Primary Health Networks
& Funding Organisations
Resources to Support Culturally Safe & Sustainable Commissioning
At present, most Commonwealth Government funding of suicide prevention programs for Indigenous people and communities is delivered via the Primary Health Networks (PHNs) to Aboriginal Community Controlled Health Organisations (ACCHOs) and mainstream organisations.
The CBPATSISP supports the National Aboriginal Community Controlled Health Organisation (NACCHO) position that ACCHOs should be funded directly as preferred providers of mental health and suicide prevention services for Aboriginal and Torres Strait Islander people, in line with the principle of self-determination.
Until this is achieved, PHNs must take responsibility for commissioning services in ways that empower Indigenous people and organisations, develop their capacity, and support their autonomy.
This section of the Manual contains resources that can help PHNs support the wellbeing of Indigenous people through culturally safe and sustainable commissioning.
PHN GUIDANCE DOCUMENTS
This section of the Manual links to key Department of Health policy documents. It is intended to assist Primary Health Networks (PHNs) in navigating and interpreting the advice provided by the Commonwealth Government in their commissioning of suicide prevention services for Aboriginal and Torres Strait Islander people and communities.
Funding, Policy & Guidance
The PHN Funding Environment for Aboriginal & Torres Strait Islander Mental Health & Suicide Prevention
The 31 Primary Health Networks collectively receive about $670 million per year (estimate 2018-19) to deliver regional and local programs in mental health and suicide prevention. This includes around $60 million quarantined for programs for Aboriginal and Torres Strait Islander people.
Of the remainder, around $400 million is for the PHNs to spend flexibly on programs according to the needs of their regions, while around $200 million is for headspace and youth psychosis services – any of which may be used by Indigenous people.
12 PHNs have also collectively received $48 million over four years to June 2020 to run the National Suicide Prevention Trial, which included two Indigenous trial sites (Darwin and the Kimberley) and another five trials which included Indigenous people among other priority populations. (1)
How PHNs should work with Indigenous Communities
The Government sets expectations for PHNs in their commissioning of Aboriginal and Torres Strait Islander mental health and suicide prevention services through a collection of guidance documents. Some are Indigenous-specific while most apply to all commissioning, and vary greatly in the level of detail they include about how to apply the guidance in PHNs’ work with Indigenous communities.
Overarching all PHN commissioning for Aboriginal and Torres Strait Islander communities (including physical as well as mental health), the Primary Health Networks (PHNs) and Aboriginal Community Controlled Health Organisations (ACCHOs) – Guiding Principles document establishes a template for the relationship between PHNs and ACCHOs, articulating principles of Indigenous health, culture and governance as they are to be applied by the PHNs across all their work…
“The establishment of PHNs provides an opportunity to build connections across the health system to further improve access for Aboriginal and Torres Strait Islander people to appropriately targeted care that is effective and culturally appropriate, and importantly, to ensure that there is full and ongoing participation by Aboriginal and Torres Strait Islander people and organisations in all levels of decision-making affecting their health needs.
There are four key factors for improving quality of life and achieving health equity across all aspects of the social determinants of health:
- connection to culture
- allowing Aboriginal and Torres Strait Islander people to determine and implement the solutions
- improving cultural awareness and respect across the wider Australian population, and
- effective partnerships – Aboriginal and Torres Strait Islander health is everybody’s business.”
This guidance also sets out in detail the respective roles of ACCHOs and PHNs working in partnership in domains including:
- Closing the Gap
- Cultural competency
- Engagement and representation
- Accountability, data and reporting
- Service delivery
Mental Health Tools & Resources
These tools and resources are intended to be read in conjunction with Primary Health Networks (PHNs) and Aboriginal Community Controlled Health Organisations (ACCHOs) – Guiding Principles.
Many are unchanged since their original publication in 2016, while some have been added or updated more recently.
Mental Health Flexible Funding Pool
This is a collection of guidelines for PHNs in commissioning under the flexible funding pool program, through which PHNs are expected to respond to the particular mental health needs in their regions.
