to 25, Dr Trust sets out the benefits of employing health workers in a medical practice and that it creates choice of whether they can go to the community controlled health centres or to private practice, and she sets out how it makes the Aboriginal and Torres Strait Islander communities feel more comfortable. And she says, finally, at 25, that she's aware of another practice that is starting to employ health workers if they have not started already. The other evidence, witness statement, concerning health workers in private practice is the witness statement of Haysie Penola, which is behind tab 22, exhibit 1, and she says at 8 that she identifies as Aboriginal. She is 32 years old. She holds a Certificate IV and she is now in a position of an Aboriginal wellbeing worker. But prior to being in that role, she worked as a medical receptionist, which is at paragraph 8 of her statement, and that while she was working as a - - - -

PN283

COMMISSIONER BISSETT: (Indistinct)

PN284

MS STEELE: I'm so sorry, Commissioner, I've been told it's tab 21 - - -

PN285

DEPUTY PRESIDENT GOSTENCNIK: Yes, 21. Yes, I figured that out. Thanks.

PN286

MS STEELE: Thank you - that she has sporadically acted as a health practitioner, even though she was employed as a medical receptionist, and she did that because the health practitioner that was employed by the practice was on workers compensation and because she was registered, so she could just step in, and then at paragraph 10, she didn't get any additional wages for covering the Aboriginal health practitioner duties; she continued to be paid under the Clerks Award as if she was performing her receptionist duties.

PN287

On the question of private practice, if I could just ask - there's three final pieces of evidence - so in Mr Briscoe's affidavit at tab 72, which I believe is volume 3 at page 919 - this document is Health Workforce Australia's report from December 2011, "Growing our future, the final report of the Aboriginal and Torres Strait Islander health worker project", and at 919, workplace environments that enable and support Aboriginal and Torres Strait Islander health workers. Under section 2.4, first paragraph, it says:

PN288

Some are employed in government health services ranging from community clinics to tertiary hospitals. A smaller number are employed in private health services or general practice divisions.

PN289

And then, similarly, in the report from Health Workforce Australia from 2014, behind tab 73 of page 136 - this is Health Workforce Australia's report from July 2014, again under, "What is an Aboriginal and Torres Strait Islander health worker" - it sets out the need for cultural safety, comprehensive care, and then says at about point 5 down the page that health workers are employed by a number of different providers, including Aboriginal community controlled health organisations, Aboriginal and medical services, hospitals, state and government, and GP clinics.

PN290

I've just been told that Dr Trust's practice is incorporated, and I've got the ABN number, if the Commission is - - -

PN291

DEPUTY PRESIDENT GOSTENCNIK: You don't need to cite the ABN number. We accept that submission, thank you.

PN292

MS STEELE: The final piece of evidence is the expert report of Associate Professor Raymond Lovett, which is in volume 2 of the Court book - of exhibit 1 at tab 6. As I said, I will invite Associate Professor Lovett to speak to the Commission about this report at a later point, but you will see he starts on page 1 by setting out the role and importance of the health professionals in closing the gap, and again repeats the evidence that the Commission has already heard that they're vital to improving Aboriginal and Torres Strait Island health and achieving health equity, and then the second paragraph on page 394 that they often play the role of a cultural broker and that they assist people in two ways: firstly, to access and assist clients through the care journey, and also to assist the non‑Indigenous health care providers how to better communicate with Aboriginal and Torres Strait Islander clients, and then he talks about liaison and extensive clinical skills and the prominent role that health workers have in consulting an individual, including home visits. He says, importantly, at 396, at the top of the page, that from his work and personal experience as a researcher, and as an Aboriginal health worker, extending the coverage of the award to cover private practice would enable the broker profession and allow the cultural brokerage model to be expended arguably into a sector that might provide service to some 53 per cent of the Aboriginal and/or Torres Strait Islander population.

PN293

In some areas of Australia, there are some communities that only have access to these community controlled health services and so if the health workers are able to be - if the profession is expanded in private practice, that will provide more opportunities for Aboriginals and Torres Strait Islander people to access this cultural brokerage and to achieve better health outcomes. He says that discriminatory practices in non‑Indigenous primary health care settings have been identified as contributing to poor outcomes, or a lack of wanting to access these services because of this treatment of Aboriginal and/or Torres Strait Islander people, and that evidence indicates that one of the best ways to reduce negative stereotypes and racism within the health care system is to have Aboriginal and/or Torres Strait Islander people involved at numerous levels in these systems. Evidence highlights that much of the disparity in outcomes between Indigenous and non‑Indigenous people can be reduced with appropriate investment in primary care where many Aboriginal health workers work, and this would include expanding the coverage of where Aboriginal health workers could work.

PN294

And he points out that in reducing the prevalence and severity of co‑morbidities, which is a function of primary care, it is suggested that specialist and tertiary hospital care could be avoided or severely reduced. It is in the tertiary care where there's the most disparities in Aboriginal health, for example, the difference in outcomes between Aboriginals and Torres Strait Islanders who suffer significantly more cardiovascular disease and heart attacks, which is responsible for one third of the gap in health outcomes, and if the role of the health workers were to cover the private sector then increased cover in this sector would have the opportunity to contribute to decreasing the current disparities, and that Aboriginal health workers employed outside of the community controlled health services, including the public sector, have no industrial recognition or distinct career path, underscored by a relevant modern award. They are outside the industrial relations system. There's a need to ensure a fair and relevant minimum safety net of terms and conditions.

PN295

He then gives some evidence of whether there has been an increase - - -

PN296

DEPUTY PRESIDENT GOSTENCNIK: Ms Steele, the various documents and reports that are footnoted and cited to support the propositions that Associate Professor Lovett makes, are they in the material?

PN297

MS STEELE: Some of them are in the material, but I can ensure that you have all of them in the material.

PN298

DEPUTY PRESIDENT GOSTENCNIK: Yes.

PN299

MS STEELE: I can do that overnight.

PN300

DEPUTY PRESIDENT GOSTENCNIK: That would be fine, thank you.

PN301

MS STEELE: I will identify which of the ones are current.

PN302

DEPUTY PRESIDENT GOSTENCNIK: Yes.

PN303

MS STEELE: There's a lot of material, but I can go through that and identify it.

PN304

DEPUTY PRESIDENT GOSTENCNIK: Thank you.

PN305

MS STEELE: Then he sets out whether there has been an increase in the number of health workers working in the private sector and says there's only two national datasets, because for the health workers they're unregulated and they don't require professional registration and that it's impossible to determine unless they're listed in the census of what their profession is, and Associate Professor Lovett was part of a team who analysed aggregate data on health workers using descriptive analysis, including calculating the number of proportion of health workers by gender, age, state and territory, and he also calculated the number of health workers for the total Aboriginal and/or Torres Strait Islander population as at the year of the census, and on page 397, he says that the total number of Indigenous health workers was not commensurate with population growth. There were 221 Indigenous health workers per 100,000 Indigenous people in 2006, and 207 Indigenous health workers per 100,000 Indigenous people in 2016. There is a copy of Associate Professor Lovett's study in evidence, which I can take you to, but effectively, the effect of the expert evidence and the government's evidence is that whilst there has been an increase, and you will see on page 397 with respect to health practitioners that there has been a near doubling of registration on a population basis since 2012, overall the growth in this sector has not kept up with population growth of the Aboriginal and Torres Strait Islander people.

PN306

Going back to my submissions on coverage, this isn't a profession that is covered by any award, and if I could ask you to look at the aide‑memoire, which is a summary of the key submissions, on the first page, point 3:

PN307

The Aboriginal and Torres Strait Islander health workers and health practitioners are a unique and culturally distinct occupation. There is no overlap in coverage between the proposed amended award and the Health Professionals and Support Services Award, as demonstrated by the following table.

PN308

And in that table, I have sought to have a short snapshot comparison, but you will see that in the proposed award that a health worker is someone who identifies as an Aboriginal and/or Torres Strait Islander and is recognised by their community as such, that is engaged in the delivery of Aboriginal and Torres Strait Islander primary health care, and employed as either a health worker, trainee, generalist health worker, advanced health worker, all the different classifications that we're putting forward, and then the final point, "has a culturally safe and holistic approach to health care." And when one looks at the definitions in the HPSS Award, there isn't any inherent requirement that any health professional employee have a culturally safe and holistic approach to health care, or that they be identified as Aboriginal and Torres Strait Islander, or that they have any specifically relevant Aboriginal and Torres Strait Islander qualification.

PN309

In terms of the history of this award, the Full Bench in 2009 was not asked to make any determination about private practice in 2009. We have put on some written submissions, which are in volume 1 of exhibit 1 - they're behind tab 2. Paragraphs 18 to 22 deal with the history of the award, and it was created by order dated 4 December 2009. At paragraph 19, the key proponent was NACCHO, and they're the national peak body representing the 143 community controlled health services, and they sought the creation of a separate and distinct award on a number of bases, including that the community controlled health services constituted a separate industry with its own unique characteristics, the perilous state of Aboriginal health, and that a mainstream award would take little to no account of the specific needs, experience, qualifications and other issues, such as the self‑determination of Aboriginal people, their communities and organisations.

PN310

In creating the exposure draft, the Commission largely adopted the draft that was provided by NACCHO and decided some matters relating to allowances, and importantly - if the Commission would just excuse me for a second - at volume 5 of the exhibit at tab 93, it's a decision of the Full Bench, Award Modernisation Statement, [2009] AIRCFB 865, and at paragraph 125 the Full Bench said:

PN311

We have decided that the operation of Aboriginal community controlled health organisations should be regulated by a separate modern award. We are satisfied that the nature of the health services that are delivered in a culturally appropriate way is sufficient to justify a separate award.

PN312

So the genesis of the award was the fact that these health services were being provided in a culturally appropriate way, which was different to any other award.

PN313

The difference is not only about the way the services are established and controlled, but is critically seen in the way the employers of the services operate. We accept that the Aboriginal health worker within Aboriginal community controlled health services is critical. No equivalent health care worker operates in what we might describe as mainstream services.

PN314

Looking in any award the principles - modern awards objectives were summarised in the four year review of modern awards of the Pharmacy Industry Award which is behind tab 51 of volume 4 of exhibit 1, and I should say I'm now moving on to the section 134 considerations.

PN315

DEPUTY PRESIDENT GOSTENCNIK: Yes.

