Transcript of Aboriginal Community Controlled Health Services.
Geraldine Wilson-Matenga, Executive Director, Centre for Aboriginal Health: Thank you for coming today, to the first Wingara Aboriginal Health series for 2019. I would like to now invite Uncle Alan Madden to welcome us to country before we begin, thank you.
Uncle Alan Madden, Eora Elder, Metropolitan Local Aboriginal Land Council: Thank you. Once again my name is Allen Madden Gadigal elder. For my first song... Apologies for the terrible weather we're having outside at the moment. Sorry. And I've been able to welcome you to my country, my language, as well, forbidden to talk our language a long time ago. New South Wales Health, I'd like to pay my respects to all involved over the many years. And I've been coming here for quite a while now and it's always an honor and pleasure to welcome one and all.
As with all welcome to country's I'd like to acknowledge Aboriginal elders, all elders past and present and pay my respects to all Aboriginal and Torres Strait Islander brothers and sisters from whatever Aboriginal or island nation you may have come from, welcome to Cammeraygal. And to all our non-Indigenous brothers and sisters a very warm and sincere welcome to you to Cammeraygal. No matter where you've come from whether it be across the seas, across the state or across town, once again, a very warm and sincere welcome to you. And as I've mentioned many times before, was, is and always will be Aboriginal land. Only three things surer than that, coming, taxation and going. It's always an honor and pleasure to welcome one and all to Cammeraygal.
Cammeraygal is one of 29 clans of the Eora nation. The Eora nation is bounded by nature's own - the Hawkesbury River to the north. Mobs up that way call it the Darkinjung, Nepean to the west the Deerubbin and Georges River to the south Kayimai. And in between those three mighty rivers is the Eora nation. In that nation there are 29 claims and the clans land we're on today is the Cammeraygal. On behalf of members of the Metropolitan Local Aboriginal Land Council and of the Cammeraygal mob, once again, a very warm and sincere welcome to you. There's an old saying out there, I think its very appropriate for you mob here today. You fella's heard it a thousand times before. They say where there's a will, there's relatives. So once again on behalf of Land Council and the Cammeraygal mob, welcome, welcome, welcome. Thank you. [Applause]
Geraldine Wilson-Matenga, Executive Director, Centre for Aboriginal Health: Thank you Uncle Allen. So thank you all again for coming today to the first Wingara for 2019 and I'd like to acknowledge also the Cammeraygal people of the Eora nation and pay my respects to elder's past and present but also like to acknowledge all Aboriginal colleagues in the room today and Aboriginal colleagues on Skype and all colleagues who are joining us on Skype today as well. So as you know this this is probably now the fourth Wingara session that we've had in the Ministry, we ran them last year but just to reiterate that the aims of Wingara are to bring visibility to Aboriginal health-related issues and develop the capacity of all New South Wales Health staff to better understand Aboriginal health and culture. And it is our goal, the Centre for Aboriginal health to share with you our knowledge and experience and to bring you Aboriginal colleagues from across the state who are here to speak and share their knowledge and experience as well.
Today I'm really excited to introduce our speaker, who I've known for a long time. Raylene Gordon, who is the Chief Executive Officer of the Aboriginal Health and Medical Research Council in New South Wales. Raylene is a proud Kamilaroi woman and prior to working at the AHMRC Raylene was also the CEO of Awabakal Aboriginal medical service in Newcastle. so today we have asked Raylene to come and speak to you about the Aboriginal community controlled health sector and the importance of that sector in terms of bringing culturally safe and secure health services, primary health services to Aboriginal communities in New South Wales. Raylene's background is in health and in education has had many years experience in driving change in both areas at the community-level. Raylene believes her skill set sits best for the community sector where accountability, transparency and innovation are required on a daily basis. As Raylene says the community sector is where you see the smallest of things make the biggest difference. So now like to invite Raylene to come and speak with us we'll share her experiences, thank you.
Raylene Gordon, Chief Executive Officer of the NSW Aboriginal Health and Medical Research Council: Just while we're setting up, talking about relatives, I've got one in the room. Buddy Colin Gibson, there he is that's my nephew, shamed ya. [Laughter].
Before I start I'd also like to acknowledge the traditional owners of the land, the Cammeraygal people, and pay respects to elder's past and present. As Geri said I've worked across government and non-government for most of my career. I used to work in New South Wales Health when the Health Service Performance Improvement branch was around if people remember that I was in the in that unit here for about eight years then I went to ACI and worked there for about two and then went to Awabakal and for about six and now I'm at AHMRC. So I'm going to try and give you a broad overview of the community control sector but I'd really like to hear what people would really want to know about the sector so I'll leave enough time at the end of people to ask questions.
