Issues Magazine

Australia 2020: The “National Conversation”

The following submissions on rural, remote and indigenous health come from the Australia 2020 “national conversation”, a continuation of the Federal government’s 2020 Summit in April.*

For many Australians living in rural and remote areas, a lack of access to primary health care services represents a major barrier to their full and effective contribution to their community’s prosperity. This lack of access is evidenced by data indicating fewer numbers of General Practitioners, nurses and allied health professionals on a per capita basis.

This lack of access to primary health care is evidenced in a number of different ways.

  • Through higher rates of morbidity and mortality than their urban counterparts. The latest evidence from the Australian Institute of Health and Welfare suggests that death rates can be 10–70% higher than in the major cities.
  • Through higher rates of hospitalisation for ambulatory-care-sensitive conditions.
  • Through fewer numbers of GPs, nursing and allied health professionals compared with their urban counterparts.
  • Through higher out-of-pocket expenses for individuals travelling to health services.
  • Through lost productivity and foregone earnings as individuals have to travel further to receive some treatments.

Given these factors, one of the most intelligent forms of support the government can provide to ensure the long-term sustainability of rural and regional communities is through increased investment in primary health care services. Such primary health care investment would achieve a number of objectives, including:

  • increased employment opportunities within communities;
  • increased incentives to stay for younger families with children; and
  • a flow-on effect throughout the communities to other sectors.

There is therefore not just a social justice argument to be made concerning access to services but also an economic argument. Higher rates of hospitalisation are extremely costly when compared with primary health care interventions. Furthermore, research has shown that early intervention and prevention in the areas of mental health can raise labour force participation rates by 17–26%. Interventions in other areas could also be expected to improve labour participation rates to some degree.

Although the number of GPs practising in rural and remote areas has grown over the past 5 years, the rise has not been sufficient to address the much lower GP-to-population ratios in small rural and remote communities. In addition, these increased numbers have been a consequence of the policy directing International Medical Graduates (IMGs) to rural and remote areas through provider number restrictions. Despite a recent increase in domestic medical student numbers, Australia will remain reliant upon IMGs for at least the foreseeable future.

Courtesy Rural Health Workforce Australia. Excerpt reproduced with permission.

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Throughout Australia volunteers are the bedrock of the social fabric, and this is more evident in the non-metropolitan areas than anywhere else. As in the cities, rural areas are dependent on volunteers to provide services in health and welfare, arts and culture, sport and recreation, conservation and a host of other services. Volunteering clearly contributes to the health and cohesion of society and is a strong indicator of social capital.

For rural Australia to survive and thrive, efforts must be made to support and sustain this voluntary activity as its very life blood. This means that the volunteer infrastructure in rural areas must be strengthened to ensure that its services provide the essential training and development components that are necessary for the maintenance and growth of the volunteer sector. The pattern of rural settlement is such that this infrastructure needs to be decentralised in order to provide effective and efficient service. Realistically, these services need to be embedded into existing infrastructure and into new and developing forms just as the volunteer ethic is embedded in rural society.

A well-trained and skilled volunteer force ensures the free flow of skills and knowledge through society. As a locus of intergenerational and social contact it ensures flow of skills and knowledge between generations and social classes as well as providing vital networks for effective social access and integration. The inter-generational skills transfer that volunteering offers has the capacity to be a workforce strategy and worthy of investigation and programmatic response. The early indicators of so-called “grey nomads” contributing in this way to rural communities forecasts what is possible.

Courtesy Volunteering SA & NT Inc. Excerpt reproduced with permission.

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When looking at the future of health services provided to those living in rural and remote Australia, it is tempting to simply to say: “Allocate 30% of the health budget to the 30% of Australians who live in these areas and everything will be all right”. To some extent this is probably true. Current levels of health funding are skewed in favour of metropolitan areas, and rectifying this inequitable situation would go a long way to solving many of the problems faced by those requiring health services in the bush. However, experience has shown that simply “throwing money” at a problem is unlikely to provide a satisfactory long-term solution.

Health Consumers of Rural and Remote Australia maintains that health consumers must be an integral part of future decision-making and that lasting solutions are more likely to come from a “ground up” rather than “top down” approach. Those living in rural and remote areas are realists. They do not expect the same level of convenient access to health services as those living in the cities. What they do expect, and are entitled to, is access to a health care system that does not ignore or discriminate against them because of where they live.

