IMPROVING HEALTH CARE IN RURAL AUSTRALIA

1
IMPROVING HEALTH CARE IN RURAL AUSTRALIA

• New models for training and care in rural
  communities and their evaluation
• Critical strategies for improving health
  outcomes for Rural Australians
  
  
• The Western Alliance initiative
• Deakin University November 2014

2
Basic Principles

• Health Care is a right not a privilege
• Health, Happiness and Productivity are
  inextricably linked
• The broad social determinants of health
  (education, workplace issues, transport, housing,
  law and order, etc) must be integrated with our
  Health System.

3
Health Care Reform

• Our goal
• A system focused on the individual that
  emphasises prevention is demonstrably equitable,
  sustainable and provides quality care in a timely
  manner available on the basis of need not
  personal financial wellbeing.
• Inequity increasingly problematic

4
What about Rural Health Care?

• More than 33 of Australians live in Rural or
  Remote communities
• They produce 65 of the Nations wealth
• There numbers are growing and feature many
  retirees!

5
Equity

• What did the recent report from the Senate
  inquiry conclude about health care equity in
  rural Australia?

6
Unacceptable Health Outcomes

• Australians living in rural and remote areas
  have much poorer access to local health services
• 2 billion dollar Medicare gap
• Significantly worse health outcomes
• A significantly shorter life expectancy than
  Australians living in metropolitan areas

7
The Chronic Disease burden

• The prevalence of chronic disease is troubling
• data shows the incidence of cancer is about 4
  per cent higher than in major cities
• Significantly higher incidence rates for
  preventable cancers
• .

8
Disease burden

• Lifestyle risk factors or health determining
  behaviours contribute to the burden of disease
  in these communities
• People in remote areas found to engage in more
  behaviours that carry risks
• Mental health problems common and have unique
  rural precipitants

9
Disease Burden

• Compared with their city counterparts rural
  residents tend to exhibit
• 10 percent higher levels of mortality
• 20 percent higher rates of injury and
  disability
• 32 percent higher rates of risky alcohol
  consumption and
• 1070 percent higher rates of peri-natal death.

10
Health Workforce shortage serious and worsening

• In rural communities not uncommon to wait 6 weeks
  for an appointment with your GP
• We have an ageing workforce,
• and inadequate numbers of GPs and other health
  professionals choosing rural practice.

11
Current situation

• Extremely dependent on Overseas Trained Doctors
  and the Bonded medical student program.
• About 47 of rural GPs are OTDs
• Deloiite Access Economics reported to government
  that to have significantly more rural GPs the
  number of OTDs would have to significantly
  increase!

12
Overseas Trained Doctors

• Use of so many OTDs problematic
• Ethics? Needed at home
• Developing countries want them back, the tap may
  be turned of
• Many only in rural towns as they cannot work
  elsewhere
• Problems with supervision and communication

13
Reasonable Expectations

• Rural communities deserve and need to be cared
  for by Australian doctors who want to work in
  their community, love rural life and have been
  trained as generalists with a rural specific
  curriculum that included procedural skills and
  equipped them to handle the rural specific needs
  of their communities.

14
Government strategies.

• Riding the OTD bonanza- cost effective
• Bond medical students
• Provide cash incentives for metro doctors to move
  to the country
• Area of need payments
• Double the number of Medical student places and
  market forces will take them to the country

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Current Government Policies

• Medical Education-----
• 25 medical students Rural
• Have lived in a rural post code for five years
  !!!
• Establishment of Rural Clinical Schools
• All students spend a minimum of 4 weeks in a
  rural clinical setting.

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Policy failure noted in reports

• Need at least 1800 more rural GPs
• Financial incentives are not working
• 13 of final year medical students planning
  careers as GPs and only 13 of them are thinking
  of a rural based career!
• On average 5 of graduates practice in rural
  areas.

17
Turning the ship around

• Is there an evidence based logic to introducing
  new policies for a new approach?
• Telling observation---70-80 of non-medical rural
  health students trained in the country stay in
  the country. SO--------

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Consensus

• What policies to improve the availability of
  doctors to rural communities are now advocated by
  -------
• The WHO. An international conference of medical
  educators, the recent Australian Senate inquiry,
  the standing committee on rural health of AHMAC,
  HWA 2025 and many others?

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What does the evidence suggest?

• Training many more rural medical students
• A return of the GP proceduralist
• Selected Rural students should have an
  intention to practice in the country
• Rural students to be trained in rural
  universities with a rural specific curriculum
  featuring Inter-professional learning
• Inter-professional learning

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Inter-Professional Learning?