PN316

MS STEELE: Are there any questions that the Commission has about why it's not covered by any award? So the general principles are set out at paragraph 126 and I'm sure you're familiar with those principles at page 1389 for review, but I wish to point out that apart from the section 134 considerations that the matters that may be taken into account are not confined to the section 134 considerations and I'll be making a number of submissions on 134 considerations, but it is an overarching submission of NATSIHWA that in this case improving the health outcomes which obviously has an economic impact for the population, but that just improving the health outcomes for Aboriginal and Torres Strait Islander health workers is by and of itself an appropriate factor for the Commission to take into account in addition to the section 134 factors, because the section 134 considerations, as is stated at the top of page 139, the broad social objectives and it's clear that the Commission isn't limited to taking into account the section 134 considerations, and the health of - NATSIHWA submits that one of the considerations is, apart from the economic considerations, that any measures that can be taken to improve the health of disadvantaged or of a population with poorer health outcomes than the rest of the population is a relevant factor that could also be taken into account by the Commission in its deliberations on the section 134 considerations. So ‑ ‑ ‑

PN317

DEPUTY PRESIDENT GOSTENCNIK: And that will be achieved on your case as another mechanism to enable the number of relevant health workers to increase.

PN318

MS STEELE: Yes, Deputy President.

PN319

DEPUTY PRESIDENT GOSTENCNIK: And therefore the communities have access to a larger number of health workers.

PN320

MS STEELE: Yes. And of course that has flow-on economic inputs, but the primacy of the health, in my submission, is as important as the economic benefits and it recognised as a national imperative in terms of closing the gap at all government levels.

PN321

So a plan to develop some of the evidence on - to take the Commission next through the evidence on that particular health issue and some of the government documents that support that, so if I could ask you, please, to look at Mr Briscoe's exhibit at tab 71, which is volume 3. I'm just having some trouble finding my own folder. There's so many folders.

PN322

DEPUTY PRESIDENT GOSTENCNIK: Yes. I'm with you. Tab 73?

PN323

MS STEELE: Yes. Sorry, 71.

PN324

DEPUTY PRESIDENT GOSTENCNIK: Seventy-one, okay.

PN325

MS STEELE: So this is a report from 20 January 2011 from Health Workforce Australia, and the purpose of the study, at page 736, is to inform development policies and to inform the requirements of national registration. So this is a study that was undertaken prior to the implementation of the national registration scheme for the health practitioners, and that's under the executive summary in the second paragraph on page 736. And then at page 738 from the second paragraph, the historical and cultural context, it's stated that:

PN326

The Aboriginal and Torres Strait people and health worker role is important because these experiences have impacted the mental and physical health of Aboriginal and Torres Strait Islander people and the way in which Aboriginal and Torres Strait Islanders interact with health services and institution.

PN327

The next paragraph deals with the broader concept of health, which I described before as incorporating total physical, emotional and mental wellbeing, and then improving wellbeing therefore involves consideration of the physical environment of dignity, community, of self-esteem and of justice, and that community health is therefore not only about health workers, it is very much about the totality of what Aboriginal and Torres Islander's people experience in their lives every day, and that health is everyone's business.

PN328

The next section deals with the burden of disease and we'll come to 2019 but unfortunately the statistics haven't improved too much since 2011, but:

PN329

The top five contributors to the burden of disease of Aboriginal and Torres Strait Islander peoples including cardiovascular disease, mental disorders, chronic respiratory disease, diabetes and injury and the risk of developing the majority of these diseases is exacerbated by lifestyle choices including smoking, drinking, substance abuse, physical inactivity, poor diet, and domestic violence. A key strategy to preventing the disease burden is through a preventative holistic approach to health care. Health education promotion activities provide an opportunity to affect behavioural choices.

PN330

Then under Health Services and Accessibility about point 7 of the page down that:

PN331

Health services need to be both available and culturally accessible and that that separate and distinct concepts, certain barriers can render available health services inaccessible to Aboriginal and Torres Strait Islander People. An individual's fear of racial discrimination might be overcome through a health worker's first approach whereby the Aboriginal and Torres Strait Islander health worker if the first point of contact in a health service for an Aboriginal and Torres Strait Islander client this can assist in establishing trusting, respectful, and understanding relationships between the client and other non-Aboriginal or Non-Torres Strait Islander health professionals. It can't be assumed that health service availability equates to accessibility. Data has shown that some Aboriginal and Torres Strait Islanders in non-remote areas actually have a higher level of unmet need than those living in remote areas. That is despite the fact that health services are more densely concentrated and therefore more available than non-remote areas. One hypothesis explaining this phenomenon is that the increased concentration of health workers in remote areas has a positive effect on health service accessibility for Aboriginal and Torres Strait Islander people. Regardless it is clear that health services must be culturally safe to be accessible for Aboriginal and Torres Strait Islander communities.

PN332

Then under scope of practice, second paragraph, again that:

PN333

The unique to the health worker scope of practice is the provision of comprehensive primary health care within a culturally appropriate and culturally safe environment.

PN334

About point 7 of the page down this report deals with distribution and demographics and again it's said that Australia does not have a clear national picture of the health worker workforce at this point of time.

PN335

However, using the best available data certain points are clear: (1) the distribution of the total health worker workforce does not align to the distribution of the Aboriginal and Torres Strait Islander population -

PN336

And this is important in the context of coverage and private practice -

PN337

because 48 per cent of the health worker workforce is located in remote or very remote areas of Australia whilst only 24 per cent of the Aboriginal and Torres Strait Islander population is located in those areas. The majority of health workers are female, 70 per cent.

PN338

And that's important because there's men's business and women's business and Aboriginal and Torres Strait Islander people, males, may not feel comfortable with a health worker who's female and vice versa because there's men's business and women's business.

PN339

Then at page 753 there's some more detail on why understanding the cultural context is equally important and that differences between the culture of Aboriginal and Torres Strait Islander people and mainstream Australian culture can influence the accessibility of healthcare services.

PN340

Cultural and linguistic differences may affect the understanding of western medical practice and the success rates of western medical treatments and care plans. Failure to understand and accommodate the diverse cultural beliefs of Aboriginal and Torres Strait Islander communities is likely to result in inappropriate responses to their healthcare needs.

PN341

At 3.2.1 there's an overview of the cultural context, and it's a simplified summary because I don't even pretend myself, having been involved in this case, to have a fully in-depth understanding of the cultural differences because it does vary from community to community and from region to region, but at a simplified level it's clear that Aboriginal and Torres Strait Islander people are culturally linguistically and ethnically diverse. There's a danger in making generalisations but there are certain core beliefs relating to health and at page 754 there's an excerpt that was drawn from the preface to the National Aboriginal Health Strategy published in 1989 which, to me, summed up a lot of the differences, which is that:

PN342

Aboriginal culture is the very antithesis of western ideology. The accent on individual commitment, the concept of linear time, the switch in focus from spiritual to worldly, the emphasis on possession and the pricing of goods and services, the rape of the environment and above all the devaluing of relationships between people, both within families and within the whole community, as the determinate of social behaviour are totally at variance with the fundamental belief system of Aboriginal people. Health to Aboriginal peoples is a matter of determining all aspects of their life including control over their physical environment, of dignity, of community self-esteem and of justice. It is not merely a matter of the provision of doctors, hospitals, medicines, and the absence of disease and incapacity. In contemporary terms Aboriginal people are more concerned about the quality life. Traditional Aboriginal and social systems include a three dimensional model that provides a blueprint for living. Such a social system is based on inter-relationships between people and land, people and created beings, and between people which ideally stipulates interdependence within and between a set of relationships.

PN343

Then Health Workforce Australia sets out some of the broad concepts at paragraph 4 that:

PN344

Health is a more holistic concept and not limited to the clinical domain. Secondly, in the next paragraph that there's a value placed on interpersonal relationships which includes relationships between families and communities but also extends to relationships with healthcare professionals, and that level of engagement that the Aboriginal and Torres Strait Islander health person has with their health services may depend upon the nature of their relationship, and with the Aboriginal and Torres Strait Islander health worker and health professionals employed there.

PN345

Then in the final paragraph there's a study talked about in the value that Aboriginal and Torres Strait Islander peoples place upon healthcare provision and interpersonal relationships where research found that the determinant of compliance with medical advice was actually based more on the development of trusted relationships with healthcare professionals than the Aboriginal and Torres Strait Islander's understanding of their own condition.

PN346

Then, thirdly, that:

PN347

The Aboriginal and Torres Strait Islander emphasised the inter-connected causal factors of health and that individual wellbeing is always contingent upon the effective discharge of that person's obligations to society and the land itself, and that creates difficulties in a mainstream health context because according to some Aboriginal and Torres Strait Islander people the causes of illness may actually be attributed to supernatural intervention or sorcery, and thus scientific explanations from western doctors are at odds with their own beliefs and their underlying beliefs may contribute to a lack of compliance with any advice that's given to them in a western medical context.

PN348

And then, fourthly, and this is important in growing the profession:

PN349

There are clear divisions between men's business and women's business in the traditional cultural belief. Any breach of gender provisions in the provision of healthcare is likely to cause great distress and shame for Aboriginal and Torres Strait Islander individuals. That's relevant in considering the needs of the patients in addition to the needs of health workers from their place of employment.

PN350

That's just a summary of longstanding and complex cultural beliefs but it does highlight some of the key differences and half-way through the fourth paragraph:

PN351

emphasises the importance of appropriately navigating the intersection between western medical practices and the cultural beliefs of Aboriginal and Torres Strait Islander peoples. Health care for Aboriginal and Torres Strait Islander community needs to be culturally appropriate to generate better outcomes. What works in mainstream health services is not always going to effectively meet the health and cultural needs of Aboriginal and Torres Strait Islander peoples.

PN352

Then at page 771 again confirmation about the gap, that it's well recognised. And at page 777, at the top of the page under the heading, 4.2.3, that:

PN353

The Aboriginal and Torres Strait Islander population has a much higher rate of mortality and a much lower life expectancy than the total Australian population. In 2003 the probability of dying between the ages of 15 and 60 was 33 per cent and 23 per cent for Aboriginal and Torres Strait Islander males and females respectively. In comparison the rates for the total Australian population were 10 per cent and six per cent.

PN354

In the second paragraph that the most recent estimate is that there's a 12 year gap for males and 10 years for females in life expectancy.

PN355

Then on page 778, 4.2.4:

PN356

Morbidity in the Aboriginal and Torres Strait Islander Population. The leading causes of disease in the adult Aboriginal and Torres Strait Islander population include: (1) cardiovascular disease; (2) mental disorder, (3) chronic respiratory disease; (4) diabetes; and (5) intentional and unintentional injuries.

PN357

And at 794 this deals with access to health services, and again it's not just a question of having a practice of, you know, a western practice nearby. That may not actually allow access to health services for Aboriginal and Torres Strait Islander people, but it says in this report in the second paragraph under the heading, 5.2 that there's been a number of studies and that few indigenous Australians - this is in paragraph 2, "obtain the full appropriate benefits of the schemes". And it goes through analysing the data and distribution and then at page 798 in the second paragraph concludes:

PN358

When considering the information from the perspective of the ASGC locations it is clear that there is a significant difference in accessibility between Aboriginal and Torres Strait Islander people based in remote and non-remote areas. Aboriginal and Torres Strait Islanders in non-remote areas actually have a higher level of unmet need than those living in remote areas. This challenges the assumption that a greater availability of health services equates to a greater level of accessibility. Although there may be fewer health services located in remote areas it appears that they might be better able to meet the needs of the Aboriginal and Torres Strait Islander people than those in the non-remote parts of Australia.

