Case Study 1: Wuchopperen Aboriginal Medical Centre – Cairns

Wuchopperen had a purpose-built, dental facility with two fully equipped clinics, a similarly well-equipped mobile dental van, and facilities for a dental technician. But in 2005, it was down to one dentist, one day a week to service their entire community of over 18,000 people. They could not recruit a permanent dentist. At that time there was a chronic shortage of dentists and even the local public hospital couldn’t identify or recruit dentists to serve in the public health system; various forms of unique advertising were tried but that didn’t work. It was really an absurd situation, where, because of the absence of the dentist, whole communities were unable to access services.

There was a year-long wait for treatment at Wuchopperen. There was a one-day a week emergency clinic operating with a local dentist. So often it was a case when people attended with emergency, they had teeth extracted and it was no more than that. There was no preventative work happening.

PARTNERSHIP AS A FIRST PRINCIPLE

Meetings at Wuchopperen with a number of staff and board members were convened. Through discussion it became obvious that the best way to achieve any outcome and support was through partnership. Everyone had to put something on the table, in order to make it work. There had to be a genuine commitment from all parties in the situation;

  •        In the case of the dentists it’s bringing their skills and expertise and potentially their foregone income.
  •        In the case of Wuchopperen it was the provision of accommodation and the use of one of their fleet vehicles, so that the dentists had mobility.
  •        In the case of FTG it was about liaising with the dental fraternity and also raising sufficient funds to cover airfares.

And that way everyone had to work hard to make sure something happened.  The principle of partnership with commitments from all parties has been a feature of other FTG projects.

BUILDING RELATIONSHIPS FOR STRONG PARTNERSHIPS

Initially FTG made a conscious decision to concentrate on working in one place and making that a successful enterprise.  FTG also saw the importance of setting achievable targets so that the aim within the first year of operation at Wuchopperen was to reach the target of the equivalent of having 26 dentist weeks supplied. That effectively meant raising money for 26 airfares – at least $15,000 to $20,000 to begin with – which was achievable.  FTG also found a well-spring of support within the dental fraternity.

The main focus at this stage was the recruitment of dentists and getting systems into place – for example developing application forms, developing a system to get flights booked and developing systems for reporting back. Basically FTG worked in cooperation with Wuchopperen Aboriginal Health Services and the practice manager. Friendships developed and strong relationships were built up between FTG members and with those people who were working at Wuchopperen.

Founding members of FTG were very aware of the importance respecting community and cultural protocols.  If outsiders were to be invited into communities for work then this had to be managed carefully and with due consideration paid to what is considered culturally appropriate.  Without appropriate respect and acknowledgement services cannot expect to connect and respond to local needs. The Muru Marri Indigenous Health Unit, in the School of Public Health and Community Medicine, University of New South Wales had knowledge, wisdom, insight and ideas about working with Indigenous peoples and cultures in community health based settings.  

GAINING MOMENTUM

There was a genuine interest by dentists to do something in the area of Aboriginal health. FTG Board was surprised by the wellspring of goodwill from the dental profession, which was known at the start of the program. The feeling was they had done well as dentists in Australian society.  FTG had commenced its work in 2006 and 2007 and then with the National Apology in February, 2008 there was more recognition of the needs of Indigenous communities, not just around concerns for the Stolen Generation but also a lot of media focus on general health issues that Indigenous communities were facing.

Dentists, like the rest of the community became more aware of the situation. When FTG put forward their idea and began advertising there seemed to be a real willingness for the dental fraternity to engage.  

There has been a tradition of dentists being involved in volunteering in programs overseas but until FTG began its work there had not been any system for dentist to work here, in Australia with local Indigenous people.  FTG were also offering one or two week opportunities, which might have been easier than going to another country for four weeks. There was a lot of interest and the idea was taken up with enthusiasm. With FTG paying the airfares and negotiating a partnership arrangement with local communities it was made very easy for the dentists to volunteer.

Testimonies for dentists below show why there was this enthusiasm

“It’s hard to know whose ‘gap’ if most filled in this program.  As an experience in learning about Aboriginal culture and compassion and enthusiasm, we would recommend all dentists take up this wonderful opportunity”

“I worked in a private practice in Sydney for a year and half but would say I had more fun in my three weeks in Cairns than the whole time in NSW.  Treating patients in the mobile dental unit particularly felt like I was doing something really different and worthwhile.”