Tools & Checklists
These tools and checklists have been developed to assist PHNs in commissioning services that empower Aboriginal and Torres Strait Islander communities, respect their autonomy, and model genuine, reciprocal relationships that prioritise Indigenous perspectives in the development of social and emotional wellbeing and suicide prevention programs and services.*
By completing these interactive checklists, PHNs can identify their strengths and any weaknesses in preparing to commission services for Indigenous people and communities. They can also return to the checklists periodically, to monitor their
progress over time towards culturally responsive commissioning.
*These checklists represent PHNs’ existing responsibilities to commission culturally safe services for Aboriginal and Torres Strait Islander people, and have been developed from the following source documents:
PHN Engagement Project
In 2017 the Australian Government established the National Suicide Prevention Leadership and Support Program, funding projects to reduce suicide and suicidal behaviour. One objective was to build the capacity of Primary Health Networks (PHNs) to lead regional suicide prevention service planning and commissioning.
The Centre of Best Practice in Aboriginal and Torres Strait Islander Suicide Prevention (CBPATSISP) is funded under the program to develop and promote best practice resources in Indigenous suicide prevention for use by PHNs through the Manual of Resources in Aboriginal and Torres Strait Islander Suicide Prevention.
In 2019 the CBPATSISP visited 14 PHNs across Australia to identify key issues in their commissioning of social and emotional wellbeing and suicide prevention services for Aboriginal and Torres Strait Islander people. The PHN Engagement Project explored PHNs’ experiences of working with Indigenous communities, highlighting common themes, opportunities and responses to challenges.
Responding to the National Mental Health Commission’s 2014 Review of Mental Health Programs and Services, the Commonwealth Government in 2015 committed the newly established Primary Health Networks (PHNs) to develop regional approaches to mental health services, including suicide prevention.
PHNs manage approximately 10 per cent of the Australian government’s expenditure in mental health and suicide prevention.
There are 31 PHNs Australia-wide. They vary considerably in terms of:
- Geographic footprints – from Country WA, which covers one-third of Australia’s land mass, to compact but densely populated metro areas.
- Levels disadvantage and population health needs
- Proportion of Indigenous populations – from 30% in the NT to less than 1% in some urban areas
- Staff numbers – from more than 100 to fewer than 40 people
PHNs do not deliver services directly. Instead they work with primary health care providers including GPs and Aboriginal Community Controlled Health Organisations (ACCHOs), and with hospitals and other providers, to plan and promote better care based on regional needs in seven priority areas:
- mental health
- Aboriginal and Torres Strait Islander health
- population health
- health workforce
- digital health
- aged care
- alcohol and other drugs.
The complex and multi-factorial nature of suicide among Aboriginal people means PHN commissioning of social and emotional wellbeing and suicide prevention services may span several of these priority areas.
The 2016 ATSISPEP report proposed principles for PHNs in serving Aboriginal and Torres Strait Islander people and communities:
- Aboriginal Community Controlled Health Organisations (ACCHOs) should be preferred providers.
- Mainstream NGOs should only be commissioned if there is no suitable ACCHO service, and only at the request of community.
- PHNs should be accountable for commissioning decisions, including supporting the expansion of ACCHO services.
Despite the diversity of PHNs and the communities they serve, several common themes emerged during the project:
Governance, Representation and Co-design
Each PHN is governed by a board, and is required to have at least two advisory councils to the board: a Clinical Advisory Council and a Community Advisory Council.
About half of PHNs have one or more Indigenous board members. Aboriginal and Torres Strait Islander representation is more consistent among Community Advisory Councils. One PHN has an Indigenous reference group advising the board.
Many, but not all PHNs, employ Indigenous staff, some of whom are in identified positions. Some Indigenous staff report feeling conflicted when the PHN’s work is incompatible with the aspirations of their communities.
Some PHNs have robust, well-established community networks for co-design, consultation and ongoing communication. This tends to be in regions with larger Indigenous populations. In other regions, PHNs seek advice from representative bodies such as Aboriginal land councils and ACCHO peaks, which do not always have the capacity to meet their consultation requests.
