It is unfair and poor public policy that mortality and morbidity rates in rural Australia are significantly worse than those in metropolitan areas. There is an urgent need for a National Rural Health Strategy, accompanied by a sustained increase in funding, workforce and other resources, to address this growing health and healthcare disparity.
Recent media reports have highlighted some of the problems facing hospitals in regional and rural areas but failed to address the real issues and the causes of increasing pressures on these hospitals. These include that in regional, rural and remote Australia there are problems attracting and retaining the healthcare workforce, difficulty with timely and affordable access to care, increased levels of risky behaviours, lower socio-economic status, and higher levels of disease, injury and suicide.
The consequences are higher rates of potentially avoidable hospital admissions, poorer health outcomes and shorter lives for the almost one-third of Australians who live outside metropolitan areas.
Earlier this year, writing in the Medical Journal of Australia, John Wakerman and John Humphreys called for “Better health in the bush”: why we urgently need a national rural and remote health strategy. They argue that there is comprehensive evidence about what service models work in different rural contexts and why, but no national strategy using this knowledge to scale up local successes and guide national health system development. This call reinforces that made in 2017 by the National Rural Health Alliance.
Despite the growing need, the Australian Government seems increasingly intent on diminishing the focus on rural health. The current National Strategic Framework for Rural and Remote Health (an Australian Health Ministers’ Advisory Council document) was commissioned in 2009 and has not been updated since 2012. It sits alone on a Department of Health website page for Regional and Rural Health that states it is “no longer in use”.
Rural health is no longer even mentioned in the Department of Health Portfolio Budget Statements, so it is not possible, as it once was, to track spending on rural health. In the 2017-18 Federal Budget, which provided $83.3 million over five years for increases in rural workforce numbers and rural training in what was termed “A Stronger Rural Heath Strategy Package”, it was claimed that $550 million is spent annually on rural health, but it is not clear how this figure is calculated.
Tackling health and healthcare disparities in regional, rural and remote areas will require increased efforts and resources in two major areas: workforce planning and primary health care. (It should be a given that Closing the Gap on Indigenous health is also a priority.) The National Rural Health Alliance estimates a rural and remote primary health care deficit of over $2 billion each year.
The key to driving needed change is attracting getting and retaining the right health workers in the right places. This means more than just more doctors and nurses; allied health professionals, pharmacists, and dentists are essential members of a multi-disciplinary team that must be expanded to include community and Aboriginal health workers, nurse practitioners, mental health professionals, midwives, dental technicians and social workers.
Specialist care will always be in short supply, but two approaches can help here. The first is that, to the extent specialists are fly-in / fly-out, there should be ongoing connections and communications with patients and local clinicians. Telehealth can make a huge difference in ensuring continuity of care. Secondly, increased support for procedural GPs and rural generalists can help bridge the gap in specialist services and provide needed local expertise, especially in times of emergency.
As Wakerman and Humphreys point out, two decades of rural medical workforce research clearly show that an integrated medical training pipeline with early and continuing exposure to rural practice is effective in delivering and retaining appropriately trained doctors. But it is important to recognise that efforts need to be made – through appropriate remuneration, professional development opportunities, family and social support, and locum services – to all members of the healthcare team to keep that team in place. Sadly, the disappearance of Health Workforce Australia has meant diminished federal capacity and activity in this area, which requires a national approach.
The need to the strengthen primary health care must also be seen as irrefutable. This means not just improving access to primary care services (including suicide prevention, mental health and substance abuse services) but also tackling the social determinants of health (see, for example, Australia’s Health 2018). Australian research led by Wakerman and Humphreys and quoted in their MJA article has identified the core services and shown how local delivery varies with population size and location; it has also described a typology of service models that, with competent regional governance, can optimise access to care in remote and rural communities.
There is a strong evidence base to underpin a new national rural health strategy. This should build upon what is already working well in rural health (including initiatives in Indigenous health such as Aboriginal Community Controlled Health Services) and look to ensure integration across systems to improve consumers’ access and patients’ experiences.
What is also needed is secure, sufficient and sustained funding to support the strategy for periods extending well beyond the election cycle and governance mechanisms that are responsive to local needs. With the provision of resources for information technology and ongoing evaluation and communication, there are very real opportunities for the development and implementation of new models of service delivery and community involvement.
The good health and wellbeing of rural and remote Australians is critical to achieving and sustaining regional growth. However, life on the land and in regional and rural towns is being made increasingly difficult by the adverse effects of climate change and natural disasters and the subsequent impacts on finances, family stability and mental health. This is not a time to ignore the health and healthcare needs of rural Australians.
Dr Lesley Russell is an Adjunct Associate Professor at the Menzies Centre for Health Policy at the University of Sydney.