PN359

At page 799 about four paragraphs down, again, the hypothesis is repeated that it may be because the health services in remote and very remote locations are more specifically tailored to the unique needs of the Aboriginal and Torres Strait Islander people than those located in urban areas and that that is supported by consideration and distribution of the Aboriginal and Torres Strait Islander community controlled health services and the Aboriginal and Torres Strait Islander health workers.

PN360

In the last paragraph on that page there's the observation that the distribution of the health worker workforce and the Aboriginal and Torres Strait Islander population emphasises that the distribution of services does not align to the population distribution. At page 805 under section 5.2.3 the report sets out the barriers to healthcare. It says in summary that:

PN361

The above section demonstrated that Aboriginal and Torres Strait Islander peoples have a higher level of unmet healthcare needs in urban areas despite there being a greater number of health services in these locations. This emphasises the fact that there are a number of barriers impeding healthcare accessibility for Aboriginal and Torres Strait Islander Australians.

PN362

Then this section emphasis some of the key barriers including cultural safety concerns, language barriers, fears of racism or discrimination, transportation barriers and the cost of healthcare.

PN363

They are all the barriers that the Aboriginal and Torres Strait Islander health workers and practitioners, through their provision of culturally safe healthcare, are able to assist with, and the report then talks about cultural safety, page 805, and, you know, repeats some of the things that we've discussed, such as the value of the separation of men's business and women's business, page 806, and that for a health service to be culturally appropriate in the eyes of many Aboriginal and Torres Strait Islander peoples a male individual would prefer to see a male health worker and there are much lower levels of male health workers than female health workers, and that healthcare services that are not aligned to these values may result in the barrier to healthcare access for male Aboriginal and Torres Strait Islander people.

PN364

Then at page 807, language barriers:

PN365

This can be a significant barrier for Aboriginal and Torres Strait Islanders who do not speak or write English or who write English as a second or third language particularly if the healthcare professionals use medical jargon.

PN366

The next barrier experiences of discrimination or racism and that experiences of discrimination or racism are not uncommon for persons of Aboriginal and Torres Strait Islander descent, and there's reference there to a study referring to a number of studies that have confirmed experiences of racism and cultural insensitivity towards to Aboriginal and Torres Strait Islander by mainstream health services, and that those sort of experiences have negative impacts on health outcomes, and then access to transport and costs of healthcare.

PN367

The next report, tab 72 ‑ ‑ ‑

PN368

DEPUTY PRESIDENT GOSTENCNIK: I'm just mindful of the time. I don't want to interrupt ‑ ‑ ‑

PN369

MS STEELE: Yes, perhaps it's a convenient time to break.

PN370

DEPUTY PRESIDENT GOSTENCNIK: ‑ ‑ ‑your flow since you're going on to another ‑ ‑ ‑

PN371

MS STEELE: Yes.

PN372

DEPUTY PRESIDENT GOSTENCNIK: I think yesterday or the day before my associate notified you of some limits to my availability today.

PN373

MS STEELE: Yes.

PN374

DEPUTY PRESIDENT GOSTENCNIK: So we'll adjourn till 2 o'clock.

PN375

MS STEELE: Yes, Deputy President.

LUNCHEON ADJOURNMENT [12.57 PM]

RESUMED [2.03 PM]

PN376

DEPUTY PRESIDENT GOSTENCNIK: Yes. Good afternoon.

PN377

MS STEELE: Good afternoon. Prior to lunch, I was about to take the Commission to the Health Workforce Australia report behind tab 72 of Mr Briscoe's exhibit, which is in volume 3, and which is the final report of the Aboriginal and Torres Strait Islander Health Worker Project dated December 2011, and the - - -

PN378

DEPUTY PRESIDENT GOSTENCNIK: (Indistinct)

PN379

MS STEELE: Yes, at tab – sorry, I apologise, Deputy President, tab 72. Thank you.

PN380

DEPUTY PRESIDENT GOSTENCNIK: (Indistinct)

PN381

MS STEELE: And at page 893 of that report it sets out the key points, and the first dot point that a highly consultative approach was taken to understanding the Aboriginal and Torres Strait Islander health worker workforce, the challenges it faces and to reach consensus in identifying opportunities for future action, and they set out the research that they did. And then at point 2 the reports states:

PN382

The poor health outcomes of Aboriginal and Torres Strait Islander people are well recognised. A contributing factor is the lack of access to culturally safe primary health services. The contribution that Aboriginal and Torres Strait Islander health workers make in improving access by delivering culturally safe primary health care is not well understood by or recognised across a range of key stakeholders, including policymakers, employers and other professionals.

PN383

And the purpose of the report under the photograph is to inform the developments of policies and strategies that will strengthen and sustain the Aboriginal and Torres Strait Islander health workforce to deliver care in response to the known burden and distribution of disease in the Aboriginal and Torres Strait Islander population.

PN384

At page 896 in the first column it sets out findings, the value and contribution of Aboriginal and Torres Strait Islander health workers identified in the report, the environmental scan and the interim report can be summarised as follows: One, they're a major health workforce delivering culturally safe, comprehensive primary health care. Their holistic approach to health care is aligned to traditional Aboriginal and Torres Strait Islander culture and philosophy.

PN385

A growing body of evidence links the Aboriginal and Torres Strait Islander health worker workforce to improved health outcomes in diabetes care, mental health care, maternal and infant care and palliative care, and the workforce is becoming increasingly qualified with Aboriginal and Torres Strait Islander health workers attaining higher level primary health care and other health qualifications.

PN386

And then at page 905 – so, page – yes, under section 1.3, the report talks about the Aboriginal and Torres Strait Islander health worker workforce setting out the history of the workforce. That it began in the first paragraph over five decades ago, and grew from the need to provide health services to Aboriginal and Torres Strait Islander people whose health needs were not being met by mainstream services.

PN387

And then it sets out that they first emerged as leprosarium workers and hospital assistants in the 1960s, and go into the conclusion in the right-hand column at about point 8 of the page, it says:

PN388

The information collected shows Aboriginal and Torres Strait Islander health workers are a unique profession in the way they perform the comprehensive primary health care role, for example clinical assessment, monitoring and intervention activities and through health promotion and illness prevention programs and chronic disease management services.

PN389

Secondly providing culturally safe health care to Aboriginal and Torres Strait Islander people, such as advocating for Aboriginal and Torres Strait Islander clients to explain their cultural needs to other health professionals, and educating or advising other health profe3ssionals on the delivery of culturally safe health care.

PN390

And then in the first full paragraph after the dot points:

PN391

The project findings demonstrate that no other health profession provides this combination of services for Aboriginal and Torres Strait Islander people.

PN392

And then the next paragraph that:

PN393

The Aboriginal and Torres Strait Islander health worker role is essential to the process of minimising demand for acute care services. Several studies demonstrate the positive impact on health outcomes, including palliative care, diabetes care, mental health care. The evidence suggests that without Aboriginal and Torres Strait Islander health workers, the gap in health outcomes may have been even wider than it is today.

PN394

Then at page 906 again under "Policy Context" in the second paragraph:

PN395

There is an increasing recognition of the importance of Aboriginal and Torres Strait Islander leadership and empowerment in tackling disadvantage. Solutions that are not developed in this way have limited capacity to create lasting change.

PN396

And I'll say more about that later when I come to the classification structure where NATSIHWA seeks to introduce a management role for health workers who have the diploma and advanced diploma.

PN397

At page 907 there's a closing gap on health, education and employment, and obviously the commitment from the Commonwealth Government at that point to spend 1.57 billion to improve Aboriginal and Torres Strait Islander health and wellbeing, and a large proportion of these funds have been invested in new workforce positions. Then in relation to health workforce policies it says, and this is on the right-hand side about point 7 on the right column:

PN398

The health care reforms outlined above will only be sustainable with the right health workforce. Health Workforce Australia was established to facilitate health workforce reform. The strategic framework is a national call for action. It acknowledges the need to increase the number of Aboriginal and Torres Strait Islander working in the health sector to improve health care for Aboriginal and Torres Strait Islander Australians.

PN399

Then turning over the page:

PN400

Another relevant workforce framework is the National Aboriginal and Torres Strait Islander Health Workforce Strategic Framework. That aims to achieve equitable health outcomes for Aboriginal and Torres Strait Islander people through a competent health workforce. Aboriginal and Torres Strait Islander health workers represent 17 per cent of the total number of Aboriginal and Torres Strait Islander people who work in health professions.

PN401

Then the next paragraph:

PN402

Both of these frameworks emphasise the importance of breaking down barriers to Aboriginal and Torres Strait Islander education and building the Torres Strait Islander health workforce.

PN403

The report then goes on to talk about the national registration, that that will facilitate workplace mobility, at the top of the right-hand column:

PN404

And the provision of high quality educational training of Aboriginal and Torres Strait Islander health practitioners and that from 1 July 2012 Aboriginal and Torres Strait Islander health practitioners will be required to be registered nationally.

PN405

Then flipping through the report to page 915 the same message on the bottom of the right-hand column in the second paragraph:

PN406

Again unique profession, no other health profession provides a distinct form of care to Aboriginal and Torres Strait Islander people.

PN407

Then at page 916, 2.2:

PN408

Strong education and career pathways provide the foundation of any workforce. As the Aboriginal and Torres Strait Islander health workforce has evolved more structure has gradually been produced.

PN409

At the bottom of page 916:

PN410

It is broadly accepted there is a need to create clearly structured and accessible education and career pathways for the future.

PN411

At page 917 the report sets out the findings that have been identified through this process in the right-hand column at about point 5:

PN412

There are not enough male Aboriginal and Torres Strait Islander health workers. Only 30 per cent of the Aboriginal and Torres Strait Islander health worker workforce is male. Fifty per cent of the target population is male. The workforce is aging, which contrasts with the young age profile of the Aboriginal and Torres Strait Islander population. There is a much lower Aboriginal and Torres Strait Islander health worker/population ratio in urban areas than in remote areas, and despite high levels of unmet health needs in cities 48 per cent of the Aboriginal and Torres Strait Islander health worker workforce is located in remote or very remote areas where only 24 per cent of the population usually lives, and a number of health services have long standing position vacancies for Aboriginal and Torres Strait Islander health workers with many vacancies lasting several years.

PN413

Then at page 918:

PN414

That many health services report retention challenges with reports of Aboriginal and Torres Strait Islander health workers leaving the workforce to pursue opportunities promising better recognition, respect and employment conditions in other health professions and non-health related fields, and that Aboriginal and Torres Strait Islander health workers are currently looking for new career opportunities within the health worker profession, but do not know where to find them.