PHNs recognise that effective Indigenous representation is at the heart of effective and inclusive service commissioning, and many of them need to do better in promoting representation, finding ways to include Aboriginal and Torres Strait Islander people appropriately in decision-making and leadership, while not overburdening them.
Scale and Capabilities of Commission Organisations
The ATSISPEP principles state PHNs should commission ACCHOs to deliver Indigenous suicide prevention and social and emotional wellbeing services.
Some ACCHOs are large organisations with highly qualified clinical staff and experienced administrative teams that can readily bid for PHN contracts and report against objectives defined by the government. Others are small and cater to defined groups either geographically and demographically, directing their energy towards their communities and less focused on applying for grants, or compliance and acquittal processes. Such organisations may miss out on funding unless PHNs work with them in ways that support their culture and priorities.
- Some PHNs offer “pitch nights” in which community organisations present their work verbally, with winning proposals selected by the community. This is more consistent with the oral cultural of Indigenous communities and avoids over-valuing administrative and government experience.
- PHNs can fund training for ACCHOs to up-skill in submission writing, levelling the playing field for them to win contracts from PHNs and other national and state government agencies.
Diversity of Indigenous Communities
PHNs reported that government funding models do not adequately account for the diversity of Indigenous communities, including consequences of colonisation and displacement that may make it hard for some people to access services closely identified with other groups.
There are also distinct challenges in commissioning appropriate services in major cities to which people travel from Country for medical treatment and family reasons - resulting in transient populations from diverse language and culture groups, who may also have high needs.
And there are significant cross-border issues particularly in the eastern states, where large numbers of people may travel to an ACCHO in a neighbouring state to seek health care. This presents challenges for planning and resourcing.
Community ownership of SEWB initiatives is essential, and engagement and co-design processes must be approached independently wherever a program is considered. Communities are keen to learn about successful programs from other regions, but these cannot simply be replicated at a different site.
- One PHN has successfully commissioned a program to address lateral violence between family groups, with an Indigenous facilitator from another state to help identify colonising practices as the real source of conflict.
- Another PHN is actively seeking out relationships across Indigenous communities in its catchment to improve diversity of representation.
The Commonwealth Government’s advice states “PHNs are able to determine the most suitable workforce from which the commissioned services can be delivered based on existing workforce supply and any other relevant considerations, noting that workforce skills and qualifications must be commensurate with the level of service being commissioned. In some circumstances funding can be considered for workforce development activities.”
Some PHNs reported that this statement has the effect of emphasising clinical roles, especially psychologists and mental health nurses, and the level of required qualifications was gradually increasing. This in turn reduced opportunities for Indigenous people who are more likely to experience education disadvantage and less likely to hold a mainstream professional qualification.
At the same time, some PHNs said it was hard to find training places for Certificate lll and lV Aboriginal health workers – a culturally appropriate credential that is highly acceptable to communities.
The PHNs wanted flexibility to commission services employing people with a wider range of qualification types in order to meet Indigenous community needs, and the ability to recognise attributes such as standing and relationships in a community, encouraging commissioned organisations to employ more Indigenous people.
Some PHNs acknowledged and regretted that commissioning of mainstream organisations had undermined the capacity of ACCHOs by attracting qualified mental health professionals away from them.
- To address these issues, one PHN has sponsored the Certificate lll Aboriginal Health Worker education of a cohort of Indigenous people, aligning the students’ elective subjects with SEWB work.
Funding Streams, Reporting and KPIs
Suicide prevention for Aboriginal and Torres Strait Islander people depends on self-determination and community empowerment, strengthening whole-of-community connection, promoting wellbeing and resilience and recognising the influence of the social determinants of social and emotional wellbeing (SEWB).
However SEWB is not a discrete PHN responsibility, and it can be unclear how SEWB activities prioritised by communities align with PHN program budgets. Some PHNs have created SEWB budgets from mental health, Aboriginal health and alcohol and other drugs funding streams. Others support SEWB programs through underspends in related areas. It remains challenging to provide holistic Indigenous suicide prevention activities within the constraint of funding rules.