We can all empathise with the deplorable state of indigenous health in this country; the difficulties faced by seriously ill people in the bush trying to arrange transport to medical care; the growing problems associated depression and anxiety disorders in our farming communities; and the lack of trained health professionals available to treat patients in rural and remote areas. As Australians, living as we do in such an affluent country, we should not be content to let problems continue to fester away simply because those affected do not have a loud enough voice to be heard over the many others clamouring for government assistance.

Health consumers know what they need. We just need to listen to them.

Courtesy Health Consumers of Rural and Remote Australia. Excerpt reproduced with permission.

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People living in rural and remote areas of Australia have poorer health than their urban counterparts. They also have lower levels of access to GPs and other primary health care services. This lack of access impacts upon the whole Australian community through higher rural and remote rates of admission to hospital for ambulatory-care-sensitive conditions and through foregone earnings and the impact upon productivity.

Given the worldwide trend towards an overall shortage of qualified medical practitioners and nurses, the way in which health care is delivered is being increasingly debated. The future for primary health care will encompass teamwork and multidisciplinary approaches as well as the adoption of ”new” professional roles such as nurse practitioners, physician assistants and allied health assistants, with enhanced scope of practice to deliver the most effective care to achieve best health outcomes.

Despite this growing trend, many rural and remote practices still consist of solo practitioners working long hours, including arduous on-call arrangements. This model of practice makes the health care needs of a population extremely vulnerable to sudden changes, such as retirement, death or illness of the practitioner.

We know this mode of practice is antithetical to the expressed wishes of more recent graduates and those GPs who are looking to change their working patterns. Attention needs to be paid to how these opposing trends can be reconciled. This will involve attention to models of practice ownership as well as service mix.

Courtesy Rural Health Workforce Australia. Excerpt reproduced with permission.

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The 17-year gap in indigenous life expectancy means that many indigenous people require greater access to services than the non-indigenous population. However, many indigenous people also live in remote communities and are experiencing the poorest levels of access to services because of a serious shortage of health personnel in Aboriginal Medical Services.

In Australia, access to such Medicare-funded services in remote indigenous communities is disproportionately lower than in urban environments. Urban populations have a higher per capita and per patient consumption of both the Medical Benefits Schedule and the Pharma­ceutical Benefits Scheme than rural populations.

As Gavin Mooney has written: “On average, Australians use Medicare-funded primary health care to the extent of just over $530 per year. The people in Double Bay … use more than $900. In the Kutjungka, in the Kimberley, the Aboriginal people are among the sickest in Australia. They use less than $80 in Medicare primary health care funds per year largely because of the non-availability of GPs.”

Because indigenous Australians die on average 17 years earlier than the general population, they require much higher levels of access to care within their own communities. Furthermore, the current failure of mainstream health programs to address these very serious health problems indicates that indigenous Australians must have access to health services that are also culturally appropriate.

Indigenous communities need to be provided with specific programs to support their health services and their health professionals. This is integral to ensure that indigenous communities are the focus of the highest level health service interventions.

Much of this poorer health relates to chronic diseases that are amenable to prevention and early intervention strategies. GPs alone cannot address this problem, even if there were not such a chronic shortage of doctors working in Aboriginal Medical Services.

There needs to a multi-pronged approach, including the following:

  • indigenous health placements and courses for all university health students;
  • Cross-cultural training and cultural sensitivity training as a core competency for all health professionals, particularly those who work in indigenous health services or in communities where there is a significant indigenous population; and
  • appropriate remuneration packages for all workers in Aboriginal Medical Services.

Poor health for Australia’s indigenous populations is also a consequence of a number of other factors including:

  • lower levels of educational achievement because of poor education services in indigenous communities;
  • lack of appropriate housing; and
  • lack of employment opportunities.

Addressing the 17-year gap in life expectancy will therefore require a concerted multi-faceted approach that is consistent with expressed community needs.

Courtesy Rural Health Workforce Australia. Excerpt reproduced with permission.

*Submissions will be reviewed as part of the government’s final response to summit recommendations. Visit www.australia2020.gov.au for more information.