It is time for us to put aside the rhetoric about systemic racism and start to take action. There are many agreements committing to self-determination for Aboriginal peoples, such as Closing the Gap, rules under the Australian Health Practitioner Regulation Agency and innumerable government policy and strategy documents. We need to actively examine how the way we routinely work is ensuring the racial hierarchy persists, and that Aboriginal people are locked out of making decisions about the health of their own communities.

There is no doubt that if you asked policy makers, they would explain how committed they are to Closing the Gap. They may have led a RAP plan or be on a RAP committee. They may organise a Welcome to Country, may have learnt some of the local Aboriginal language and voted yes in the referendum. These actions are important, but they also allow a safe space where people feel they are being good allies, providing a get out of jail free card to avoid challenging the real power structures.

If you pay attention, you see examples of this everywhere. Recently there was a particularly obvious example of using the way things have always worked to attempt to exclude Aboriginal people. The Aboriginal Controlled Health sector led the addition of a First Nations Schedule to the National Health Reform Agreement. This is intended to provide greater accountability for the health system to provide high quality care for Aboriginal and Torres Strait Islander people. A series of measures were co-designed across the Aboriginal Controlled Health Sector and provided to government. This work is clearly in line with the Closing the Gap commitments of government and also various health system requirements including the AHPRA requirements of clinicians, and standards for cultural safety in health care settings under the Australian Commission on Safety and Quality.

But when it came to the pointy end when the decisions were being made on the governance for this schedule for government, there was no automatic inclusion of NACCHO, the national peak body for Aboriginal Controlled Health Services, as would be considered obvious. Instead, there was a discussion about whether NACCHO could be included, with one jurisdiction objecting. The effect of having to discuss inclusion rather than it being automatic demonstrates a failure in how we do usual business. To the less interested observer, this was a fair and reasonable discussion because it followed agreed processes. The problem of course is that those terms of reference, agreed processes or ways of doing business have not been agreed to by everyone involved, but rather only those in power.

Our health system has many of these examples. There is a well-established clinical hierarchy that places doctors at the top. Doctors are ultimately responsible for clinical decision making that goes beyond the scope of practice of other clinicians. This makes sense in how the systems of clinical governance have been established, the way in which different clinicians are trained and the associated substantial system of rules that health systems must follow. There is however a big problem if we think about how the clinical hierarchy, and its associated power hierarchy, interacts with race. Aboriginal Health Practitioners (AHPs) are AHPRA registered practitioners. They have a clinical scope of practice which includes independent practice for matters such as vaccination, clinical assessment and support for management. Their scope of practice is less than nurses (ENs and RNs) and doctors. Systematically, AHPs have the least amount of control over clinical decision making. Acknowledging that Aboriginal people can be doctors or nurses, the way things work in practice is that Aboriginal people are underrepresented in these other clinical fields.   Is it any surprise that the health system has been unable to shake off the systemic racism that is clearly in place when we structurally have most of the Aboriginal health workforce in the clinical group with the least clinical decision making authority?

Some of the way we do things are easy to change, and some, such as the clinical hierarchy much harder to change. None of it will change if we don’t start trying to see where how we have always done things systematically empowers some people and disempowers others.