ACCHOs and other Indigenous community organisations commissioned by PHNs to provide services typically offer support as required – often round-the-clock, and inclusive of families and community members rather than focusing only on the individual client. This approach is in line with principles of SEWB and Indigenous suicide prevention but it may be at odds with an ‘episodes of service’ model on which PHN funding is calculated.
Additionally, ACCHOs may receive funding from multiple Commonwealth, state, local government and NGO agencies for overlapping activities. It may be challenging to show clearly what each agency is specifically resourcing and what outcomes they have achieved individually.
These issues are compounded where PHNs commission programs modelled on Indigenous healing principles (strengthening connection to Country, community and culture) alongside clinical services. Such approaches are inherently more difficult to measure in the short term.
Program evaluation is another concern for many PHNs. Qualitative evaluation approaches, that assess depth of engagement, participant satisfaction and changes in behaviours, may be more appropriate than quantitative measurement. Some PHNs applied the ATSISPEP evaluation framework, which includes steps for organisations, communities and services, but others found this challenging to use.
The Role of Mainstream Services
In 2016-17, according to the Australian Institute of Health and Welfare, ACCHOs delivered primary health care services to around 371,600 people – about half of the Aboriginal and Torres Strait Islander population. Other Indigenous people appear not to use an ACCHO for their health care – either for reasons of accessibility or choice. Even in regions with strong ACCHO services, mainstream services may still have an important role for Indigenous people.
PHNs must therefore ensure funded mainstream services practise culturally responsive mental health support for Indigenous people. Several PHNs emphasised the importance of skilling GPs through cultural competence training to more sensitively explore mental health and social concerns with their Aboriginal and Torres Strait Islander patients, rather than defaulting to physical health concerns.
Most PHNs provide cultural responsiveness/awareness training for their own staff, and often include staff of funded services. The training ranges from online training modules to experience-based development programs led by local Elders. Several PHNs recommended the cultural respect training programs of the Australian Indigenous Psychologists Association and the Royal Australian College of General Practitioners.
PHNs with relatively smaller Aboriginal and Torres Strait populations may not have dedicated staff to commission services appropriate for Indigenous people, making it challenging to meet community needs.
- A PHN with a large Aboriginal and Torres Strait population is developing a cultural supervision program to support non-Indigenous clinicians working in communities, pairing them with Elders, and encouraging them to reflect deeply on their learning.
Suicide Prevention Trials
There has been strong suicide prevention trial activity throughout Australia, with trials funded by the Commonwealth Government (12 x trials), the Victorian government (12 x trials) and the Paul Ramsay Foundation (5 x Black Dog Institute’s NSW and ACT Lifespan trials). Most of these are being evaluated in 2020-21.
Among the 31 PHNs, 20 have hosted at least one trial. Of a total 29 trials, two (7%) are focused wholly, and another five (17%) partly, on Aboriginal and Torres Strait Islander people. The others are also expected to serve the needs of Indigenous people through their broader community focuses – for example, on youth, older people or the LGBTI populations.
The extra resourcing for suicide prevention has been welcomed by PHNs and communities, and supported innovation that would otherwise not have been possible. However the initial timeframes for implementation and reporting (later extended) were considered incompatible with the long-term relationship building with Aboriginal and Torres Strait Islander communities needed for co-design and cultural safety.
PHNs are keen to engage about culturally safe commissioning of suicide prevention and SEWB services for Aboriginal and Torres Strait Islander people and communities, and to share examples of success, responses to challenges and barriers, and approaches to evaluation.
These priorities have informed the PHN section of the Manual and the information and resources that are included.
Reconciliation Action Plans
Under the Commonwealth Government’s Primary Health Networks (PHNs) and Aboriginal Community Controlled Health Organisations (ACCHOs) – Guiding Principles (2016), all PHNs should, “have in place, or be progressing towards, a Reconciliation Action Plan endorsed by Reconciliation Australia”.
Reconciliation Australia, “promotes and facilitates reconciliation by building relationships, respect and trust between the wider Australian community and Aboriginal and Torres Strait Islander peoples,” based on five dimensions: race relations, equality and equity, institutional integrity, unity and historical acceptance.