PN415

And at about the third paragraph:

PN416

A number of systemic issues affect recruitment and retention. Inequity in pay and conditions is identified. Widespread perceptions of pay inequity between the government health sector and the community controlled health sector.

PN417

Then the last paragraph in the right-hand column on page 918:

PN418

Improving health outcomes for Aboriginal and Torres Strait Islander Australians is currently one of Australia's most pressing priorities. Building a strong pipeline of Aboriginal and Torres Strait Islander health workers with the right skills will better equip the Australian health system to meet these needs in future. A more collaborative and strategic approach to planning the Aboriginal and Torres Strait Islander health worker workforce is essential.

PN419

And in 919 I just ask the Commission to note, and I may have taken you to this previously, but there's a number employed in private health services, which is the first paragraph under section 2.4.

PN420

Section 2.4 the report speaks about the workplace environments that enable and support these health workers. You will see on page 920:

PN421

The types of workplaces

PN422

This is in the second column:

PN423

that supported fewer recruitment or retention challenges were characterised by cultural awareness and respect. A strong long term commitment to the professional development of the workers.

PN424

Then the second last dot point:

PN425

Strong leadership and management, and importantly Aboriginal and Torres Strait Islander health workers in management roles, and that health services with those characteristics seem to develop a reputation in the community as an attractive place of employment.

PN426

At page 921, the first full paragraph in the left column:

PN427

The workplace environment is clearly an important area of focus for Aboriginal and Torres Strait Islander health worker workforce development efforts. Aboriginal and Torres Strait Islander health workers are expected to play a key role in supporting the health of their community. For Aboriginal and Torres Strait Islander health workers to do this well they first need to be enabled and supported in the workplace.

PN428

That will be relevant obviously to the amendment that NATSIHWA seeks in relation to ceremonial leave, but also in relation to the classification change to enable there to be a management role for these health workers.

PN429

The next report is behind the next tab, which is tab 73, and this is the July 2014 Health Workforce Australia, Australia's Health Workforce series, Aboriginal and Torres Strait Islander Health Worker Practitioner and Focus. Much of this type of evidence I have taken the Commission to already, but at page 1036 in this report it sets out what is an Aboriginal and Torres Strait Islander health worker and you will see there it's the same common themes of the culturally safe healthcare, comprehensive primary healthcare and adapt the roles that they perform in response to local health needs and contexts. Again that they're employed by a range of different service providers, including the GP clinics.

PN430

Then at 1037 it talks about the health practitioners being a registered component of the health workforce, and that from 2012 under the national registration scheme practitioners who use the name of health practitioner are required to be registered and that other health workers are not required to use those titles and are not required to be registered.

PN431

At page 1038 there's definitions of the two associations that I have already referred the Commission to. So there's a definition of NATSIHWA and then also the definition of the main employer of the Aboriginal and Torres Strait Islander health workers being NACCHO, and it's set out there that it's the peak body representing over 150 Aboriginal community controlled health services.

PN432

This report goes through setting out what is known about this workforce, and at page 1040 it says from 1996 to 2011 the health workforce has almost doubled. But whilst there has been an increase in the size of this workforce it hasn't been commensurate with the increase in the population growth of Aboriginal and Torres Strait Islander people.

PN433

Then on page 1041 it sets out the age profile by gender of males and females, and at page 1042 the hours worked, and you will see that they worked on average 36.4 hours per work in 2011. At page 1047 is the statistics relating to where the Aboriginal and Torres Strait Islander health workers are employed by remoteness areas and the number per 100,000 Aboriginal and Torres Strait Islander population, and you can see that those figures demonstrate that there are more health workers in the very remote and remote locations as opposed to the major cities, inner regional and outer regional areas.

PN434

Then at 1048 we learn that in 2012 there were 265 registered Aboriginal and Torres Strait Islander health practitioners. Then at page 1068 in the last three dot pages which is the pages on the side the Health Workforce Australia finds that from the census data that there's a higher percentage of females than average being Aboriginal and Torres Strait Islander health workers, and that they have one of the longest average working hours, and only eight of the 44 selected occupations had longer working hours, and one of the largest increase in working hours from 2006 to 2011; only one other occupation had a greater increase.

PN435

At 1077 there's an analysis of what the census data shows, and it shows that there has been substantial growth in the last 15 years, it's predominantly female, and that the workforce is mainly employed in clinical roles.

PN436

The next report at tab 74 is a report by the Australian Government and the Australian Institute of Health and Welfare, and this is a report on Aboriginal and Torres Strait Islander health organisations, online service report, key results, 2016 to 2017.

PN437

At page 1099 it sets out that the primary healthcare - this is under the heading "Primary healthcare services for indigenous Australians" - it sets out that those services play a critical role in helping to improve health outcomes for indigenous Australians, and that indigenous Australians may access either mainstream or indigenous primary healthcare services, which offer prevention, diagnosis and treatment in a range of settings, and that the services are funded by the Australian State Territory Governments.

PN438

At 1137 this report deals with the role of Aboriginal and Strait Islander health workers under the graph at the very bottom of the page, and it says:

PN439

Aboriginal and Torres Strait Islander health workers have an important role in improving the health of Aboriginal and Torres Strait Islander people. In 2013 the community services and health industry skills released new health training packages.

PN440

That's the area of interest to you, Deputy President, about the new health training packages that contained a suite of updated qualifications, skillsets and units of competency in first aid, workplace health, safety and telehealth, and at this point now the numbers of registered health workers in June 2017 has grown to 357, and there's 357 practitioners with a Certificate IV and then 141 with a community stream and 273 with a Certificate II qualification.

PN441

The next document that I would like to refer the Commission is behind tab 75 in volume 4. This is a publication in the Australian and New Zealand Journal of Public Health and it's entitled "A national profile of Aboriginal and Torres Strait Islander health workers", and its authors are Alison Wright, Associate Professor Ray Lovett, and Mr Briscoe, who is the CEO of NATSIHWA, and in this publication in the first paragraph there's the recognition of the importance and increasing evidence of the role of health workers in models of care and facilitating culturally appropriate care, and that that increases in patient contact time, improves follow up practices and enhances patient referral linkages.

PN442

Then in the next paragraph it talks about the government policy documents to build a competent workforce to deliver equitable health outcomes for Aboriginal and Torres Strait Islander people, and to increase the number of Aboriginal and Torres Strait Islander people in the health sector.

PN443

Then in the middle paragraph that in 2002 the Australian Government introduced a national registration which - 2012 - which created the health practitioner, but that only captures one dataset of this workforce, because the health workers are not required to be registered.

PN444

Then on the next page there's a description of the method of which is basically a cross sectional study of indigenous health workers using the ABS census data from 2006, 2011 and 2016, and under the results there's an overall increase of 338 people who reported their occupation as an indigenous health worker, but in the second column:

PN445

The total number of indigenous health workers was not commensurate with population growth. There were 221 indigenous health workers per 100,000 indigenous people in 2006 and 207 indigenous health workers per 100,000 indigenous people in 2016. There was a greater proportion of female indigenous health workers in the workforce, 71 per cent, as well as declines in the proportion of male indigenous health workers from 29.5 per cent in 2006 to 26.8 per cent in 2016. There were declines in the proportion of indigenous health workers aged 15 to 24, 25 to 34 and 35 to 44, and in comparison for all of the older age groups there were substantial increased in the proportion of indigenous health workers, in particular there was a 7.5 per cent in indigenous health workers aged 55 to 64 and a 3.6 per cent increase in health workers aged 45 to 54.

PN446

Then the next paragraph talks about proportions of increases and decreases in the states. There has been a marked decline in the proportion of indigenous health workers in Northern Territory, South Australia, Victoria and Western Australia and slight increases in the other states. The discussion is under the heading "Discussion" in the third column, and despite policy rhetoric about the importance of growing the workforce the authors remain concerned that there has been inadequate growth in Aboriginal and Torres Strait Islander workers since 2006, and that the slight increase in numbers is not commensurate with the growth of the Aboriginal and Torres Strait Islander population generally, and the most notable declines have been in the proportion of young adults and males and workers in the Northern Territory, and only notable increases in two areas. The aging health worker population presents concerns and strengths. They suspect that the decline in younger indigenous health workers is due to the lack of people obtaining qualifications, traineeships and skills. Workers are moving on to other professions.

PN447

At the end of that paragraph in their exploratory study of Aboriginal health workers, which is the study of Felton Bush I refer to at paragraph 11, they found that many Aboriginal health workers wanted career advancement in management, which is currently not a career opportunity that's available to health workers and it's something that NATSIHWA seeks to insert into the classification structure.

PN448

The next paragraph:

PN449

That the increase in Aboriginal and Torres Strait Islander health workers in Queensland may also highlight this jurisdiction's employment policy strength. Queensland Health has a defined career structure for health workers and practitioners in the state system which provides pathways to advance into the profession.

PN450

Then in the third paragraph on the first column, the third full paragraph they talk about the limitations of their analysis being the inability to analyse the health practitioners separately, and the last paragraph:

PN451

Workforce retention recruitment issues are complex and compromised by data limitations, but the conclusion above "Acknowledgement" that overall the small increase in the number of Aboriginal health workers nationally from 2006 to 2016 masks the issues in workforce growth retention and recruitment. Using simple descriptive analysis we have highlighted immediate concerns including growth that is incommensurate with population increases, a stagnant proportion of male indigenous health workers and an aging workforce. This analysis adds weight to the call for a national indigenous health workforce strategy and the need to address critical recommendations in our growing for future report.

PN452

Then at tab 76 there's the National Aboriginal and Torres Strait Islander Health Workforce Strategic Framework 2016 to 2023, and at page 1213 in the introduction it says:

PN453

This strategic framework is a mechanism to guide national Aboriginal and Torres Strait Islander health workforce policy and planning, and the framework focuses on prioritisation, target setting and monitoring the progress against growing and developing the capacity of the Aboriginal and Torres Strait Islander health workforce.

PN454

The third paragraph - well, second paragraph:

PN455

It will assist in contributing to the needs of the health workforce, and that the framework has been developed by the Aboriginal and Torres Strait Islander health workforce working group, a working group of the Health Workforce Principal Committee of the Australian Health Minister's Advisory Council with input from key Aboriginal and Torres Strait Islander health stakeholders.

