At St Vincent’s Hospital in the Melbourne suburb of Fitzroy, a handful of patients are sitting quietly in the waiting room. Some are holding their heads, another props up her bruised ankle on a chair.
Dr Jonty Karro is the director of the emergency department at the busy inner-city hospital. On any given day you will find him here caring for patients, as well as overseeing a team of doctors working to save the lives of some of the city’s most vulnerable people.
There are five categories of triage, one being the most urgent cases seen immediately. (ABC News: Patrick Stone)
One policy – an approach to triage which aims to assess and begin treatment for First Nations people within half an hour of their arrival – has had great success in closing the significant gap in wait times between Indigenous and non-Indigenous patients.
“Our First Nations patients were waiting two to three times as long for care in certain triage categories and also weren’t waiting for care three times more often than non-First Nations patients,” Dr Karro told the ABC.
“We’ve eliminated the gap between our First Nations and non-First Nations patients in terms of their waiting time to be seen by a clinician.”
Under the policy First Nations people who might have been categorised as a less-urgent triage category four or five are now given a minimum category three.
Patients who present at emergency departments are triaged based on need, urgent cases are always seen first. (ABC News: Patrick Stone)
It has been applied to only about two First Nations people a day out of the 150 or so patients who pass through the ED daily, the hospital said, and has had no negative impact on ED access and patient flow.
“I want to be absolutely clear that this policy has not resulted in any increased waiting times for any non-First Nations patients,” Dr Karro said.
Last month the hospital’s policy was named a finalist in the Victorian Public Healthcare Awards for Excellence in Aboriginal Health and Wellbeing.
Medical staff at St Vincent’s Hospital Melbourne treat complex needs of patients presenting to the emergency department. (ABC News: Patrick Stone)
It has also received the backing of the Australian Medical Association, the Australian Indigenous Doctors’ Association, the Australasian College for Emergency Medicine, the Royal Australasian College of Physicians and the Victorian branch of the Australian Nursing and Midwifery Federation.
But it became embroiled in controversy soon after the award finalists were announced.
Media reports framed the triage process as “discrimination” and the Victorian opposition alleged the hospital was “treating people based on their race … instead of their medical needs”.
St Vincent’s Hospital Melbourne has identified strategies to improve care for First Nations patients in its emergency department. (ABC News: Patrick Stone)
As he keeps watch over the busy ED, Dr Karro said the “urgency” of a First Nations patient’s condition is not always clear in the few minutes that the triage nurse must make the judgement call.
First Nations people presenting at St Vincent’s “suffer a much greater proportion of serious chronic illness”, he said.
The inner-city population also has a high proportion of other complexities like homelessness, drug and alcohol problems and social disadvantage, Dr Karro explained.
“So with an equity lens, giving them the additional supports they need, like we do for many other groups, is really important to us.”
Dr Jonty Karro said the policy has closed the gap in wait times for First Nations patients presenting to the ED. (ABC News: Patrick Stone)
The hospital said that research showed that if First Nations patients were seen within the first hour of their ED presentation they are more likely to remain engaged with care.
Dr Karro said they have made inroads on this, but there is still work to be done.
“If someone doesn’t wait for care that condition can sometimes get worse, resulting in more likely that you need a hospital admission, more likely you develop complications … and suffer further disadvantage.”
Dr Jonty Karro and Nicole Watt discuss the changes to the wait times for First Nations patients. (ABC News: Patrick Stone)
In the treatment area, Dr Karro is deep in conversation with the head of the hospital’s Aboriginal Health Liaison Service Nicole Watt about the success they have had in narrowing the wait-time gap.
Ms Watt was part of the working group that helped advise on the new policy and saw the challenges firsthand.
“Some patients were finding it difficult to stay in this setting and sometimes it would take me a couple of days to get them to the department,” she said.
A number of initiatives were trialled to improve access, she said. “But it wasn’t long-lasting and our longer wait times would revert back to what they previously were.”
The new policy was designed in consultation with the Aboriginal community, including the peak body for Aboriginal health in Victoria VACCHO, and introduced in April last year.
Abe Ropitini from the Victorian Aboriginal Community Controlled Health Organisation (VACCHO) says patients often had nowhere else to go at short notice. (ABC News: Patrick Stone)
VACCHO’s Population Health Executive director Abe Ropitini told the ABC this new approach recognised the “anxiety or fear” many Aboriginal people experience in hospitals, which have “a particularly serious historical legacy of trauma and harm”.
“They were the places where interactions with racism were really acute, and some of those interactions involved hospitals being places where babies were taken from mothers,” he said.
“It wasn’t too long ago, for example, that we had a lot of Aboriginal people who were worried that it wouldn’t be a nurse that’s triaging them when they go to an emergency department, but it would actually be a security guard meeting them and having the initial discussion.
“That doesn’t happen anymore … but there are still genuine reasons to be worried about the experience that you will have as an Aboriginal person when you’re going to a hospital.”
Closing the gap in action
St Vincent’s Melbourne Emergency Department is based in inner-city Melbourne. (ABC News: Patrick Stone )
Patients in the two most urgent triage categories — such as those experiencing cardiac arrest, severe pain or difficulty breathing — continue to be prioritised, the hospital said.
The triage process also takes into account other demographic factors, such as whether someone is pregnant, elderly, or a child.
Dr Karro said elderly trauma patients, for example, are automatically triaged as the more urgent category two because, like First Nations people, they often have conditions that are “underappreciated” upon first presenting to the triage nurse.
The hospital said ED wait times for Indigenous and non-Indigenous patients are now comparable: an average of 68 minutes.