So the community control sector was born out of Aboriginal people experiencing discrimination and racism in the health system back in the day, there were quite a few people that were advocates around at the time and Redfern was actually the first Aboriginal medical service to get started back in 1771. Redfern still plays a key role in the Aboriginal community control sector in terms of advocating for new services across, across the state in fact they were responsible for helping set up the national body which is NACHO, the National Aboriginal Community Controlled Organisation, which is the key peak body at a national level. And they also were the first to advocate to start Aboriginal health and medical research council at the state level.
So Redfern, in the history of community controlled sector is a very significant organisation and built really built the foundations for what we have today. The concept around community control is important to understand in our sector because many of our boards are made up of community people and that's the way the movement started back in 71, so boards of Aboriginal people in local communities got together and advocated and started a service, there's now around 49 of those across New South Wales. This concept of community control is something that I think it's a strength but it's also proven to now under the government regulations seen as a weakness, so on many boards you will have elders, mixes of community people who've worked and advocated long and hard. Sometimes that doesn't sit well with where government wants you to go. I mean there's a lot of talk now around skill-based boards where you know they're wanting you to have experties in finance in legal, to be on your board, whereas that's inconsistent with the concept of community control where these services were born out of people fighting hard for services in their community and they're just community people. And so now that's sort of there's a shift around the governance of our organisations to comply with what government want to see happen in communities and so that's a real struggle at the moment for our services and it's starting at the national level. So NACHO has been trying to get their constitution changed for about three or four years now and it still hasn't got over the line. AHMRC will go to the members in October and try and get their constitution changed.
So you can see from the national to state and it's actually impacting local services, the governance of an organisation, so that concept of our community controlled is very is a very challenging space to work in. And I can say that being a CEO of a big organised Aboriginal organisation in Newcastle, where you have a mix of experience on the board and very different priorities to what the government want you to do to deliver. So that's really important to know when you are dealing with an Aboriginal organisation, they're not just got to meet the funding contracts and the guidelines, the KPI's, they've also got to work with a board of people who have come from an era where they've fought very hard for what they have in a very proud for what they have and to introduce change is a very very slow process. So that's one of the challenges that I think many funders, many government organisations, have when dealing with community controlled organisations.
The definition of Aboriginal health, I'm not going to read this out to you but it's very different to what mainstream people see as health. We look at all the impacts that everything that impacts on a person's ability to access health care. This is one of the challenges around and I'll talk about funding a little bit later on but it's a concept that is very hard to understand if you've never worked in this space. So this concept around comprehensive primary healthcare, I didn't understand it when I worked in the government, I didn't really truly get the concept of comprehensive primary health care until I worked in an AMS. And I've been a patient of an AMS for most of my life and I still didn't get that concept so how do you deliver how do you actually deliver comprehensive primary healthcare, for what that means on a bit of paper. So it's transport, its social security, its housing, it's all those social determinants of health. So when you're trying to cost a service and you try to apply the funding, how do you how do you cost that into a funding model that fits with the government's agenda and I'll talk a little bit more about that.
So this is the ACCHO sector across Australia and why New South Wales is so significant is because we have the biggest membership across all the states. So our peak organisation AHMRC has a very big influence across Australia because we have the most members and it's because of, I think it's because of Redfern and that being the first AMS and spreading all the AMS's across New South Wales that we've actually grown to be the biggest state and we have the population. So there's around 140 Aboriginal community controlled organisations across Australia. We are the largest employer of Aboriginal people in any other industry and that again has its challenges with health, talk a little bit more about that and there's 49 member services in in New South Wales. Each of those, imagine this, so we're the peak organisation, we've got 49 organisations that are all autonomous with their own boards, running their own service, and we've got to try and advocate on behalf of all those communities, it's not an easy job.