PN456

So the aim on page 1214 is:

PN457

To contribute to the achievement of equitable health outcomes for Aboriginal and Torres Strait Islander people through building a strong and supported health workforce that has appropriate clinical and non-clinical skills to provide a culturally safe and responsive health outcome. That implementation of the framework is expected to contribute to the delivery of the following outcomes. Firstly that Aboriginal and Torres Strait Islander people are being strongly represented across all health disciplines. Secondly, the representation of Aboriginal and Torres Strait Islander people in the health workforce being proportional to the composition of the total population; health workforce planning that optimises access to healthcare for Aboriginal and Torres Strait Islander people, workplaces that attract, encourage and develop the talents of Aboriginal and Torres Strait Islander health professionals; that Aboriginal and Torres Strait Islander health professionals are supported to lead the development of social, human, economic and cultural capital within the health workforce, and Aboriginal and Torres Strait Islander health professionals playing a vital role in enhancing the Aboriginal health workforce capability through a range of career pathways.

PN458

Then under the key policy linkages it says:

PN459

The framework has been developed within the overall policy context of the national Aboriginal and Torres Strait Islander health plan 2013 to 2023, and its specific goal is to ensure that Australia has a health system that delivers clinically appropriate care in a culturally safe, non-discriminatory and free from racism high quality responsive and accessible for all Aboriginal and Torres Strait Islander people; that the health plan provides a long term evidence-based strategic policy framework as part of the overarching Council of Australian Governments, COAG's approach to closing the gap to indigenous disadvantage which was set out in the National Indigenous Reform Agreement signed in 2008.

PN460

At 1216, the cultural respect framework. It says:

PN461

This framework is consistent with the cultural respect framework for Aboriginal and Torres Strait Islander health which commits the Commonwealth Government and all states and territories to embed in cultural respect principles into their health systems from developing policy and legislation to how organisations are run through to the planning and delivery of services.

PN462

At 1218:

PN463

The vision that the framework shares provision of the Australian health system free from racism and inequality where all Aboriginal and Torres Strait Islander people have access to health systems that are effective, high quality, appropriate, affordable, and that the health system is comprised of an increasing Aboriginal and Torres Strait Islander health workforce delivering culturally safe and responsive healthcare.

PN464

Then the report sets out the commitment to various principles. First of all the centrality of culture, and I will note the final dot point:

PN465

Cultural knowledge, expertise and skills of Aboriginal and Torres Strait Islander health professionals are reflected in health service models and practice.

PN466

Then:

PN467

Health systems effectiveness to developing a health workforce with appropriate clinical and cultural capabilities to address the health needs and to improve the health outcome of Aboriginal and Torres Strait Islander people is central to increasing access to health services.

PN468

Then workplaces must be free of racism. Then on page 1219, "Partnership and collaboration" which is a partnership between Aboriginal and Torres Strait Islander people and government and non-government sections, and that all sectors including the Aboriginal and Torres Strait Islander health workforce should be actively involved in decision-making. Then under "Leadership and accountability":

PN469

Strong quality Aboriginal and Torres Strait Islander leadership at the senior manager and executive levels is central to planning and designing culturally respectful healthcare services for Aboriginal and Torres Strait Islander people. Intentional leadership and talent development initiatives are required to advance Aboriginal and Torres Strait Islander people in both targeted and mainstream positions. Creation of structured career pathways is a vital element in leadership development and retention of Aboriginal and Torres Strait Islander employees. Commitment to achieving a culturally proficient and safe health workforce must come from the top and then filter down. This is the key to growing the Aboriginal and Torres Strait Islander workforce. Strong leadership from both Aboriginal and Torres Strait Islander and non-indigenous health professionals is central in building social participation and eliminating racism from the health system, and workplaces must be encouraged to attract and develop Aboriginal and Torres Strait Islander people across all levels of the organisation including management and representation in governance arrangements.

PN470

Then at page 1220 there's key strategies including developing clear career pathways and providing - in strategy 2:

PN471

Providing opportunities for the development of leadership capability and ensuring that Aboriginal and Torres Strait Islander people are able to participate in management, in decision-making in governance activities.

PN472

Then at 1221:

PN473

Supporting culturally safe and responsive workplace environments for the Aboriginal and Torres Strait Islander.

PN474

Then I would like to just next go through some of the key elements of the report at tab 77, "Our choices our voices close the gap", and at page 1227 there's the acknowledgement by the Australian Prime Minister in his closing the gap 2019 report to parliament, that the target is not on track, and at paragraph 4:

PN475

The stories profiled in this report demonstrate that when Australian and Torres Strait Islander people are involved in the design of the services they need we are far more likely to achieve success. These stories that illustrate that our choice and our voice are vital if we are to make gains and to start to close the gap.

PN476

I am not going to go through the entirety of this report, but it does highlight that there's a number of stories in the report, and at page 1228:

PN477

The overriding principle on the success of health and Aboriginal and Torres Strait Islander initiatives is that they're based on Aboriginal and Torres Strait Islander leadership and governance, which is imperative to the success and longevity of the programs.

PN478

I am reading from about point 5 on the right-hand column.

PN479

The stories also highlight the importance of cultural determinants of health such as strength, resilience, identity and importantly self-determination.

PN480

Then there's in the first full paragraph:

PN481

That the ACCOs are an essential success component of the provision of holistic, affordable and appropriate primary healthcare.

PN482

Then at page 1232 there's the statement:

PN483

Aboriginal and Torres Strait Islander people have a right to access the healthcare they need in the location they choose.

PN484

Then the last report I want to go through, and it might be a convenient time to perhaps call the experts, if that suits the Commission, because they don't - they would prefer not to be in attendance in court tomorrow, so it's a little bit out of sequence.

PN485

DEPUTY PRESIDENT GOSTENCNIK: That's all right.

PN486

MS STEELE: So at tab 78, this is an academic article called "Cultural respect and general practice: a cluster of randomised controlled trial" by a number of authors, and in the first paragraph - well, the summary at the top is useful:

PN487

The gap in life expectancy between indigenous and non-indigenous Australians remain large. Urban indigenous Australian controlled health service are under-resourced and mainstream primary care services are not culturally sensitive. A practice-based respect program including the workshop with advice from a cultural mentor and guided by the care partnership of indigenous practice organisations did not significantly influence indigenous health check rates or cultural respect levels, and cultural respect programs may require more than 12 months to increase indigenous health check rates.

PN488

In this study the authors set out on the first page in the first paragraph the health and care gaps. It talks about the rebate for medical for Aboriginal and Torres Strait Islander people, which is item 715 in the second paragraph:

PN489

And that GPs can now engage suitably qualified practices nurses or Aboriginal health workers to assist with the assessment, including patient history taking, and that the amount for this Medicare item of having an annual health check has increased from 11 per cent to nearly 29 per cent in New South Wales and Victoria. However the rate is still low and access to comprehensive care planning for indigenous Australians is poor.

PN490

Then:

PN491

Aboriginal community controlled health services are important providers of primary healthcare. However, most indigenous Australians living in urban areas also use standard primary care and GP services.

PN492

Then it sets out some of the statistics that indigenous Australians comprise 3 per cent of the Australian population, and 38 per cent are in New South Wales or Victoria.

PN493

One-third of indigenous Australians live in major cities, but only 16 of the 138 community controlled health services are in major cities, and urban community controlled health services have lower staff client ratios than regional and remote community controlled health centres. Indigenous Australians frequently encounter cultural disrespect in mainstream primary care services.

PN494

And there's a report that indicates that 16 per cent of indigenous Australians have experienced racism in health settings in 2012 to 2013, and that 20 per cent of respondents reported that doctors, nurses and other hospital clinic staff were discriminatory, and 7 per cent avoided seeking health care because of unfair treatment. Then in Victoria of 755 adult indigenous persons who were surveyed 29 per cent have experienced racism, and that these authors had previously identified trust, access, flexibility, time, support and outreach of working together as key aspects of cultural awareness and cultural respect.

PN495

Now, the authors of this survey undertook - tried an approach to try and increase the number of active patients coming in to seek access to this Medicare rebate, and unfortunately with the method that they tried to try and increase the proportion of Aboriginal and Torres Strait Islander health workers coming into access this free Medicare item they weren't able to increase the access to the healthcare, but I just wanted to draw the Commission's attention to some of the issues which are reflected in that further academic study, and if it's a convenient time, now might be an appropriate time to call the experts and to ask them to just elaborate on their report and if there's any questions that the Commission might have - I mean we have covered most of the policy documents, and I have been through - I have taken the Commission to part of Associate Professor Lovett's report. Would that be convenient?

PN496

DEPUTY PRESIDENT GOSTENCNIK: Yes. If it assists, Ms Steele, at least from my part I don't need a lot of persuading about the problem.

PN497

MS STEELE: All right.

PN498

DEPUTY PRESIDENT GOSTENCNIK: To the extent that there are problems and I am more interested in what contribution in an award that we might make might have to some finer movement or a solution.

PN499

MS STEELE: Yes. Well, perhaps that can be the focus - that's the question that you could ask each of the experts, because that really is the focus. So I call Associate Professor Lovett.

PN500

DEPUTY PRESIDENT GOSTENCNIK: I make that comment to be helpful with the way in which you conduct your case. I don't want to unnecessarily interrupt you or cut off anything - - -

PN501

MS STEELE: No. I appreciate that comment, it's very helpful, and it is very obvious from the documents, and you will see when you look at their reports that their reports are targeted to the positive outcomes that come from making the changes that NATSIHWA seeks, but given that there is no opposition in this case I thought it would be appropriate to allow the Commission to see these experts and to test those questions if the Commission thought necessary.

PN502

DEPUTY PRESIDENT GOSTENCNIK: Go ahead.

<RAYMOND WILLIAM LOVETT, AFFIRMED [2.50 PM]

EXAMINATION-IN-CHIEF BY MS STEELE [2.50 PM]

PN503

DEPUTY PRESIDENT GOSTENCNIK: Yes, thank you very much. Take a seat. Yes, Ms Steele.

PN504

MS STEELE: Can you tell the Commission, please, Associate Professor, something about your current role and qualifications?‑‑‑Yes. The program leader of the Aboriginal and Torres Strait Islander health program at the National Centre for Epidemiology and Population Health, at the Research School of Population Health, the ANU. It's a bit of a mouthful.

PN505

DEPUTY PRESIDENT GOSTENCNIK: A bit like my surname?‑‑‑Sorry.

PN506

A bit like my surname.

PN507

WITNESS: So my background - so my health professional background is as a registered nurse, an Aboriginal health worker, an indigenous policy adviser, and now as an Aboriginal health researcher.

PN508

MS STEELE: Can you tell the Commission in the context of Aboriginal and Torres Strait Islander health what is health equity?‑‑‑So health equity is the concept of improving indigenous health to the same level as the rest of the population. In equity terms that means you may, or usually will require additional resources and capability to be put in place to achieve that outcome, as opposed to health equality which is giving everyone the same treatment.