• Silo mentality in the delivery of health care.
  Team Medicine much better.
• Patients referred to professionals in
  geographically dispersed facilities
• Insufficient mutual respect and knowledge of what
  other health professionals can offer
• Very Dr centric system (Super-GP clinics etc).

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INTEGRATED PRIMARY CARE

• World wide shift
• Team medicine Practice team consists of
  doctors, nurses and allied health professionals
  (including dentists) with team funded by
  extension of MBS
• Team learning to prepare for IPC practice.

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Contemporary Primary Care?

• Enrolled patients
• Personalised medicine to prevent illness
• Early intervention strategies
• Team Management of C C disease
• Hub and Spoke models for better clinical,
  business and quality outcomes
• Care in the community for many currently sent to
  hospital.

23
Primary Care?

• Once we have settled on a clear vision for the
  model of care desired we must train/assemble the
  clinicians who can provide it

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Evidence based reforms

• Rurality not postcode all important
• Affirmative action selection
• Six year undergraduate program
• Problem based learning featuring IPL
• Rural specific curriculum
• Early and extended acquisition of procedural
  skills

25
Evidence based reforms

• Balanced hospital and community training
• Create IPC Clinics for care and teaching
• Positive small town experiences.
• Hub and Spoke model
• Final year a sub-intern year
• Rural internship / accelerated vocational
  training
• Health Services research unit

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The Way Forward

• Suggestions for discussion and further analysis
• The definition of a rural student should be
  changed for next years intake
• The quota for rural students should increase to
  30
• Universities that do not meet the required quota
  for two consecutive years to lose unused rural
  places
• Mandatory rural rotations for all students to
  cease

27
The Way Forward

• The number of full fee paying students should be
  capped at present levels with planned expansion
  of this program diverted to rural students.

28
The Way Forward

• New rural based medical programs should develop
  clinical services for the public and in so doing
  provide new clinical training opportunities.
• Recognising rural educational disadvantage, rural
  based programs should use an affirmative action
  approach to enroll best suited students

29
The Way Forward

• Rural based, whole of course education for
  students with a genuine rural identity will
  provide many more doctors for rural communities.
• Graduates from such programs must be able to
  continue with rural based vocational training.
• New initiative should facilitate the re-emergence
  of more GPs with procedural skills at the same
  time as we continue efforts to attract more
  specialists to rural practice

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The Way Forward

• Medical Schools , particularly any new rural
  based schools, should do more to improve the
  professional satisfaction of small town
  clinicians increasing the likelihood of students
  being attracted to such settings.
• There is more than enough data for it to be
  unreasonable to ask rural communities to wait a
  few more years to better assess current programs
  before trying new initiatives.

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The Way Forward

• The Dangerous Dilemma
• General acceptance that we need more rural based
  medical education for rural students
• At least seven Universities interested in
  starting whole of course rural based programs. A
  clear recognition of dissatisfaction with the
  status quo.
• BUT------

32
The Way Forward

• Universities and their medical schools struggling
  financially
• They would be very reluctant to give up any
  current student places
• They warn that clinical training opportunities
  are saturated with more than 16000 students in
  training
• They are struggling with the mandatory
  requirement for rural rotations and would not
  want to donate them to a new program

33
Community and University Advocacy

• No vision or commitment to these structural
  reforms in Canberra.
• Minister Crean advised-------
• We listen to proposals that enjoy really strong
  community support
• Dont be whiners, bring us solutions to your
  problems
• Rural apathy must be reversed

34
Western Alliance Leadership

• Working to improve the impact, quality and
  quantity of research in the region through
  strategies that promote
• Translation of research evidence into practice to
  improve quality of care and health outcomes for
  regional and rural communities
• Utilisation of multidisciplinary,
  cross-disciplinary and trans-disciplinary
  approaches

35
Western Alliance Leadership

• Recruitment, training and up skilling our best
  junior and mid-career researchers and clinicians
  to help ensure the future leadership of health
  research in the region
• Enhancement of advisory and quality assurance
  mechanisms.

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Western Alliance Initiatives

• Advocacy for structural reforms
• Establish and assess proof of concept IPC
• Champion Rurality of students / IPL learning
• Facilitate procedural training for GPs
• Hub and Spoke model IT,CPD,TeleHealth, small
  town assistance / documenting outcomes
• Health research unit assessing and sharing

37
Summary

• Status quo unacceptable, 4600 Australians dying
  each year because they live in the bush!
• Rural Australians deserve efficient access to
  Australian doctors who have the special skills
  they need and love rural life.
• Current programs will not deliver this outcome,
  new approaches must be tried. Good policy not
  politics should drive innovation.
• A Continuing passionate partnership between
  community and university (e.g. The Western
  Alliance) needed to win the day