Most of us consider health care to be a basic human right, rather than a privilege. In both philosophical and practical terms, the availability of high-quality health care is a national imperative. But for people living in the countryside, this right is compromised.
It’s been clear for a decade or more that we need to reform our health system to meet contemporary needs. But making necessary adjustments continues to be problematic. While cost ineffectiveness (and therefore sustainability) is a major concern, health-care inequity is increasingly the most distressing feature of our health system. Addressing it should be the driver of the reform agenda.
Nowhere is health-care inequity more evident than in Australia’s rural and remote communities. If you live away from major metropolitan areas you are 42% more likely to die prematurely of preventable disease. If you live in western New South Wales, you will die, on average, four-and-a-half years earlier than a person living in North Sydney.
Successful treatment of cancer diminishes steadily the further you live from major cancer treatment centres. And, a very recent study demonstrates that women living in the country have far inferior health compared with their metropolitan cousins.
For such a wealthy country, this situation is intolerable and it’s likely to get worse without new approaches. Rural Health Workforce Australia recently reported that while “mortality rates across all parts of the country fell steadily between 1997 and 2006, the mortality gap between the major cities and other areas remained fairly constant.”
The lack of access to adequate health services is the indisputable driver of this inequity. Insufficient numbers of health professionals in general, and doctors, in particular, is the major contributing factor. We need at least 1800 more GPs in rural Australia to cope with current demand.
We urgently need to find ways of increasing the number of doctors in the bush and simultaneously use the current health workforce more productively. Current policies aimed at achieving these goals are clearly inadequate.
A report delivered to the government last year on the future make up of the rural medical workforce concluded that any significant increase was only likely to be achieved by increasing the number of overseas-trained doctors from the current 42% to 50%, and increasing the number of “bonded” locally trained doctors.
Rural Australians understandably want to be cared for by doctors who enjoy a career in the countryside. Indeed, they want doctors who’ve had the opportunity to develop the critical skills needed for rural practice, which can be quite different to those needed for metropolitan communities. Surely our goal must be to accommodate these reasonable aspirations.
But the situation isn’t hopeless. Recent international conferences sponsored by leading health agencies, including the World Health Organisation (WHO), have agreed that health workforce shortages that plague rural communities can only be addressed with two new approaches.
The first involves medical training for many more students with really strong rural affiliations, who – at the time they commence medical studies – prefer country life. To get such people to study medicine may require universities to apply affirmative action criteria, as educational disadvantage in many rural communities may make it difficult for rural students to compete with metropolitan students for university places.
What’s more, these students should be trained with rural-specific curricula. A major emphasis should be placed on procedural skills, for instance.
At the moment, all Australian universities are required to have a quarter of their medical student places occupied by rural students. But the definition of a rural student is totally inadequate; you can qualify for the designation if you’ve lived five years of your life in a rural postcode. Unfortunately, this has nothing to do with any aspiration for a country-based career.
Even with this inadequate definition, fewer than half of the universities meet the target. In effect, more than 100 rural medical student places in 2010 went to non-rural students.
All medical students rotate through rural-based terms and a small number may, as a result, be attracted to country life. But the majority have no intention of abandoning metropolitan careers. A recent study showed that only 2.7% of Australia medical graduates would practice in rural areas. So, there’s a very strong case for reallocating existing medical student places to rural-based universities and tightening the definition of rural student. This latter should include an assessment of the real likelihood that the student wants to work in rural or remote Australia after graduation.
The second strategy concerns the need to use our health workforce more intelligently with an emphasis on “team medicine”. Many health systems, and certainly our own, are doctor centric and a silo mentality hinders integrated patient care.
There’s a worldwide ambition to make integrated primary care the norm and have health professional teams work within one practice. To facilitate the cultural changes necessary to break down the silos, health education must move to an inter-professional learning model, which fuses some aspects of the curricula for medical, nursing, allied health and dental students. Team learning will prepare people for team practice.
Simon Crean (minister for rural development at the time) advised rural communities to be stronger advocates for their needs and come to government with solutions, not problems, on the ABC1’s Q&A late last year. These communities should champion the new approaches described here, as should all of us responsible for training the next generation of health-care workers.