PN509

You have provided a report to the Commission in which you have provided your expert opinion on the consequences that might come from the changes that NATSIHWA are seeking to make to the current award. Could you please explain to the Commission in your opinion what your professional opinion would be about the effect on the Aboriginal and Torres Strait Islander health workforce of expanding coverage to the Aboriginal and Torres Strait Islander health workers and health practitioners working in private practice?‑‑‑So you've heard that currently the award is restricted to a small sector of the health workforce, so the 140-odd Aboriginal community controlled health organisations. In my submission I state that that covers less than half of the population, and in fact we're probably missing this category of worker for somewhere in the vicinity of 53 per cent of the population in other areas of Australia, so if you look at geographic spread as well. So the impact of expanding the award to private general practice in particular will allow more appropriate care and will allow the expansion of the profession into those areas as well.

*** RAYMOND WILLIAM LOVETT XN MS STEELE

PN510

DEPUTY PRESIDENT GOSTENCNIK: Associate Professor, what are the barriers now to private providers employing health workers?‑‑‑So if you - - -

PN511

I understand there is some confusion about what other persons should be paid. Is that the only barrier?‑‑‑I think there's probably a clear lack of knowledge or understanding that this workforce actually existed in the private sector as well. Clearly you heard a case study, but that was from an Aboriginal doctor in Western Australia who is clearly aware of this profession. So there would be a lack of awareness of these staff, and in some areas a lack of understanding that employing these categories of workers would actually improve access to healthcare to a private general practice as well. And in saying that, you know, not understanding pain conditions is a barrier. I think it would be a large barrier as well.

PN512

But if one doesn't know about the existence of this workforce award regulation by itself isn't going to address that issue, there needs to be - - -?‑‑‑No, it's not the only thing, but I guess we've heard in terms of Health Workforce Australia some other strategies, and at the policy level that have indicated that a lot of work needs to be done around making the health workforce more generally understand that these professionals exist and clearly delineating their role compared to other health professionals and the value that they can add. So there's probably still quite a lot of work to do in that space as well.

PN513

Is there any consideration being given to encouraging, mandating the employment of these workers by practices who provide health services to the indigenous community?‑‑‑It'd be great if they did. You know, we do it in other areas in health as well, so - - -

PN514

And you obviously couldn't have it immediately because of the numbers, but over time?‑‑‑Yes, I think you would see a build up in numbers over time if - I guess if those sort of approaches were taken, affirmative action approaches. I don't know - I guess you would be guessing at this stage, but I mean there's - you know, as we said before there's 140-odd of these services where they currently mostly work. I can't pull the number of private general practices across the country off the top of my head, but it would be in the vicinity of thousands. So, you know, in areas, some of the areas I work in across Australia currently I can think of at least three communities where there are no Aboriginal community controlled health organisations, and the services are provided either by the state or by private general practice, and I can recall in those three sites that there are no Aboriginal health workers employed. So that - and these are majority Aboriginal communities.

*** RAYMOND WILLIAM LOVETT XN MS STEELE

PN515

How well equipped are the states to roll out training for these workers to be able to work in urban areas where there seems to be a bigger problem in terms of numbers?‑‑‑Quite a difference. You think, you would have to think that it would be easier in urban areas to get the training up and running, because there's more, generally there's more RTOs or registered training organisations in urban areas, but that's highly dependent on - - -

PN516

So I take it that there isn't a great number of RTOs currently running the program?‑‑‑I mean Karl, the CEO of NATSIHWA will probably have better information on that than me.

PN517

MS STEELE: Have you given any consideration to the proposal to increase the number of Medicare items to expand that, is that something that in your opinion is likely to lead to an increase of Aboriginal and Torres Strait Islander health workers and health practitioners in private practice once that Medicare item comes through?‑‑‑You would have to think so. As soon as you provide additional rebatable items in a private sector then it will make it much more attractive in my view to employ Aboriginal health workers and practitioners in those areas because they will be generating income.

PN518

DEPUTY PRESIDENT GOSTENCNIK: Just on that. Is that why the provision of those additional rebatable items that there are no other rebatable items that an indigenous person could not otherwise access?‑‑‑Are you talking about a client or - - -

PN519

Are those additional rebatable items services that are otherwise not available through a private clinic for example?‑‑‑So they're not currently available.

PN520

Right?‑‑‑For this classification of worker. So some of them are. I mean I chair the current review that's been mentioned a number of times around the Medicare Benefit Schedule and there have been a number of recommendations to expand, including the group - the group MBS item. So there are - those are yet to be accepted by the Commonwealth but those recommendations have been broadly well accepted from the stakeholders that we've received feedback from very recently, in fact, yesterday. So there's no opposition to any of this.

PN521

DEPUTY PRESIDENT MASSON: But the issue is, as I understand it, the identity of the class of worker that provided the service in order that the rebate may be claimed rather than the absence of the service in the first place. It's just not being currently accessed?‑‑‑Well, some different categories of worker can claim some of these items now. But in particular areas with high Aboriginal populations you would have to think that employing local people to perform those roles would be much better and much more of an incentive. So, therefore, employing or training local Aboriginal health workers or health practitioners would be seen as much more favourable say compared to a registered nurse or another nursing category.

*** RAYMOND WILLIAM LOVETT XN MS STEELE

PN522

DEPUTY PRESIDENT GOSTENCNIK: And potentially increase the take-up of that service?‑‑‑That's right. If you've got local community members - you know - most of the research in the work that I do at the moment goes to that very point. If you have local people, and in fact we practise it ourselves in all our research work. If you have local Aboriginal people involved in the service delivery in the local area the uptake of those services and the use of those services is much greater by local people.

PN523

MS STEELE: Now in terms of the changes to classification that are sought by NATSIHWA in part of this Modern Award review process there are two principal changes?‑‑‑Mm.

PN524

The first one is an uplift for the health practitioner. And I wondered if you could tell the Commission in your opinion what impact, in your opinion, that having an uplift in wages for the registered health practitioners would be likely to have to the Aboriginal and Torres Strait Island retention and recruitment et cetera and career pathways?‑‑‑Aboriginal health workers and health practitioners are just like many other categories of workers. They do look for career progression, including whether that's in management or pay so that would be of interest to these categories of workers as well. I think you're seeing in some of the statistics that you mentioned just previously around the aging workforce. So you'll see the drop-off particularly in the younger age categories is that people reach a ceiling at a certain point and you realised there's no further professional development and no more career development opportunity for you within your profession. So you seek to look elsewhere and that's why - usually why - health professional groups like this are aging. And you're seeing in this instance quite a number of the younger age groups moving out of the profession. And I think this is one of the reasons why is that there is a clear lack of ability to foresee advancement within the general classifications of those professions.

PN525

Are you able to tell the Commission the change of work and change of practise that occurred to health practitioners as a result of the registration in July 2012? In terms of qualifications and practise of a difference that occurred as a result - - - ?‑‑‑Yes.

*** RAYMOND WILLIAM LOVETT XN MS STEELE

PN526

- - - of registration?‑‑‑Yes. There was clearly, I guess, a further professionalisation of the workforce and that came through the training structure being changed and increased. So mandated increases in the number of subjects and topic areas that people had to undertake to receive a qualification but also the extent of the increase in the clinical training hours required as well which is entirely appropriate, I guess, when you are seeking to further professionalise a workforce like this. But at the same time, it does put barriers in the way of either existing workers, or future workers who had an understanding around the workforce and are having to - you know - go through a different process now. At the same time you're probably also dealing with an issue of changes in pay structures as well and I guess at that time you may also see if there are no management structures or administrative classifications within those structures - you know - that the work forces either stay very flat and that may explain some of that as well. Yes.

PN527

You would be aware that one of the other substantive change that NATSIHWA is seeking to make is to create a new grade six or have a management role for health office to be involved in implementing and designing health programs?‑‑‑Yes.

PN528

What effect do you think that impact, if the Commission were to accede to that change, what impact do you think that would have on the - in your opinion - on the Aboriginal and Torres Strait Islander Health workforce?‑‑‑I think it's a pretty simple kind of impact that would have is that the lack of kind of future progression that we currently see will be there and, I guess, in at the community level if you - if you can't see it - you know these senior people in these positions - you know - having aspiration in these communities is very important. Often there's senior health workers, even though they're not senior health workers there at the moment, are really looked up to as role models but having this category of worker instated in the Award I think would just validate - you know - what communities expect to see and what workers should be able to aspire to if they so choose.

PN529

Yes. You mentioned three rural areas?‑‑‑Yes.

PN530

Is there anything that you can say about the allowances that NATSIHWA is seeking for heat or isolation?‑‑‑Yes. I probably can't say anything about that. Could you - is there anything else that you can tell the Commission about the importance of having Aboriginal and Torres Strait Islander people in leadership roles in achieving health outcomes?‑‑‑It goes back to the point I just made then. If you can't see it, does it exist? So you really - you do need to have Aboriginal and Torres Strait Islander people in these leadership roles.

PN531

DEPUTY PRESIDENT GOSTENCNIK: Taking that proposition would making a provision in an award for a classification and in and of itself isn't going to achieve that outcome is it? Presumably employers in the industry now have capacity to employ particular people into management roles and haven't done so that the availability of a classification?‑‑‑Sorry. I'm finding it very hard to hear you.

PN532

Sorry. It just seems to me - - -

*** RAYMOND WILLIAM LOVETT XN MS STEELE

PN533

MS STEELE: Yes, I should have said deputy President that he has a difficulty with hearing this.

PN534

DEPUTY PRESIDENT GOSTENCNIK: That's all right. I have a difficulty with speaking loudly so we're in trouble. It seems to me that there are other barriers to the engagement of senior practitioners in management positions, other than the absence of award regulation. There mere insertion into an award of a classification will not necessarily result in an uplift in the number of people occupying these positions because there are - it seemed to me - there are other barriers that exist now which award regulation won't necessarily cure?‑‑‑I mean I can only point to what I put in my submission which is around career structure and the systematic review that's been done specific to Aboriginal and Torres Strait Islander health professionals. So I mean we could note what I have written there around - you know - fundamental factors involved in sort of staff turnover and people leaving their professions concerning retention in existing, I guess, structures. But that also sort of talks to the notion of - you know - having really well understood roles and responsibilities including at senior - either administrative or management levels which has also been highlighted as a barrier for keeping Aboriginal and Torres Strait Islander health workers more generally. So I think just having a higher classification of worker in an award , you're right, it probably in and of itself doesn't create an incentive - you know - a whole incentive. But it would have to go some way to creating or incentivising people's willingness to stay or to seeing these positions in the community as valued. So - yes, it may not be the whole story but I am sure it is a big part of the story.

PN535

Yes, I'm just - perhaps if I could reflect on an award with which I'm more familiar than this one - the Nurses Award?‑‑‑Mm-hm.

PN536

About 80 per cent of graduates are female?‑‑‑Yes. I remember.

PN537

There's a career structure?‑‑‑I was the only male in my class.

PN538

There's - - -?‑‑‑'92.

PN539

- - -a career structure, including up to Director of Nursing?‑‑‑Mm-hm.