I thought I'd talk about some of the emerging issues in the sector that are happening right now, there's a real GP shortage across New South Wales. Even on, so the North Coast, the Central Coast and Newcastle can't get GP's to the sector. A real shortage. I'll use Central Coast as an example so they have the equivalent of they got around 5,000 active patients on their books. They've got the equivalent of one GP, so they got four GP's but they all work part-time and they said they got the equivalent of one and that's because GP's can earn more money in mainstream practice. So they're doing, they want to help, so they're doing their their stint in an AMS, but they're they've actually got a food on the table too so they're, they're choosing to work across the two settings. So that, trying to get GP's in the sector is a, it's a national issue and one that requires a lot of attention. We, one strategy that the sector is trying to do is recruit registrars and hopefully keep those registrars. The other thing we're trying to do is set up a locum service where we can actually get doctors out to the likes of Walgett and Bourke in areas that don't have a GP. That's really relevant when I talk about the funding model because if you haven't got GPs, you can't claim medicare so you're not actually sustainable.
The other thing that's happening in our space is the Aboriginal health practitioners, so there's a real push on Aboriginal health workers becoming Aboriginal health practitioners and so all the push is towards the clinical model in our sector and that's because the clinical model attracts money, it attracts Medicare. But at the same time what's happening is so if everyone's moving clinical who's doing all the wraparound service work the follow-up the transport, the Centrelink, the housing, that there's actually a gap that's been created in the sector because the push towards Medicare creating that business model that's not consistent with comprehensive primary health care. So that's a real issue.
The other real issue is around primary health networks. So a couple of years ago Medicare Locals changed to primary health networks the primary health networks get now get any new funding in Aboriginal health and they commission the services out. So that means that an Aboriginal community control service needs to be able to be competitive in terms of tendering for services. So any new money, particularly for mental health, drug and alcohol, are the two big ones, which are the probably the two top issues in our sector across no matter where you where you live, all the money's going to those primary health care networks and their tendering and commissioning of services is not ideal so you actually have to have very snazzy tender riders and very efficient systems if you're going to be able to tender for that money. So that's a real threat to the sector it's probably the worst, this is probably the worst I've seen the sector in a really long time it's almost like we've gone back to 20 years where the best submission writers got the money because that's what this actually is. So I dont know whose idea was to do that but it wasn't a very good one and that the services are actually suffering that now and what's actually happening as well is that it's making services compete in there. So the community control sector was built on supporting communities where this is actually we're now in competition for money from our own services, so it'll be interesting to see how the Primary Health Networks sort of evolve that commissioning process. We've opted, we've given them a couple of models around quarantine funds for the sector, around select tendering, there are other models and unless they adopt that national across the country, I think that our sector will be threatened further.
The next one around the addressing the social determinants of health is one that I think the sector has struggled with for a really long time, so as part of this commissioning process, they'll ask you to cost a service, so how much does it cost you to deliver a chronic care program to a patient, and they will put criteria that says you can have 12 visits of this, five visits of that, three of these, three of that. That actually doesn't work in our sector because we deliver what a patient needs, not to a guideline where you have 12, five, two or one. So and that the cost of driving someone to housing, to their housing appointment, and being there all day, the cost of being in court support for a family, how do you cost that out? And how do you put that? How does that make you effective? How do you tender and be competitive for funds, when the social determinants of health have not been addressed in any of the funding models. So that's a real issue. That's not an easy one to to address but it's something that if we're going to get real about the cost of services to Aboriginal people in improving health outcomes we have to look at that. So NACHO is actually doing a piece of work on that at the moment about what they call needs based funding. So how much does it actually cost for all of that to deliver? How do you, how do you want to cost that out so they're doing that as we speak.
I talked about the role of the Aboriginal health worker it's great for Aboriginal health workers to have a career progression, but what's happening around, who's delivering the wraparound services. And the other thing about that is it's really been forced I think, in my opinion around Medicare, so Aboriginal health practitioners can claim more than a nurse can, for example. So for me, if I was going to have a career, I'd do nursing because you've got all these other options, your workforce opportunities are broader. But as an Aboriginal health practitioner, you're sort of, that's your going to be your career progression and that's where you go so I think there are a number of issues that needs to be looked at around the the Aboriginal health practitioner. There's also, we find it very hard to attract and keep people in our sector because our Award is inequitable. So staff employed in the community controlled sector come under the Aboriginal community controlled health services award and it is so much lower than any other award. We lose staff, they come to us, we train them up and then they'll pop over to the LHD because it can get them paid so much more money and you don't blame people for doing that, everyone has to do that, but the award is a real issue for the sector. And I don't think people I meet, you can always pay above or above award rates and most services do but, I think that sends the wrong message ,that if you work in the community controlled sector you're less skilled, you're worth less money. So I think that is an issue that needs to be addressed as well and when we're talking about workforce needs, a lot of people forget that there's, they're looking at the clinical model around the clinicians and the allied health but there's actually boards and managers that need to be considered in in our sector, because it takes a team of people to care for one person so it's not just about that clinical model.
