Health Policy Document - a new direction

A NEW DIRECTION FOR HEALTH SERVICES IN RURAL AND REGIONAL NSW

Health Policy Document

Prepared by

Richard Torbay MP
Member for Northern Tablelands

HEALTH SERVICES IN RURAL NSW
Recommendations for provision and management of sustainable health services and facilities in regional areas

Table of Contents Page


EXECUTIVE SUMMARY 1

SUMMARY OF POLICY RECOMMENDATIONS 5

A. BACKGROUND 11

B. RECENT REPORTS – Implications for Health Delivery 13
in rural and regional areas
i. NSW Rural and Regional Taskforce 13
ii. NSW Auditor General’s Report – (Sept 08) 15
iii. Indicators of Health Performance 15
iv. Report on the Audit of Hospital Workforce - (April 08) 16
v. Final Report – Garling Special Commission of Inquiry 16
vi. Caring Together – The Health Action Plan for NSW 17
vii. Australian Health Ministers’ Conference - E-Health Strategy 17
viii. A Healthy Future for all Australians 19
ix. A National Health & Hospitals Network for Australia’s Future 21

C. SPECIFIC ISSUES & TRENDS FOR NSW 23

D. RURAL HEALTH WORKFORCE REFORMS 25

E. INFRASTRUCTURE 32

F. INFORMATION TECHNOLOGY 34

G. TRANSPORT 36

H. VISION FOR RURAL & REGIONAL HEALTH SERVICES 38

I. ESTABLISHING REGIONAL HEALTH AUTHORITIES 42

J. REGIONAL HEALTH POLICY RECOMMENDATIONS 39



HEALTH SERVICES IN RURAL NSW
Recommendations for provision and management of sustainable health services and facilities in regional areas

EXECUTIVE SUMMARY

The delivery of health services, both in NSW and nationally are under increasing pressure and struggling with rising demand for health services. The pressures confronting Health Services are being driven by an ageing population; longer life expectancies; increasing costs; higher consumer expectations of health care and technological change.

In 2005, the NSW Futures Planning Project identified that it is not sustainable to address health needs simply by providing more health services. A co-ordinated partnership approach with governments, individuals, communities and government agencies and the corporate sector through a Regional Health Authority approach, has the potential to create an integrated health system that will reform the way in which all health service funders and providers work together to deliver health services to people in rural and remote NSW. Regional Health Authorities can improve our health systems productivity by reducing the waste and inefficiency which exists within the current health system structure (the Commonwealth Government’s review of the Health system conducted by the National Health and Hospital Reform Commission during 2008 and 2009 found that Australia’s health system is fragmented and inefficient, with hospital productivity at 25% below optimum levels).

People living in rural communities have the right to the same levels of health and health care as their city counterparts. However, rural people in NSW live, on average, five years less than people from the more advantaged metropolitan areas. In addition, rural NSW faces a number of other health challenges – relatively low population growth limited largely to regional centres, increasing difficulties with attracting and retaining health professionals, a necessary concentration of some specialized health services in centres at some distance from where people live, and rural dwellers overall having a poorer health status than the population as a whole.

Rural health care is not the same as urban health care. There are specific needs and problems that require a specific focus of attention. This paper proposes the establishment of Regional Health Authorities to manage and coordinate the delivery of health care facilities and services to rural and regional communities within NSW.

Benefits of a Regional Health Authority System:

In moving toward an integrated Regional Health Authority system, both Commonwealth and State governments need to focus on both planning (creating an integrated continuum of care) and service delivery (improving population health and improving care). The Regional Health Authority approach would enable the following:
Ø Reduction of service fragmentation and the development of more holistic person /family/community centred approaches to health care delivery.
Ø Establishment of co-ordinated and collaborative processes for the delivery of multiple cross program services to residents of rural and regional NSW.
Ø Over-arching planning approaches from primary to tertiary care to further an integrated approach to achieving better quality, safe and sustainable health care goals.
Ø Knowledgeable health care professionals being pivotal to the services provided to patients. In Australia and throughout the world, it is anticipated that the current shortage of health care professionals will be exacerbated by a lack of training capacity and the escalating demand for health care services.
Ø Development of a sustainable health care system that anticipates and advocates for the training of health care professionals to meet tomorrow’s demand for health care services. This will involve not only ensuring that the proper number of health care professionals are being trained but also ensuring that they have the skills required to work in a health care environment that is constantly evolving with the identification of better practices and introduction of new technology for more effective and efficient health care delivery. To do this, it is essential to make the health professions more attractive to prospective students by providing a healthy and attractive work environment with an emphasis on attracting prospective professionals into rural areas. It is also essential to ensure capacity to provide the necessary training in rural areas. A Regional Health Authority approach will enable the increased flow of personnel and development of a more integrated educational and collaborative approach to delivering health care in regional communities. Regional Health Authorities linked with Universities providing programs in rural medicine and nursing will attract specialists and enhance overall training opportunities, within both the tertiary areas and the primary care arena.
Ø Increased opportunities to partner with other large organizations enabling structural re-organisation to support integrated service delivery across rural and regional NSW
Ø Integration (and reduction) of financial, information and administrative processes.
Ø Development of a ‘one layer’ system in health across NSW, with a truly integrated approach from primary to tertiary care.