PN540

But the senior administrative composition of the nursing profession is about 50-50?‑‑‑Mm-hm.

PN541

And is not reflective of the actual population. So there are other barriers?‑‑‑Yes.

*** RAYMOND WILLIAM LOVETT XN MS STEELE

PN542

To the appointment of - in this case - women, to senior managerial positions even in a profession which is dominated by women?‑‑‑Yes.

PN543

And so there's - the insertion of a senior classification or classifications is one piece of the puzzle but it can't be the only piece of the puzzle in these?‑‑‑No, but at the same time if you don't have that classification of worker - - -

PN544

I understand that?‑‑‑- - - then zero people can be part of that.

PN545

Yes?‑‑‑Yes.

PN546

Thank you.

PN547

MS STEELE: Does the Commissioner have any further questions? Otherwise I might call the other expert.

PN548

DEPUTY PRESIDENT GOSTENCNIK: Thank you. You're excused?‑‑‑Thank you.

<THE WITNESS WITHDREW [3.13 PM]

PN549

MS STEELE: I call Ms Wright.

PN550

THE ASSOCIATE: Please say your full name and address?

PN551

MS WRIGHT: Yes. Alyson Wright (address supplied).

<ALYSON WRIGHT, AFFIRMED [3.14 PM]

EXAMINATION-IN-CHIEF BY MS STEELE [3.14 PM]

PN552

DEPUTY PRESIDENT GOSTENCNIK: Yes, thank you, Ms Wright. Take a seat?‑‑‑Thank you.

PN553

Ms Steele?

*** ALYSON WRIGHT XN MS STEELE

PN554

MS STEELE: Could you please tell the Commission something about your experience and working in research with indigenous Australians?‑‑‑Sure. So for the - since I graduated from my first degree which was a science degree I have been primarily based in Alice Springs. I worked for two large non-government organisations, the Central Land Council and the Centre for Appropriate Technology in research roles. And then in 2016 I did my Masters in Applied Epidemiology, going back to the ANU.

PN555

Yes, and are you able to tell the Commission your opinion on effect of the impact on Aboriginal and Torres Strait Islander health practitioners and health workers if award coverage is extended to private practise?‑‑‑Yes. Sure. Okay so I wrote about this in my report, I think - - -

PN556

DEPUTY PRESIDENT GOSTENCNIK: Twenty-five and onwards.

PN557

THE WITNESS: So there's no current award for Aboriginal and Torres Strait Islander health workers and health practitioners who are practising in general practice. As you've heard previously today we don't know exactly of the numbers in general practice and that we know across both the Aboriginal community controlled sector and the award structures within government that there's variation.

PN558

So in regards to that I point to a report by Hudson, in 2012, which just showed the variety in incomes associated with the Aboriginal and Torres Strait Islander and Health Practitioner Award. She analysed data obtained from State and Territory websites that indicated the average wages for Aboriginal and Torres Strait Islander - Aboriginal health workers varied between $28,000 and $52,000 per annum.

PN559

So that was in 2012 that data which was after the current Aboriginal Community Controlled Health Service Award in 2010. She also showed the comparison between other community service occupations in that and found that the Aboriginal Health workers received the lowest average weekly pay.

PN560

MS STEELE: Are you able to tell the Commission your opinion as to whether including the set career structure, as a means for career progression will increase participation, in your opinion, in the Aboriginal Torres Strait Islander professional workforce?‑‑‑Sure. So we know - - -

PN561

DEPUTY PRESIDENT MASSON: Just before you move on, sorry?‑‑‑Yes, sure.

*** ALYSON WRIGHT XN MS STEELE

PN562

That report you referred to of Hudson, was there any analysis of what proportion of those workers that I think were employed by State and Federal Government and covered by agreements versus in the community sector?‑‑‑Not to my knowledge but certainly that's one of the items you have requested. So I can look back at that report and highlight if there has been any of that comparison done.

PN563

So I would imagine that if there were both State or Federal Governments they would generally - their employment might assuming it would be regulated by enterprise agreements whereas it's not clear what the percentage of employees within the community sector would be regulated by agreements as opposed to the award?‑‑‑Okay. So did you want me to talk about the career progression and structure?

PN564

MS STEELE: Yes?‑‑‑So in my opinion both the level 5 and the level 6 would support Aboriginal and Torres Strait Islander health workers and health practitioners. In particular, as it's been noted there was a change in 2012 which it required if you were an Aboriginal Health practitioner, it required you to continue your registration and through that not only was there training requirements but there was the additional continual professional development requirement. It requires you to prove that you've done CPD annually and that that has to be compiled and sent to the Board - the Practitioner Board.

*** ALYSON WRIGHT XN MS STEELE

PN565

Yes, and perhaps if you could state your opinion about the proposed grade 6 management position and how - what effect that's likely to have on the Aboriginal and Torres Strait Islander health work force?‑‑‑Sure. So there is level 6 which is of course the management level. There is currently no management level as we've heard today in this court. I highlight in answering this the experience or the story of one of the Aboriginal and Torres Strait Islander health workers who I have worked with for many years. He is based in a community called Ali Curung. He was employed when the Aboriginal health workers first started. So he was selected by his community to be an Aboriginal health worker in the Northern Territory when health workers first started. Aboriginal community leaders and elders selected who was going to be their health worker. He worked in that position for 20 years and he loved, from his experience, he loved the job. It was important to him. It was important to his community but he also talks about no progression. So 20 years in a role where there's no progression is particularly hard and he also thought that he was undermined by the comings and goings of nurses in his community. He wanted to work more in his community and less in the clinic, which was hard to do under nurses, and he wanted to work more closely with elders and leaders in his community around health and preventative health measures. But he was challenged by a system that didn't allow him to do that. He was challenged because he wasn't in a management or leadership role to be able to move and change the path of how health was determined in his community. He's now working in the Art Centre - the Community Cultural Centre. He's not using any of his health knowledge per se, or any of his clinical experience, but he is seeing that by building self-determination he can enable health to improve. That's what he believes in and there is evidence also to support those claims. So he says, 'I love the job and working with my people but after 20 years in the role I'd seen so many nurses come and go from here. They were moving up in their career from their experiences working in remote. But I was stuck. Not really moving upwards and not really able to move from my community. That's why I'm here now working in the Art Centre, rather than that clinic. I do can do more for my people through working with them - if they're working with our culture than I can do bandaging up their bones. I need to keep elders strong and that's easier to do working with community organisations than working with the government clinic.' And in that community there is only one health service option, and that is the community government clinic. It's now serviced by an Aboriginal receptionist and two non-indigenous nurses.

PN566

And in your opinion you've heard the deputy President ask the question about whether merely changing the award with that would have any discernible impact. On the creation of the management - on the availability of any management position - - -?‑‑‑Yes. It's - - -

PN567

What's your opinion on that?‑‑‑Yes. I heard that question. I thought it was a very good question. There are obviously a range of barriers to it. Aboriginal health workers and health practitioners are working in management levels already. There are structures that have supported that but not within their own profession. So what this would create is an award structure that would enable the recognition to stay in their profession and not necessarily move into - and to support the growing younger generation of people coming through Aboriginal health workers and as the report showed the piece of research that I and colleagues in the room today did was that there are yet fewer younger people entering the profession. It's an ageing profession. There is a group of employees who are continuing to stay in the profession, who love the work and who could actually move up into management roles within the health worker profession which would enable them to support a growing younger population, moving into the health profession as well.

PN568

Does the Commission have any further questions?

PN569

DEPUTY PRESIDENT GOSTENCNIK: No, thank you.

PN570

MS STEELE: Thank you?‑‑‑Thanks.

PN571

DEPUTY PRESIDENT GOSTENCNIK: Thank you, Ms Wright. You're excused. Thank you for your evidence?‑‑‑Thank you.

<THE WITNESS WITHDREW [3.25 PM]

*** ALYSON WRIGHT XN MS STEELE

PN572

MS STEELE: I'd like to take the Commission to finish on the coverage topic now and to take the Commission to our written submissions which are at page 82 of volume one for considerations. So I'm not certain if the Commission has had the opportunity to look at the written submissions but the submissions basically outline the changes that are contended for and then there is detailed written submissions on each change.

PN573

The changes with respect to occupational coverage and new award title that order submissions commence at page 79 of Exhibit 1, paragraph 38, and the principal submission at paragraph 38 to 41 is that it's necessary to extend coverage to an occupation because it's a culturally and distinct occupation that's not covered by any other minimum. Well, it's not covered by any Modern Award and that as required by section 134(1) of the Act extending coverage, this is at paragraph 42, Health Workers and Health Practitioners who are employed in private practice would provide them with a minimum safety net of terms and condition to workers who are not covered by any Modern Award and that that change would promote social inclusion to encourage increased workforce participation and recognition and that these are all relevant considerations pursuant to section 134(1)(c), (e), and (g).

PN574

All of the interested parties supported the coverage extension, apart from AFEI who initially objected during the conciliation process on the basis that the health workers and health practitioners who were employed in private practice may already be covered by another Modern Award. It appears from their written submissions filed earlier this week that they are no longer pressing that objection and that their key - the key objection of AFEI - in their submissions is that NATSIHWA is unable to prove precisely how many people are employed in private practice and that the HPSS Award might be amended but without any proposal as to how that award might be amended.

PN575

In response to that NATSIHWA's submissions, firstly, that it's irrelevant - the number of people to be able to prove precisely the number of people who are employed in private practice, there are clearly health workers who are employed in private practice who aren't covered by Modern Awards.

PN576

There has been evidence of that from Dr Trust in the Commonwealth documents, also from Associate Professor Lovett, and that it would not be possible to amend the HBSS Award in any easy way that would provide the health workers in private practice with - - -

PN577

DEPUTY PRESIDENT GOSTENCNIK: It certainly wouldn't be possible in these proceedings to do so.

PN578

MS STEELE: Yes.

PN579

DEPUTY PRESIDENT GOSTENCNIK: And that's a whole and other case.

PN580

MS STEELE: Yes. It's a whole and other case but in any event the one thing that is important to the Aboriginal and Torres Strait Islander health work profession is to have some consistency and to have - you know - equity in the same career structure between Aboriginal and Torres Strait Islander health workers employed in - private practice - you know, as a matter of equity they should have the same minimum terms and conditions. And that appears to be the principal objection that is sought to be made by AFEI at this point. I'm not - - -

PN581

DEPUTY PRESIDENT MASSON: But just on that - - -

PN582

MS STEELE: Yes.

PN583

DEPUTY PRESIDENT MASSON: I mean by the introduction of award coverage in private practice which might otherwise already have persons covered by other awards are there equity issues there that need to be considered in terms of having multiple instruments providing potentially different terms and conditions in the one workplace?

PN584

MS STEELE: The persons who are employed in private practice aren't covered by any State Award.

