(SUPPLIED: Mark Burdack, CEO, Healthy Communities Foundation Australia addresses National Health Workforce Summit on People-Centred Health Workforce Planning)
Below is an extract from a letter written on behalf of rural and remote people to the Minister for Health Ageing, The Hon Mark Butler, seeking greater participation of rural and remote people and organisations in planning for the future of rural and remote health.
The Hon Mark Butler MP
Minister for Health and Ageing
PO Box 6022
House of Representatives
Canberra ACT 2600
9 February 2023
Proposal to Establish a Strengthening Medicare Rural and Remote Taskforce
We would like to congratulate you on the Strengthening Medicare Taskforce Report. We are greatly encouraged by the language of the report and the commitment of the government to increasing community involvement in health policy design and delivery, team-based care and the focus on rural and remote communities.
In the context of the planning and implementation of the Report, we are writing to you to propose that the government consider establishing a Strengthening Medicare Rural and Remote Taskforce to develop options and recommendations to the Government and National Cabinet for rural-specific reform.
Strengthening Medicare Rural and Remote Taskforce
One of the major concerns of rural and remote people is the lack of direct engagement by government with rural and remote health consumers in the design and delivery of rural health and workforce policy. Rural and remote people often feel that their local knowledge and expertise is not valued as highly as that provided by city-based academics, industry and rural health agencies.
This lack of direct input into rural health health and workforce policies and programs has contributed, in our view, to the underperformance of current policies and programs to address the challenges in rural and remote communities.
Over the last decade or so, the number of rural generalists in NSW has declined from 800 to 200 (-75%); the proportion of medical graduates wanting to become GPs has declined (from highs of around 40% to lows today around 13%); the proportion of rural medical students wanting to work rurally has remained largely unchanged despite significant growth in the number of “rural origin” medical students; the number of allied health practitioners working rurally has declined; rural and remote general practices have closed; and rural hospitals have dramatically reduced the scope of basic services available locally. These are all statistics which we are sure were apparent to the Taskforce and would come as no surprise to you.
Rural and remote communities would argue that a major gap in the government’s approach to the design and delivery of rural and remote health and workforce policies is a lack of direct input from the experts - the people who live and work in these towns.
Exclusion from public policy development is not unique to rural and remote people. Many vulnerable communities have historically been subject to exclusion including Aboriginal and/or Torres Strait Islander people, LGBTQI+ people, refugees and migrants and people from culturally and linguistically diverse backgrounds contributing to poor policy decisions and program outcomes.
Governments have generally recognised however the impact of the marginalisation of diverse voices in policy development, but this recognition has largely bypassed rural and remote people. This may reflect the fact that ‘rural and remote’ is largely viewed as a geographic concept.
We would argue, however, that ‘rural and remote’ is not a geographic concept, but a socioeconomic and cultural one.
Geography in an administrative category used to describe the spatial dimension of disadvantage. Geography alone, however, is not a driver of disadvantage.
One of the critiques of rural health planning processes is the use of a broad geographic categories to bundle remote, rural and regional communities together without proper recognition that the circumstances of people living in Brewarrina and Bathurst for example could not be more different.
Rural health advisory panels typically include representatives that are largely based in major or regional cities and large towns. Rarely does the membership of advisory and consultative groups include people who could reasonably be described as being from a lower socioeconomic background, despite the fact that this constitute the bulk of rural and remote residents.
The Commonwealth Government recently re-established the Youth Advisory Steering Committee for which we congratulate you and the Cabinet. Consider, however, if this Committee was chaired by a 75-year-old man, included no representatives below the age of 18 years, and only included heterosexual people from Anglo-Saxon backgrounds. Would this Committee be viewed as legitimate by young people? Would it offer the government high quality advice that would lead to well-formed policies and programs that addressed key issues for young people in Australia? The same holds true in the government's approach to the design of rural and remote health policies when we create and impose policy solutions without the input or advice of rural and remote people that have a lived experience reflective of the majority of the community.
By using geography alone, rather than socioeconomics and culture, as a framework we risk focussing on the wrong dimensions of the challenge, leading to an assumption for example that a wealthy rural landowner can be fully representative of the experiences of all rural and remote Australians.
We are not devaluing the contribution that can be, and is, made by many people who have dedicated a substantial proportion of their working lives to addressing disadvantage in rural and remote communities. Far from it.
But in our view, governments must diversify their sources of expertise to ensure that the views, lived experience, knowledge and wisdom of people who represent the majority of residents in rural and remote towns are considered in policy planning and decision making.
In this context it is important to note that all the peak bodies for rural health largely represent the interests of industry professional bodies, not rural and remote people directly (rural doctors, rural health committees of major health professional associations, rural clinical schools, university departments of rural health). While these bodies sometimes consult with rural and remote people, this does not mean that the needs, expectations and knowledge of rural and remote people is directly represented to government. Too often rural and remote people complain about “solutions” being imposed on their communities that they know will not work in their local context.
Rural and remote simply want what all Australians want - better access to local GPs living and working in their communities as part of a cohesive primary health care team, and better access to integrated social assistance services that are crucial to addressing the social determinants of disadvantage.
