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 COMMISSIONED 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.

WORKFORCE

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.