A Reconciliation Action Plan (RAP) is a strategic document which supports an organisation’s business plan and includes practical actions to drive reconciliation both internally and in the communities in which the organisation operates, by supporting organisations to develop respectful relationships and creating meaningful opportunities with Aboriginal and Torres Strait Islander peoples. There are four tiers of RAP, representing different levels of experience of and commitment to reconciliation principles within an organisation.
In this regard, a RAP is strongly aligned with suicide prevention principles in Indigenous communities, which also emphasise Indigenous leadership and respectful relationships that acknowledge past and continuing injustices alongside strengths and capacity. A RAP is current for one year for the initial Reflect level RAP, rising up to three years for the more advanced Stretch level RAP.
Most PHNs have completed at least one RAP, according to a review of PHN websites (September 2020). These RAPs, which are linked below, provide a resource for other PHNs as they begin or move along their RAP journey.
A Reflect RAP clearly sets out the steps you should take to prepare your organisation for reconciliation initiatives in successive RAPs. Committing to a Reflect RAP allows your organisation to spend time scoping and developing relationships with Aboriginal and Torres Strait Islander stakeholders, deciding on your vision for reconciliation and exploring your sphere of influence, before committing to specific actions or initiatives. This process will help to produce future RAPs that are meaningful, mutually beneficial and sustainable. – Reconciliation Australia
Coordinare (South Eastern NSW PHN) (June 2019 to June 2020)
South Western Sydney PHN (January 2019 to January 2020)
WentWest (Western Sydney PHN) (June 2018 to June 2019)
South Eastern Melbourne (June 2018 to June 2019)
Brisbane North (June 2019 to June 2020 – now beginning an Innovate RAP)
Darling Downs West Moreton PHN (March 2020 to March 2021)
Northern Queensland PHN (September 2018 to September 2019)
WAPHA (March 2018 to March 2019)
An Innovate RAP outlines actions that work towards achieving your organisation’s unique vision for reconciliation. Commitments within this RAP allow your organisation to be aspirational and innovative in order to help your organisation to gain a deeper understanding of its sphere of influence, and establish the best approach to advance reconciliation. An Innovate RAP focuses on developing and strengthening relationships with Aboriginal and Torres Strait Islander peoples, engaging staff and stakeholders in reconciliation, developing and piloting innovative strategies to empower Aboriginal and Torres Strait Islander peoples. – Reconciliation Australia
Central and Eastern Sydney PHN (June 2018 to June 2020)
Nepean Blue Mountains PHN (June 2018 to June 2020)
North Western Melbourne (February 2018 to February 2020)
Gold Coast PHN (February 2018 to February 2020)
NTPHN (December 2017 to December 2019)
Eastern Melbourne PHN (March 2020 to March 2022)
A Stretch RAP is best suited to organisations that have developed strategies, and established a strong approach towards advancing reconciliation internally and within the organisation’s sphere of influence. This type of RAP is focused on implementing longer-term strategies, and working towards defined measurable targets and goals. The Stretch RAP requires organisations to embed reconciliation initiatives into business strategies to become ‘business as usual’. – Reconciliation Australia
Brisbane South PHN (May 2018 to May 2021)
An Elevate RAP is for organisations that have a proven track record of embedding effective RAP initiatives in their organisation through their Stretch RAPs and are ready to take on a leadership position to advance national reconciliation. Elevate RAP organisations have a strong strategic relationship with Reconciliation Australia and actively champion initiatives to empower Aboriginal and Torres Strait Islander peoples and create societal change. Elevate RAP organisations also require greater transparency and accountability through independent assessment of their activities. – Reconciliation Australia
No PHNs have published an Elevate RAP
Some PHNs have not completed a RAP but have instead undertaken a comparable formal process of engagement and documented commitments with their Aboriginal and Torres Strait Islander communities.
Hunter New England and Central Coast PHN
Western NSW Primary Health Network
Suicide Prevention Trials
This list shows all PHN-centred suicide prevention trials, supported through Commonwealth or State Governments or philanthropic funding.