To effectively address rural and regional health issues, the Regional Health Authority would adopt the following operating principles:

1. Empowering people to make healthy choices
A good health system encourages people to be more aware and active in managing their own health, helps promote healthy environments, and works with others to mobilise community support for healthy choices.

Implications for the Regional Health Authority:
Many rural towns have a strong sense of community, and a willingness to focus on projects that benefit all local residents. There is significant scope in rural towns for joint action at the local level by government services, local businesses, schools, sporting clubs, community and cultural organisations, and the media, to reduce health risks and create healthy environments. The Regional Health Authority would play a coordinating role in empowering health initiatives within regional communities.
2. Working together to create better health care experiences and outcomes
A good health system provides services that are matched to people’s needs, and enables the whole community to participate in creating the best possible experiences and outcomes for those using the system.


Implications for the Regional Health Authority:
Because of the increasing difficulties in maintaining some local health services (due to a worsening shortage of doctors, nurses and allied health professionals), it is imperative that increased efforts are made to engage local rural communities in discussions about what services can and should be available locally, and what services need to be provided on a more centralised basis and will therefore necessitate patient travel. The Regional Health Authority would engage with regional communities and be responsible for implementing Information and Communication Technology (I&CT) solutions to improve consumer access to:
· ‘Up-to-date’ information about what health services are available, and about treatment options,
· Quality health care services which can be provided via remote electronic communication, and which reduce the need for travel (by both consumers and providers).
To reduce the need for acute hospital admission over the longer-term, the Regional Health Authority will be responsible for shifting the focus of health services more towards protection, prevention, detection and early intervention services, and services provided in the community.

3. Integrating regional planning, funding and services
A good health system uses an integrated approach to planning, funding and service provision that considers health care within the broad range of factors affecting health and wellbeing.
Implications for the Regional Health Authority:
Developing integrated networks of health and human services within local rural communities and regions is absolutely vital to maintaining adequate and appropriate services in those areas, and could play a major role in ensuring the ongoing viability of many rural towns. The Regional Health Authority will be responsible for providing a more integrated approach to the delivery of human services at a regional and community level. This will reduce overall infrastructure costs through cost-sharing arrangements, address some of the “critical mass” problems which each agency faces when working independently, and will allow joint planning and service delivery which more efficiently and effectively addresses the community’s priority needs, and improves the coordination of care. This approach also allows the development and implementation of strategies that are customised for a particular place and/or group of people.
The Regional Health Authority will implement a governance framework that ensures accountability and funding arrangements and infrastructure (including I&CT) which supports integrated regional service delivery.

4. Improving value, economy and sustainability in health care
A good health system makes the most effective use of available resources and ensures that costs are kept under control to promote sustainability. The services provided to meet the health needs of the community are appropriate and cost-efficient.

Implications for the Regional Health Authority:
The costs of maintaining services in rural towns are often higher than in larger regional centres and metropolitan areas. In addition to the freight charges added to the cost of goods which have to be transported to rural towns, many small rural hospitals operate with some degree of unavoidable inefficiency because their “critical mass” costs (eg. safe overnight staffing levels) cannot be reduced any further to match low volumes of activity. This is accepted as part of the Government’s community service obligation which requires that, as far as possible, communities have ongoing access to basic health services locally even where this results in higher costs.
The recent development of new models of care such as Multipurpose Services have maintained local access to services and reduced net infrastructure costs through co-location of primary, acute and aged care services. Increased investment in health protection, illness prevention, early intervention and chronic disease management in the community will also pay long-term dividends in reduced demand for hospital services.
The Regional Health Authority would continue to pursue efficiencies that have been delivered through the consolidation of corporate and business support functions across a number of rural health services. These sorts of initiatives must continue to be pursued as the health needs of rural NSW continue to change.
The Regional Health Authority will be responsible for ensuring that where ongoing advances in high cost technology for diagnostic and therapeutic purposes leads to an increased consolidation of these services into fewer centres that the effects of this will be mitigated by improved information and communication technology which will connect rural communities with regional and metropolitan hubs and facilitate remote access to quality advice, service and support (while at the same time supporting more efficient work practices).

5. Ensuring the availability of a flexible, skilled health workforce
A good health system plans and uses its workforce creatively and intelligently to ensure an adequate supply and distribution of high quality health care workers. Health workers will be equipped with the right education and skills for the different roles they are asked to perform.

Implications for the Regional Health Authority:
The current and worsening statewide shortage of medical, nursing and allied health providers is most pronounced in rural and remote NSW, with many towns struggling to maintain even basic primary health care in the form of a General Practitioner and a Community Nurse. It is clear that urgent action is required on a number of fronts, to: support, retain and develop the existing workforce; encourage additional students to undertake health provider education; and attract skilled staff to work in rural and regional areas.
Regional Health Authorities will be responsible for working to amend structures to allow greater flexibility in the workforce, and to reconfigure different health workers’ roles and responsibilities in delivering services. The successful establishment of the role of nurse practitioner illustrates what is possible in this regard, as does the expanded role of enrolled nurses in particular settings, and practice nurses working with General Practitioners. The education and employment of “technical assistants” to support certain allied health professional groups is also gaining support. Regional Health Authorities will be responsible for remodeling Education and training options for health care workers to support new models of service delivery and the consequent new workforce demands.