Aboriginal health as a business. This is the thing that, I talked about the primary healthcare networks, it's actually turning our sector, into our disadvantage, into a business. So people are, as soon as that tendering process came out, everyone was interested in Aboriginal health because there was money involved. So you would see service providers who never delivered in that space before suddenly being interested in tendering to deliver Aboriginal health services. So then that impacts on our sector. So the other thing that, so most services are funded from multiple sources and the Commonwealth are proposing a new funding model which is based on clinical activity, so at the end of the day what it means is, normally if a patient came into an Aboriginal Medical Service, all that opportunistic care we would do there and then. One visit, we've got the person in, let's check the ears, eyes, let's do everything. What the new funding model and you can you could claim all of that so that means that you could account for the clinicians time, what the new funding model is proposing is that you would do you get paid for one visit, no matter what happens in that consult or in that visit to the AMS, you get that's one occasions of service, so what it's actually encouraging you to do if you think about it from a business point of view, is do what you were going to do today. They come in for a sore toe, fix the sore toe. But don't check ears, eyes, don't do a health check, don't do any of that, make them come back tomorrow because then that you can count that then. That's the new funding model they've put forward, which is so against the comprehensive model of care. So that funding model is being put on hold for 12 months because if it just got so much backlash that they're reviewing that at the moment, but what it what it means is that services will have to actually think more, they'll have to deliver care differently, which is not what we want to do. We want to deliver care comprehensive care the way we've done before. And what it also pushes reliance on Medicare. We are never going to be able to address Aboriginal health issues and out and make and get outcomes just on Medicare. So we do need a mix of grant funding and Medicare, so everything is pointing towards, make more money, get more business systems in place because you'll need your Medicare. You're never going to be able to deliver Aboriginal health just on Medicare.
The commissioning process I talked about before is really it's affecting services in a way that that's not healthy and and it's attracting providers to the to Aboriginal health that are not, they're not best placed to deliver Aboriginal health services. And the other area that's happening is, the other thing that's happening in the sector is that because there's such a threat to the environment to the funding, to the funding model, services are actually looking at what other business can they get into. Aged care is a big one and so is NDIS and so is out of home care, so you'll see across New South Wales, there are a number of services who have moved into delivering aged care, NDIS and out of home care. Big providers of those services. That's because not necessarily, it's because you have to look at different revenue streams now, you have to look at how your business operates, it's no longer just about health. All these other areas are providing other revenue streams for services so they're looking into those to be sustainable. The compliance with all of those services is through the roof. To deliver NDIS, to deliver aged care, out of home care that compliance is massive. So again that up's your what we call backup house services you know your administration services so it's taken away from service delivery so it's a real the industry is changing. This is the funding model that I talked about. We did a piece of work around the data quality, so what they did was they, they tried to give each service an estimate of how much, based on their clinical activity they had at the time, here's what you would get in the next under the new funding model. What they found was that depending on the system that you had in place whether it was best practice, communicare or medical director, there was a 28 percent difference in the activity that was being recorded based on the system that you had, so that that affected 28 percent of your funding. So the data quality is not good enough to even run the funding model that they're that they're proposing. So 28 percent could be you know 280,000 which is a lot of money to a small service. So there is real data quality issues and then like I said the reliance on Medicare is it's not ideal, it's good but it's not it's a revenue stream. It should be looked at as a revenue stream and not as the sole funding model.
So in terms of AHMRC our job is to make sure all those 49 services with their own boards and their own communities run well. And it's also to support mainstream organisations to improve their health outcomes as well. And the other thing the AHMRC was established for is to be the leading provider of training for Aboriginal Health Workforce needs, so we've got a registered training organisation in Little Bay and that runs all the training for the sector. What we're looking at right now I thought I'd just give you a brief overview of what the AHMRC is working on at the moment. Currently we operate like this. So we have 12 regions across the state. There's one director from each state that comes and represents their communities on our board and our constitution is tied to that model. What we're doing at the moment is looking at consolidating our regions down to four and having two directors from each region, that make up our board. So that would be in line with what the government is now calling good governance and we think it's a better way to do things. So we're actually looking at how, how a state based organisation delivers services on a regional basis and if you look at most state based organisations they have regional offices, so AHMRC is looking to move in line with that. Which could fit closely in most cases and it fits closely with the LHD structure and the PHN structure, so we think that that'll allow for better working relationships. So really we're looking at having the central office, with four regional offices that we, that we do our business with. They're the, you probably can't see those but from there the AMS's that would sit in those regions.