It is only fair that people who live in rural and remote Australia, and who reflect the types of people who comprise the majority of residents, are given seats at the policy table. Rural and remote people have far more to offer than being a focus group on matters that pertain to their own futures.
Based on these reflections, we are heartened to see some of the comments in the Taskforce report, for example: “Rural and remote communities should have the flexibility to design and fund solutions that better reflect the reality of what’s needed and can be sustainably delivered. This can only be achieved through consumer and community engagement, collaboration, and co-decision making at the local level”. We endorse these comments which we believe support the following proposal.
As a charity, part of our job is to listen to rural and remote people and to advocate for and with them for reforms that actually work. The views we have expressed publicly on this and other matters of rural health policy clearly challenge the status quo, but as you have said the status quo is no longer an option.
The absence of people who live and work in rural and remote Australia in the design of rural health and workforce policy, the development of rigorous and achievable outcomes and the independent oversight of the performance of providers has in our view loosened the accountability of providers to rural and remote people and the Australian taxpayer for the successful delivery of outcomes. Governments have spent significant amounts of taxpayer’s money, too often in metropolitan and regional cities, to achieve very little improvement in health services for rural and remote people.
If we are to Strengthen Medicare for rural and remote people, we need a new deal for rural and remote communities that is based on their input, direction and oversight on the same terms as would typically be afforded to other vulnerable groups in Australia.
The national vision and performance targets for rural and remote health should reasonably be set in consultation with rural and remote people, as is the case for so many other vulnerable groups.
Rural and remote people understand rural and remote health better than anyone else. They understand the subtle differences between towns, villages and hamlets that can have a major influence on population health and workforce attraction outcomes. They understand the drivers of good and poor health, the strategies that are needed locally and how they will work in their communities. Equally important, they can see what is happening on the ground and whether programs are working or not ensuring that policies can be adapted and changed to improve performance and outcomes for their communities.
When rural and remote communities are empowered to drive solutions to local problems, and receive long term funding to support this, the evidence shows consistently that they are better able to deliver solutions.
The Strengthening Medicare Report acknowledges this. Yet we lack the structures and systems to ensure genuine participation of rural and remote people in the policy planning and delivery process. We argue that this needs to change if we are to achieve long term systemic change in rural and remote health outcomes.
We propose the establishment of a Ministerial Strengthening Medicare Rural and Remote Taskforce comprised of people and clinicians who live and work in rural and remote communities with real knowledge and experience of what works and what doesn’t. A draft Terms of Reference is attached to this letter for your consideration. We would be happy to suggest possible names for members of the Taskforce if you wish.
We have also attached to this letter a copy of the “Rural Community Hubs” proposal for your consideration as part of the pre-Budget process. Community Hubs are a model of service delivery that have grown organically in rural and other communities to improve the way people access services, and to foster greater collaboration between professional disciplines to address the social determinants of health. We would argue that this model should be given close consideration by the government as a flexible, community-led and place-based delivery solution that aligns with the recommendations of the Strengthening Medicare Taskforce and will contributed to improved life and health outcomes in vulnerable communities, while supporting increased sustainability of services in rural and remote communities.
We would be happy to discuss this proposal at your convenience.
Richard Anicich AM Mark Burdack
Chair Chief Executive Officer
DRAFT TERMS OF REFERENCE
The Australian Government is committed to improving primary health care for all Australians. In making this commitment, the Australian Government recognises that people living in rural and remote communities face unique challenges due to their socioeconomic and cultural context that require different models of care and service delivery frameworks that reflect local circumstances and which are informed by the experiences and knowledge of people living and working in these communities.
The Strengthening Medicare Rural and Remote Taskforce will have as its primary focus people from lower socioeconomic backgrounds living in Modified Monash Model MMM3-7 locations. The Taskforce will provide concrete recommendations to the Australian Government by the end of 2023. The taskforce will focus on:
· improving patient access to face to face general practice services, in and after hours.
· improving patient access to GP-led multidisciplinary team care, including nursing and allied health thereby strengthening the relationship between the patient and their care team
· making primary care more affordable for patients
· improving prevention and management of ongoing and chronic conditions
· reducing pressure on hospitals.
Specifically, the Rural and Remote Taskforce will make recommendations to the government on the implementation of the Strengthening Medicare Taskforce report recommendations in the context of rural and remote people including but not limited:
· new and innovative funding and delivery models, including specifically blended and/or multi-jurisdictional funding and delivery arrangements.
· the appropriate use of technology to augment and strengthen local primary health care access and what, if any, reasonable constraints should be considered to prevent the substitution of technology for local health and medical care when this is what is required.
· health and medical workforce recruitment and retention strategies including the future organisation and delivery of health and medical education and training to increase the flow of graduates to rural and remote communities.
· integrated models to better address the social determinants of health and improve lifetime health outcomes including reducing preventable illness and avoidable hospitalisation.
· innovative models for improved integration, coordination and collocation of health, social assistance and community development services.
For more information contact Mark Burdack on 0418974988.