Olivia O’Donoghue says the policy improves care for First Nations people. (Supplied)
Dr Olivia O’Donoghue, acting president of the Australian Indigenous Doctors’ Association and a descendant of the Yankunytjatjara and Narungga nations, said the policy was “about fairness, not favouritism”.
“It definitely aligns with the national commitments to Closing the Gap, cultural safety and reducing preventable harm, and it strengthens the healthcare system for everybody,” she said.
Aboriginal and Torres Strait Islander people on average die eight years younger than non-Indigenous people, according to the Productivity Commission.
Nationally, First Nations people die from avoidable causes at three times the rate of non-Indigenous people and have more than double the rate of disease burden.
Dr Glenn Harrison said the triage decision improves access to care for Indigenous patients. (ABC News: Patrick Stone)
Emergency physician Glenn Harrison, a proud Wotjobaluk man who works at hospitals in Melbourne and Geelong and is an Australasian College for Emergency Medicine board member, told the ABC the triage policy is “closing the gap in action”.
“Aboriginal patients do wait longer to be seen and as a result have less access to care, less assessments, less access to pain relief initial investigations, including antibiotics sometimes as well,” Dr Harrison said.
“They do disengage from that service from lack of care and equity within the system.”
In August, the deputy NSW coroner found Wiradjuri man Wilfred “Whippy” Robert Williams — who had “a fear or aversion to hospital” — died at home after leaving Cowra District Hospital without seeing a doctor in 2019.
She found his death was likely preventable with appropriate and timely medical care, and the hospital’s triage process was “flawed” and “lacked cultural safety”.
The deputy coroner urged authorities “to examine how research reflects that certain vulnerable groups have much higher ‘did not wait rates’ than the general population”.
Last year, a NSW coroner also found the 2021 death of Kamilaroi-Dunghutti man Ricky ‘Dougie’ Hampson, 24 hours after being discharged from Dubbo hospital, was preventable.
The coroner found the patient, who also had an aversion to hospitals, was misdiagnosed and sent home, despite indicating he had “10 out of 10 pain”.
“We are scared to go to hospitals. Our fear is real,” his father said outside court.
St Vincent’s Hospital Melbourne sees a higher percentage of First Nations patients daily than other EDs in the city. (ABC News: Patrick Stone)
Abe Ropitini said there were many reasons the seriousness of First Nations people’s health conditions may not be understood at first presentation, including previous adverse experiences in hospitals.
“They could have language barriers, they could be still experiencing a degree of stigma about their condition, they may not be forthcoming about what’s going on until they’re in a confidential private space,” he said.
“It’s not the case that Aboriginal people receive special treatment when they go into hospitals.
“What is happening is a bias is being addressed that would otherwise continue to result in unjust, inequitable outcomes.”
Nation’s doctors rally behind policy
As the media storm rained down on St Vincent’s earlier this month, the hospital’s CEO Nicole Tweddle released a scathing response, describing the criticisms as “an ugly and unnecessary display of wilful ignorance”.
She was joined by the nation’s major medical groups, who released a joint statement backing the policy.
“Recent divisive and racist comments opposing this policy, particularly from doctors in positions of authority, are opportunistic, uninformed and deeply concerning,” the statement from AIDA, ACEM and the RACP said.
“Such inflammatory rhetoric deliberately undermines efforts to create a culturally safe healthcare system and perpetuates the systemic racism that continues to harm Aboriginal and Torres Strait Islander peoples.”
St Vincent’s Hospital says patients in urgent categories, such as those presenting with cardiac arrests or chest pains, are unaffected by this policy. (ABC News: Patrick Stone)
The Australian Medical Association (AMA) president Danielle McMullen agreed.
“The measures taken by St Vincent’s Hospital Melbourne in triaging First Nations peoples are a proactive and positive step in helping to improve health care outcomes for these patients,” Dr McMullen told the ABC in a statement.
The secretary of the Victorian branch of the Nursing and Midwifery Foundation Maddy Harradence told the ABC in a statement that recent commentary was an “abhorrent attempt to undermine” the policy.
“This policy puts into practice what nurses and midwives already know: that one size does not fit all in our healthcare system and we must acknowledge the social determinants of health.”
Hospitals around the country are looking at initiatives to improve cultural safety in emergency departments. (ABC News: Patrick Stone )
The Victorian Opposition Health spokesperson Georgie Crozier, a former nurse, told the ABC this was a “divisive policy” that “contravenes long standing multiple medical and nursing codes of conduct, and medical ethical considerations”.
“The triaging of patients should be based on medical need, not based on race.
“Unlike Labor who for years have neglected the vital areas of community and primary health care, the Liberal and Nationals will have a comprehensive plan that will drive better health outcomes for all Victorians, including Indigenous Victorians.”
Abe Ropitini is VACCHO’s Population Health Executive director. (ABC News: Patrick Stone)
Mr Ropitini, a proud Māori and Palawa man, said the media and political debate has been deeply hurtful for First Nations people.
“I think it’s extremely disappointing that we’re seeing politicians using this issue as a political football. It is a basic expectation of our health system that everybody is entitled to equitable outcomes.”
“That is, recognising that not everybody is presenting to an emergency department with the same level of advantage and skill when it comes to communicating what they’re experiencing.”
He said dozens of people have contacted VACCHO concerned about the divisive nature of the conversation around the policy, given the work that has been done to make health spaces more welcome for First Nations people.
“Access to healthcare is a 50-metre race and Aboriginal and Torres Strait Islander people are starting 100 metres behind the start line.”