I thought to finish on has anyone seen this? The article written by Summer Finlay around being a good Indigenous ally. Did you see that? Yeah, yeah it's it's quite good. Yeah, so I thought anyone that hasn't seen it being you're all here today, you're obviously interested in, in Aboriginal health, Aboriginal issues, I thought this was one of the better articles I've seen around for a while about non-Aboriginal people being advocates for Aboriginal health so yeah I thought I'd just put that one in there and if you wanted to have a look at it you could. That's the end of the formal presentation but I am happy to take questions if anybody, would like to.
Audience: Thank you for your presentation, I had a quick question around Traditional Healers, Aboriginal Traditional Healers. Is there a place in Aboriginal community controlled health organisations for Aboriginal Healers formally?
Raylene Gordon:Yeah there is while I was at Awabakal, there was a group that are traveling around now. And the question was around Aboriginal healers, is there a place in the Aboriginal health sector space for traditional healers? Really in. In primary health, yes. So at Awabakal we use them. So at a state level they're trying to advocate to get in more communities but my take on that was because there were some elders in Newcastle that were very uncomfortable with having traditional healers from other areas come into their country and so we made it by of course by choice but I actually had a session. Unbelievable. And unless you've actually experienced traditional healers yeah it was beautiful. Yeah but it is a community by community basis so they approached us at AHMRC and said help us get into New South Wales, we think there's a real need here. Yeah, we couldn't do that because it's really by community. Same as bush medicine, we've had people approach us and say would you promote but our product? We can't do that either because we're not, that's a community thing as well. Someone else must have a question.
Audience: Normally in any kind of primary health care, you'd think that having a good relationship between patient and GP is kind of core, and then how you explained how that's completely impossible really because it's just a bunch of part time GPs, so isn't that something that kind of needs looking at, how you develop that relationship?
Raylene Gordon:Yeah it does. And that the use of locums and that, not ideal and what's happening with the reliance on medicare. So everyone knows about the Aboriginal Torres Strait Islander health check? Everyone is promoting that health check, that should be done by your regular GP. And that's because of that relationship so your you shouldn't go to a normal practice and just have a health check because it's not your regular GP it's about that relationship with your GP. It's a bit hard when you don't, one, have GPs, two, don't have regular GPs and and three if you go, what's happening is a lot of Aboriginal people who attend mainstream GP practices they're having their ticking them off as having a health assessment and the patient doesn't even know it. And so what's happening is that those they're claiming the $214 that you can get from delivering it doing a health check on Aboriginal person and then the Aboriginal person is coming back to the AMS is for all their wraparound care that we can't claim for because it's been done it at another practice. So yes, the relations, the GP shortage and the GP relationship, yep. It's a well, it's a state-based, if they can't get them in it north coast and Newcastle and Central Coast how they're going to get them in Bourke and Bree and so it's a real you, we are working with the national bodies on that but it's a it's a bigger question about why GPS don't want to come to the sector? That's the question, because I don't think there's a shortage of GPs, there's a shortage of GPs wanting to work in the sector.
Audience: Why is that?
Raylene Gordon:Why do I think? Yeah, I think, I think pay is one part of it and I think the sector's been moving towards, so there's one AMS I know that pays a percentage of billings to their GPs, so there's that incentive to create, to have that, to be comparable with the mainstream sector, but to do that you need to have very sophisticated systems in place to be able to work out what a GP is worth at the end of the day, what they've made and what they've billed, what they billed in Medicare and then they get a percentage of that. I think money is one part. The other part is where are the GP's who just want to give back, who are really interested in Aboriginal health and want, where are they? They're in our sector now but there's not enough of them and that's one of the things. You know, you you don't work in Aboriginal health for the money. So where are the yeah it's a bigger question about you know the training of doctors and registrar's having a good experience in the sector and all of that. It's multiple things. I think it's more than money.
Audience: We have on average over the last 4 years, I think around 16 Aboriginal doctors go into our system, that's interns, obviously they do their time and they leave and they either go interstate or in to the private sector as you know. I'm wondering whether there's any opportunity to have you know partnerships with LHDs while those Aboriginal students or doctors are there doing their intern, whether they can actually do some time in the AMS? Has that been discussed?