Case Study 2: Dental Blitz with the Larrakia Nation, Darwin, Northern Territory (2012)

FTG was approached by the Larrakia Nation Aboriginal Corporation (LNAC) to assist in a ‘dental blitz’ in Darwin. The LNAC, through the HEAL program, had mobilised a coalition of interested groups and social forces including St Vincent de Paul and Northern Territory Department of Health, Oral Services (OHSNT). The aim was not specifically to meet the needs of the Larrakia Nation people but for the predominantly Aboriginal population who were homeless around Darwin; arguably this group is one of the most marginal and vulnerable groups in Australian society.

The OHSNT made clinical facilities available at the Darwin Dental Clinic (DDC) for FTG volunteer teams, and conducted an orientation/induction day prior to commencing activities. The FTG team, the DDC staff and the HEAL coordinator, revised treatment protocols to specifically meet the needs of this situation; particularly because there would be unknown medical histories such as rheumatic fever and perhaps undiagnosed Type 2 Diabetes. Special attention was also devoted to changing procedures for early morning patients and ensuring that patients were prepared food-wise and made comfortable prior to any treatment.

The logistics and transport were in the hands of the HEAL coordinator who collected people from known gathering places with a number of vehicles, and set up post-operative care arrangements, further assistance with these practical details, especially transport and meals was provided by Ozanam House (a St Vincent de Paul institution).

The partnership activity was a notable success and consequently engendered a great deal of confidence from OHSNT in the professionalism and outcomes delivered by FTG. This developing relationship and confidence in FTG services was important in another project which would be conducted later in Darwin.

Another outcome of the program that is clear, from work in Wuchopperen and from this initial work in Darwin, was that the program was enabling cross-cultural relationships and learnings.  One of the dental assistants who volunteered in Darwin in 2012 described it this way

“I feel privileged to be involved in the FTG program in a ‘hands on way’, and look forward to the possibility of again volunteering to assist in such a beautiful and worthwhile cause.  Meeting the Larrakia people and hearing their stories, has, enlightened me in a way, that at times, made me feel both incredibly happy and incredibly sad.”

Another testimony from a volunteer on the project demonstrated the importance of the partnership approach and having buy in from all parties

“I had an amazing time it was a fantastic experience, one that I will never forget! The patients were fantastic. The organising details were fantastic…getting everyone appointments and getting them in the chair.  Staff at the Darwin Dental Clinic were especially helpful, they were always happy to lend a hand…”

The success of the ‘dental blitz’ and contribution of FTG volunteers was recorded in the in the Larrakia Nation newsletter, a section of which is shown below http://larak.in/larrakia/newsletters/Larrakia%20Nation%20News%20Sep12.pdf

Case Study 3: Deadly Yirra Project, Tomelah & Bogabilla, NSW-Qld border (2012 -2014)

The needs of these communities, falling between two state government arrangements are significant and have been well-documented.

Word had circulated that FTG had been able to meet some dental needs where they weren’t being met. FTG received an invitation to assist that community with dental services and to go and visit the community and start conversations with the community. However the partnership process was challenged because there was no AMS or structural arrangement so that accommodation needs for volunteers could be met.  Nor were the partnership inputs which had been available in previous projects.

The nearest clinic was 10 kilometers away in Goondawindi. This was a Queensland dental health facility located on the Goondawindi hospital campus but QLD would not treat New South Wales patients. The nearest NSW clinics were in a public hospital facility and in Pius X Aboriginal Corporation, both in Moree, 130 kilometers away.  The logistics of having to travel a long way to the dental health services in Moree was a significant barrier, and the affordability and accessibility of the service also presented difficulties.

None of the models tried before would work in this new situation, FTG had to be innovative.

Being a relatively small and relatively informal organisation allowed FTG to think ‘outside of the box’ and there was the possibility of working in, out of, and around institutions current institutional arrangements.  Current arrangements were not servicing the communities effectively in terms of meeting oral health needs.

FTG was able then to contact and be in dialogue with chief dental officers in QLD and NSW.  Both of whom acknowledged that none of their strategies would reach and service those communities – the state based services were geared up to work through AMS’s, so if that system wasn’t working then the dental health services, which were meant to be attached would not work either.

FTG was able then to do something unusual and facilitate discussions for a cross border arrangement; where QLD health was able to make a facility available at their Goondawindi campus and NSW would compensate them for the servicing of NSW patients. It was unusual to have such a specific localised arrangement but there was a genuine recognition of the need and recognition of capacity to respond.  The area was recognised as an area of high need and significant resourcing had already been spent in supporting education and welfare programs. It area was already one in which cross departmental work was already occurring from NSW. There was already a program called the ‘Connected Communities Program’ which made the school and the principal a central focus for effort. There was recognition that this was an area of high need and was one of 15 across the state of NSW (that had been identified as such).