Trials in bold are focused wholly or partly on Indigenous people and communities.
|National Suicide Prevention Trial - Regions/Priority Populations||NSW LifeSpan Trial||VIC Place-based Trial|
|New South Wales|
|Central and Eastern Sydney|
|Nepean Blue Mountains|
|South Western Sydney|
|South Eastern NSW||
Illawarra Shoalhaven – from August 2017
Suicide Prevention Collaborative
Remote Western NSW, including:
– Bourke LGA
– Brewarrina LGA
– Cobar LGA
– Lachlan LGA
– Walgett LGA
– Wedding LGA - Aboriginal and Torres Strait Islander peoples
– Men in farming and mining
– Youth, particularly Aboriginal and Torres Strait Islander peoples
|Hunter New England and Central Coast||
Newcastle – from Aug 2017
ACCHO Awakabal is a membership of the Leadership Group
Central Coast – from Dec 2017
(Central Coast LHD lead)ACCHO Yerin is a member of Suicide Prevention Central Coast
Murrumbidgee – from April 2018
|North Western Melbourne||
Whole PHN region
– Lesbian, Gay, Bisexual, Transgender, and Intersex (LGBTI) people, including young people
|South Eastern Melbourne||
Great South Coast
Entire Brisbane North PHN region
– Young and middle-aged males
– LGBTI people
– Aboriginal and Torres Strait Islander peoples
|Darling Downs and West Moreton|
|Central Queensland, Wide Bay, Sunshine Coast||– Maryborough – North Burnett – Gympie – Men – Aboriginal and Torres Strait Islander People|
– Townsville region
– York Peninsula
– Ex Australian Defence Force members and their families (Townsville region)
– Aboriginal and Torres Strait Islander peoples (York Peninsula)
– Murray– Youth
– Mt Magnet
Men aged 25 to 54 years, in particular men working in primary industry, fishermen, farmers and miners and the building industry.
– Dampier Peninsula (including Beagle Bay, Lomboadina/Djarindjin and One Arm Point)
– Fitzroy Crossing
– Halls Creek (including Warmun)
– Wyndham and the Kutjunka region (including Balgo, Billiluna and Mulan) Aboriginal and Torres Strait Islander peoples
– Cradle Coast (Burnie LGA, Central Coast LGA, Devonport LGA)
– Break of Day– Men aged 40 to 64 years
– Men and women aged 65+ (sub group 65 to 74 years, sub group 75 to 84 years)
Greater Darwin region
Aboriginal and Torres Strait Islander peoples
|Australian Capital Territory|
|ACT||ACT Health in partnership with Capital PHN – from November 2018|
Stories of Positive Commissioning
These stories highlight positive practice in commissioning of social and emotional wellbeing and suicide prevention services in partnership with Aboriginal communities and community-controlled organisations. They demonstrate innovative approaches to co-design, service planning, delivery and governance as well as responses to challenges in culturally safe commissioning.
While every community has unique needs, these case studies present models for success that communities and PHN funders may find helpful in thinking about their own situations.
PHNs have developed their own tools and resources to support the commissioning process. This is a collection of PHN resources most likely to be useful in commissioning Aboriginal and Torres Strait Islander mental health, social and emotional wellbeing and suicide prevention services.
Many other organisations have developed resources that may be valuable to PHNs in commissioning Aboriginal and Torres Strait Islander mental health, social and emotional wellbeing and suicide prevention services.
Exploration & Design– outcomes of PHN crisis response and post-vention workshop
Guidelines for best practice psychosocial assessment of Aboriginal and Torres Strait Islander people presenting to hospital with self-harm and suicidal thoughts – CBPATSISP and Menzies School of Health Research
The Apology - Healing Foundation Fact Sheet
Human Services Standards evidence guide – Victorian Government 2015
Contracting for Indigenous Health Care: Towards Mutual Accountability – 2011 article in Australian Journal of Public Administration
The Overburden Report: Contracting for Indigenous Health Services – 2011 Cooperative Research Centre for Aboriginal Health
1: Parliament of Australia Accessibility and quality of mental health services in rural and remote Australia, 4 December 2018 – https://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Community_Affairs/MentalHealthServices/Report/c02