Raylene Gordon: Not to my knowledge but I think we spoke with Kerry about some work for some issues yesterday. I think it's something that could be considered. I mean the registrar's that go through the sector, choose to because they see so much more than they would in mainstream practice, so they learn so much more, they learn quicker, because the presentations from GPs I've spoken to, they they wouldn't see anymore, they wouldn't see some of the conditions that they see in AMS's in mainstream so if you can just get them there you can quite often keep them, but that's an issue is getting them there.
Audience: Would be keen to have that conversation.
Audience: Thank you for your presentation. I'm wondering if mental health presents some unique challenges in the work that you're presenting on? I know it's a huge thing and it's got it's own problems even in the mainstream health sector, but I'm wondering if there's anything you'd like to say on that?
Raylene Gordon:Only to say that it's really difficult. So we've got anecdotal sort of evidence that culture and culture programs really complements the clinical counselling and psychology work and all that, but it's um it's very hard to evidence that work around how that impacts on someone's treatment. So the so there's some very good models across the, in our sector, across the state, around how culture and traditional practices then complement, sort of, the clinical model, but it's not well-documented or evaluated that that actually is making, is getting good runs on the board. So that that's all I would say about, most most services are underfunded for mental health. That's, that's a given. But the services who are funded and choose to fund cultural activities are often questioned about the impact of those. So if they want to run a men's group, if they wanted to take them out into a camp, it's like well where's the outcomes. So that's a real issue. So it's not acknowledged or that type of, I call it 'treatment' is not respected.
Audience: Hi Raylene. Thanks for sharing your insights. It's really interesting to hear all of these things. I was just wondering whether you could share what you would like to see in terms of governance in terms of Aboriginal medical services, to protect the community-controlled aspect while also sort of meeting the requirements for accountability for government funding? How do you see a good governance model looking into the future?
Raylene Gordon:Yeah that's a good question. Do I believe in skill-based board? Yeah do. Do I believe in community control? Absolutely. That's been the success of the sector to date. I think a combination would be good. How that happens though, and I've been around the table of many discussions around that and why isn't community expertise considered skill based and all of that, but I think the reality is you know we're operating in an environment that we need to have access to technical expertise around legal, finance.. So my ideal board and be have our community control board but have a sub-committee where you had your technical experts that sort of were asked when needed to advise. That's what I would have. I would have a sub committee They wouldn't be part of the board though because at the end of the day, when everything goes, when you need your community to be on board with any change, they're the ones that do it ,not those. So I would have that set up.
Audience: So is that model that's changing with NACHHO?
Raylene Gordon:Yeah NACHHO and that are moving towards that sort of arrangement, not in that structure but that arrangement ,to have as a skill mix of community and and the technical side of it yet and it's taking a very long time to get over the line because people are still, and rightly so, community control is the that's what they're fighting for. Thank you everybody for listening.
Geraldine Wilson-Matenga: Thank you so much Raylene and you know I think I might have said this before but I really encourage anybody any of our colleagues both out in the LHD's, but within the Ministry, if you have not been to an AMS come with us on a visit. Because you really don't understand really the complexities and the challenges that a AMS face day-to-day going about their business and also the important role that they play in communities are so much more than a primary health service or an AMS. They are real hubs in the community do all those wraparound things and I think that we don't often recognise that and value that. And I'd also just like to say Raylene and that you know in terms of our partnership agreement as well we've had a very long-standing partnership between the Ministry and the Aboriginal Health and Medical Research Council in that that arrangement is replicated on the ground between our LHDs and AMSs and just how important that is particularly given the complexities that you talked about in that changing environment something that we need to be really mindful of and how we support AMSs to do the business, and and actually work through some of those challenges in partnership with our AMSs, at the end of the day we all want the same thing we want to improve that regional health outcomes. Did you want to say anything about the partnership? What you'd like to see going forward or we can leave that for another day?
And I thank you very much for sharing your experience and the work you are doing, the incredible work you do and will continue to do and we look forward to working with you in your capacity as the CEO of the AHMRC and thank you everyone for coming today and if you do have any feedback or further questions or you'd like to know a bit more about the Aboriginal community controlled health sector drop us a line at Center for Aboriginal health mailbox or contact anybody in the Centre or myself and I can put you in touch with Raylene. Well, thank you everybody.