After extensive community consultations for more than a year, dialogue with the Chief Dental Officers of Queensland and NSW, the Federal Body of the Australian Dental Association and negotiations between the parties, the Deadly Yirra dental service commenced on October 2, 2012.

The service was delivered at the Goondiwindi Dental clinic on the grounds of Goondiwindi Hospital, under the auspices of the Darling Downs Hospital and Health Board (DDHHB).

The parameters of the cross border agreement were:

  •        Eligibility: population of Boggabilla, Toomelah and environs with priority to be given to Aboriginal community members, not limited to Health Card holders
  •        Costs: NSW Health to reimburse DDHHB for all costs
  •        Dentists: recruited by FTG and credentialed by DDHHB.
  •        Period: initial six-month period with a possible further six-month extension.

A ‘Service Statistics and Community Feedback Report’ was prepared in March 2013 using information collected by DDHHB, patient reviews collected after treatment at the Goondiwindi clinic, feedback from dentists and the Deady Yirra community steering committee (made up of key community members and local stakeholders).  There was a high level of community support and uptake for the service, starting almost immediately. As confidence in the service has grown so have the occasions of service, despite times with reduced levels of service and holiday periods.

In total there were 514 occasions of service in the period from October 2012 to January 2013. See Tables 1 and 2. Note: The reduced level of service in December (1 week) and January (2 weeks) was due to unavailability of dentists and Xmas break; however the weekly average use of the dental service remained higher, despite the holiday period.

The dentists were highly productive as shown through the numbers of occasions of service data (n515). A total of 12 weeks service was provided from October 2012 to January 2013 by three highly experienced retired dentists, their visits alternating with stays for periods between 1 to 3 weeks. A total of 1,592 procedures were undertaken at a total cost of $154,726.  Besides emergency procedures dentists undertook wherever possible a comprehensive treatment regime for patients.

The high level of productivity is strong evidence of high community uptake and reflected the high need for a dental service that is easy to reach, accessible and culturally appropriate. It also reflected community cooperation and organisation, as well as confidence and trust in both the dentists and in the service delivery model.  The number of procedures for such a small community is evidence of how much work was needed and long-term neglect.

Patient feedback included comments such as

“Staff were professional but friendly, they made all my children feel at ease – particularly my 3 year old daughter who has autism.  If this wonderful service didn’t exist we could not help with our dental issues.”

“It is a great service, saves a lot of time and money when you have a family.  And it is not as far to travel to Moree, 130 kilometers.”

The agreement was that the service was to be provided for 6 months and then another solution had to be found.  At the 6 month point both the QLD and NSW government wanted to reconsider what was going on – for different reasons. However the NSW government then came to an agreement with The Poche Centre at Sydney University who took over, and committed themselves to a long-term ongoing service. That program goes on and now there is a permanent dental service.

Case Study 4: Danilla Dilba Health Service, Darwin, NT (2013)

This service had heard of FTG when it carried out earlier work with the Larrakia nation in Darwin but Danilla Dilba had not been involved in that process. There were some internal difficulties in the service and new staff and a new board had come into the service.  During this time though funding was cut and this left their clients/patients in precarious circumstances.

The service approached FTG on the basis of wanting to maintain commitments to their patients, in the absence of any funding. There were no salaries for dentists or dental assistants nor any funding for consumables.

So FTG recruited teams of one dentist and two dental assistants. The Practice Manager was an oral therapist and there were two chairs – so FTG was able to ensure coverage. FTG worked on the basis of teams of three rotating every two weeks.  FTG sustained that service for 7 to 8 months.

Accommodation is very expensive in Darwin, and quite unexpectedly the rent being billed to FTG was reduced about one third of what it should have been.  FTG found that the landlord had heard about the good work that the team was doing and reduced the rent!

There was a demonstrated need, there was demonstrated management capacity, FTG showed that it was able to meet the needs for 8 months, funding was restored and then FTG moved on.

“Danila Dilba Health Service has been extremely fortunate in having had the invaluable assistance and support of the Filling the Gap team over the past 12 months. The professional support and assistance of the volunteer dental team has enabled DDHS to provide much needed dental services to Aboriginal people who in all likelihood, would not have been able to access treatment elsewhere.

The volunteer dental program has enabled DDHS to plan and budget for the establishment of our own dental team in 2014.

DDHS strongly supports and encourages other Aboriginal community controlled health services to collaborate with The Filling the Gap team and their volunteers particularly in communities where there is limited or poor access to dental services.”  – Olga Havnen, (CEO Danila Dilba Health Service, Darwin)