PN585

DEPUTY PRESIDENT MASSON: No. I'm talking about whether there are other persons in other classifications.

PN586

MS STEELE: There's - - -

PN587

DEPUTY PRESIDENT MASSON: In private practice. You might then introduce different instruments with different terms and conditions putting the classification structure aside.

PN588

MS STEELE: Well, in private - I'm not aware of any - well, I'm not aware of any awards covering that would impact upon the employment of these health workers who have to be - who have all of the pre-requisites of being Aboriginal and Torres Strait Islander heritage, have the culturally safe approach to health care and to have done one of those specific qualifications.

PN589

DEPUTY PRESIDENT MASSON: No. I understand that.

PN590

MS STEELE: Yes. And - - -

PN591

DEPUTY PRESIDENT GOSTENCNIK: Well, I think the deputy President's question is a different one.

PN592

MS STEELE: Yes.

PN593

DEPUTY PRESIDENT GOSTENCNIK: And that is one as between relativity between a worker who, in private practice, who would be covered by the award you propose be varied and the conditions that are contained therein and the other workers in that same private practice who might be covered by a different award.

PN594

MS STEELE: Yes.

PN595

DEPUTY PRESIDENT GOSTENCNIK: And whether that raises any issues about either relativities as between the rates of pay or the terms and conditions under which workers working under the same roof if you like might have different conditions.

PN596

MS STEELE: It may be easier given the time for it and given that that's something that hasn't been raised by any of our opponents, if the Commission would be happy for me to provide a comparison document tomorrow to deal with that point.

PN597

COMMISSIONER BISSETT: I think part of the issue is the complexity that arises for the person who's running the private practice in having two different industrial instruments that apply in the workplace that have two quite disparate - or potentially disparate terms and conditions for the employment. One applying to the ATSI health workers and one applying to the other health workers who might be covered, for example, by the HPSS Award.

PN598

MS STEELE: Yes.

PN599

COMMISSIONER BISSETT: Yes.

PN600

MS STEELE: Then I'll take that question on notice and perhaps that could be the first thing that we deal with tomorrow.

PN601

DEPUTY PRESIDENT MASSON: I should just make the final point.

PN602

MS STEELE: Yes.

PN603

DEPUTY PRESIDENT MASSON: It's not unknown in many industries and organisations.

PN604

MS STEELE: Yes.

PN605

DEPUTY PRESIDENT MASSON: To have more than one award applied but I am just raising the question.

PN606

MS STEELE: Yes.

PN607

DEPUTY PRESIDENT MASSON: As to whether that's been considered.

PN608

MS STEELE: So I won't go over - I will just note that paragraphs 42 to 46 deal with the lack of overlap with the HPSS Award and then from paragraphs 48 on there's NATSIHWA's submissions on the section 134 considerations which is that there isn't any overlap with the HPSS Award and that there is a clear occupational dividing line. And that providing the Modern Award would ensure equal remuneration for work of equal or comparable value to that performed by the health workers and the health practitioners inside these community controlled health services and that the numbers of these health workers in private practice are increasing and that the lack of Modern Award coverage has resulted in uncertainty regarding the applicable pay rate and there was the evidence of Dr Trust on that.

PN609

Also, the point that Aboriginal and Torres Strait Islander health workers working in private practice and working in community controlled health centres should be able to access the indigenous specific benefits that are available to the health workers and health practitioners in the community controlled health services, such as ceremonial leave, which is obviously important which is in clause 30 of the Award and the bilingual qualification allowance. But given that they're all persons of Aboriginal and Torres Strait Islander background that access to those practitioners in private practice that they shouldn't be denied those indigenous specific conditions because it's difficult to make the health system more culturally appropriate for Aboriginal and Torres Strait Islander health people if the work places themselves aren't made more culturally appropriate for the health practitioners and health workers themselves.

PN610

And then the submissions talk about the increase in further review of the Medicare Benefit Scheme and the likelihood that they'll be increased. There is - noting the time - tomorrow I will take the Commission to the National Scope of Practice that's being developed in respect of the Aboriginal and Torres Strait Islander health workers. But, effectively, NATSIHWA's submissions are that if it is expanded to include the health workers, not only in the community controlled health centres, that this will bring greater and certainly inconsistency within the occupation, because employers will be able to have reference to the classifications and descriptions in the award and that that will according to the evidence of the experts and the government's policy direction promote social inclusion through increased workforce participation.

PN611

You've heard from the experts that the - and from the evidence that these community controlled health centres aren't everywhere in Australia. There is evidence to suggest paragraph 63, and this is - I didn't take you to this - but in the statement of Mr Karl Briscoe, at paragraph 144, he gives evidence of his experience that Aboriginal and Torres Strait Islander people often drive past multiple mainstream medical providers due to the lack of having a health worker or health practitioner and that evidently there is a need for the ATSI people to access health in a culturally safe banner.

PN612

So save for coming back to your question tomorrow morning they're the submissions on coverage. The next - section two is quite short and I can probably cover that in the next 10 minutes and then I think at that point it would be best to break because the classification structure is a much larger topic.

PN613

So in the aid memoir on page - - -

PN614

DEPUTY PRESIDENT GOSTENCNIK: While we're on that do you need us to start a bit earlier tomorrow to make sure that you're finished tomorrow?

PN615

MS STEELE: Well, if the Commission was happy to do that?

PN616

DEPUTY PRESIDENT GOSTENCNIK: Well, we can start at 9 am tomorrow.

PN617

MS STEELE: 9 am, thank you for that indulgence. That's very helpful. That is the largest topic and we have covered the bulk of the evidence. So in the aid memoir you will see the changes that are sought by NATSIHWA with respect to progression, previous service and evidence of qualifications. Basically it sets out in the left-hand column the proposed change and then details the source of the proposed clause where it's come from.

PN618

Now these changes were uncontroversial and not opposed by any of the interested parties. They're supported by NACCHO.

PN619

DEPUTY PRESIDENT MASSON: Just on that, Ms Steele.

PN620

MS STEELE: Yes.

PN621

DEPUTY PRESIDENT MASSON: When you're say they're supported by NACCHO, are you referring to the correspondence - - -

PN622

MS STEELE: Yes.

PN623

DEPUTY PRESIDENT MASSON: - - -from NACCHO?

PN624

MS STEELE: Yes.

PN625

DEPUTY PRESIDENT MASSON: And my reading of that letter it appeared to be primarily dealing with the expansion of the proposed expansion of coverage from community organisations to private practice. But you say the letter should be taken as being support for all of the changes?

PN626

MS STEELE: I can understand, deputy President, how you might read the letter that way. The position is that NACCHO does support all of the changes and if necessary, you know, I could lead some evidence from Mr Briscoe as to them having received the award and being supportive of all of the changes in the award but - - -

PN627

DEPUTY PRESIDENT MASSON: Well, from my part I would be assisted by that.

PN628

MS STEELE: Yes.

PN629

DEPUTY PRESIDENT MASSON: Because my reading of the letter was a narrower - - -

PN630

MS STEELE: Yes.

PN631

DEPUTY PRESIDENT MASSON: - - -expression of support.

PN632

MS STEELE: Yes. Well, perhaps that's something that we can do at 9 am tomorrow morning.

PN633

DEPUTY PRESIDENT MASSON: Thank you.

PN634

MS STEELE: Noting the time.

PN635

DEPUTY PRESIDENT MASSON: Yes. No, that's all right.

PN636

MS STEELE: Yes. All right. So, effectively, in the current award which you can find at tab one, there is no recognition or there is no set means for progression previous service and evidence of qualifications. And there isn't any formal mechanism which can have obviously unintended consequences of having people put at different pay - different grades and put at grades that aren't commensurate with their skills which may disincentivise transfer between different employers - and hence limit the expansion of the occupation which is recognised as integral to meeting the broader health objectives. And so, with respect to progression, NATSIHWA sets out - well, at 68, that the provisions taken together are intended to clarify the existing operation of the award with respect to progression within a grade and to provide a balanced and fair mechanism for classification and minimum wage determination on commencement for employees and employers.

PN637

And then with respect to the progression clause which you can see as being effectively uplifted from the social Community Home Care and Disability Services Industry Award, NATSIHWA submits that if the award is amended to provide this to find mechanism at paragraph 70 that it will clarify the operation of the award, that it will encourage the health workers and health practitioners to pursue a higher level of skills and/or qualifications in order to progress through the classification levels with a view to retaining the existing workforce and, at 70.3 to increase the attractiveness of the profession to potential or prospective health workers and health practitioners by providing prospects for promotion and associated wage increases for workers employed in the community health centres or in private practice, therefore creating an incentive for Aboriginal and Torres Strait Islander persons to enter the health practitioner work - health professional workers of Aboriginal and Torres Strait Islander workers.

PN638

Likewise with the recognition of previous service on the page you will see that that clause has been effectively uplifted from the Educational Services Teachers' Award and, again, paragraph 73 and 74 encompass NATSIHWA's submissions on that clause that the current award doesn't provide any formal mechanism for employers to recognise an employee's experience and it will allow consistency of what is taken into account in a person's previous experience in transferring from one role to another role.

PN639

And, finally, the evidence of qualifications clause which is on the next page of the aid memoir that has been uplifted from the Educational Services Teachers' Award and - the submissions on that are at paragraph 76 and 77 which is, as a practical matter, it's necessary to enable employers to verify a prospective employees previous qualifications and experience and there's evidence that managers recruiting new health workers and health practitioners base their wages on their qualifications and their previous experience and that health workers and health practitioners currently receive pay raises on the basis of attainment of new skills or of qualifications proven of their existing skills and their experience. And that's at 67. The evidence is set out in footnotes 66 and 67. But noting the time it may be convenient to finish now and we'll come back to that evidence tomorrow.

PN640

DEPUTY PRESIDENT GOSTENCNIK: Yes, thank you very much. Thank you for your contributions today. We'll adjourn until 9 am tomorrow.

ADJOURNED UNTIL FRIDAY, 26 JULY 2019 [3.45 PM]

LIST OF WITNESSES, EXHIBITS AND MFIs

EXHIBIT #1 WITNESS STATEMENTS IN COURT BOOK - TABS 5 TO 38 AND TAB 41................................................................................................................................... PN46

EXHIBIT #2 WITNESS STATEMENT OF KARL JOHN BRISCOE PLUS ANNEXURES................................................................................................................................... PN47

RAYMOND WILLIAM LOVETT, AFFIRMED............................................. PN502

EXAMINATION-IN-CHIEF BY MS STEELE................................................. PN502

THE WITNESS WITHDREW............................................................................ PN548

ALYSON WRIGHT, AFFIRMED...................................................................... PN551

EXAMINATION-IN-CHIEF BY MS STEELE................................................. PN551

THE WITNESS WITHDREW............................................................................ PN571