6. Staying at the forefront
A good health system is alert to the changes in the world around it, and quick to respond to new issues as they emerge. It will be flexible enough to adapt to new circumstances, and robust enough to sustain itself in the face of external pressures.

Implications for the Regional Health Authority:
Rural and regional NSW offers considerable scope and impetus for trying out innovative ideas and new ways of doing business. Active pursuit of whole-of-government and intersectoral approaches to planning, funding and service delivery is an obvious example. Harnessing the potential of new generation communications technology also holds great promise for addressing the tyranny of distance. The platform for action will be a sound assessment of costs and benefits (taking into account evidence and experience of what works). The Regional Health Authority will be responsible for assessing and implementing cost effective and innovative practices to provide a high standard health system that is responsive to the needs of rural and regional communities.

SUMMARY OF REGIONAL HEALTH POLICY RECOMMENDATIONS

1. Regional Health Authority:
It is recommended that as part of the Commonwealth Government Health and Hospitals Network Reform agenda, that the NSW Government, supports the establishment of Regional Health Authorities in rural and regional NSW (referred to as ‘Local Hospital Networks’ by the Commonwealth Government) to manage State, Federal, Local Government and Private sector health funding. The Regional Health Authority for each geographic area would:
Empowering regional communities
a) Work with local councils, other health service providers, other government agency service providers and local communities to develop holistic local models for health care to attract, support and retain general practice doctors and procedural specialists in rural and regional locations (this can include practice facilities and resources, training for non-medical support, ancillary heath care, and connection with community health facilities for health promotion/preventive action within local communities);
Meeting needs by working together
b) Develop, in conjunction with local councils and other health service providers, models of locally based integrated community health care connected with local medical practitioners, broader community health care services (particularly mental health, aged care and post hospital care) and preventive health care activities within rural towns and villages, linked to regionally based hospitals and the development of networks of local health care providers (doctors and ancillary health care) to enhance local support for local primary health services;
Integration
c) Implement a governance framework that includes a Board comprised of local health, management and finance professionals with an appropriate mix of skills and expertise to ensure transparency and accountability in the financial management and administration of the Rural Health Authority;
d) Develop integrated networks of health and human services that reduce overall infrastructure costs through cost sharing arrangements and allow joint planning and service delivery between local hospitals which more efficiently and effectively addresses the community’s priority needs, and improves the coordination of care;
e) Implement plans to shift the focus of health services more towards protection, prevention, detection and early intervention services to reduce the need for acute hospital admission over the longer-term.
f) Enhance access to post acute hospital care and ancillary health services for those in rural localities, including working with the Ministry of Transport to address community transport options to meet needs, where such an option is viable;
Matching needs with financial resources
g) Enhance support to post hospital acute care and support to carers and family support through appropriate and affordable accommodation strategies;
h) Support the development of new models of care in rural and regional areas such as Multipurpose Services that maintain local access to services and reduce net infrastructure costs through the collocation of primary, acute and aged care services
Workforce
i) Implement actions (outlined in recommendation 2 below) that support the development of greater flexibility in rural and regional health workers roles, as well as to supporting, retaining and developing the existing regional health workforce and encouraging additional students to undertake health and medical studies in order to work in rural and regional areas;
Staying at the forefront
j) Be responsible for assessing and implementing cost effective and innovative practices to provide a high standard health system that is responsive to the needs of its local communities.
Specific Needs
k) Develop accessible and appropriate health care services in rural and regional locations (particularly in the areas of mental health, aged and geriatric care, sexual health, drug and alcohol abuse, ancillary health care) including options such as transport and mobile local service provision to meet local needs, especially for young people, older community members, and those with disabilities who are unable to readily access services in large regional centres;
l) Work closely with Aboriginal Medical Services to determine the feasibility of developing culturally sensitive Obstetrics/Midwifery services in locations other than regional centres;
m) In line with Priority 4 of the State Plan, review the scope and the accessibility of primary health care services for Aboriginal clients with a view to proposing innovate methods to further improving outcomes.
n) Work with the Commonwealth and State Government and the relevant dental health professional association, to enhance the provision and accessibility of dental health practitioners in rural and regional locations, including the availability of public dental care services to meet the needs of rural and regional communities;
o) Work with the Commonwealth and State Government to encourage the development/establishment of dental schools/programs in association with regional universities to assist with the training of additional dental health practitioners in regional communities.

2. Rural Health Workforce Reforms:

The current and worsening statewide shortage of medical, nursing and allied health providers is most pronounced in rural and remote NSW, with many towns struggling to maintain even basic primary health care in the form of a General Practitioner and a Community Nurse. It is clear that urgent action is required on a number of fronts, to: support, retain and develop the existing workforce; encourage additional students to undertake health provider education, and attract skilled staff to work in rural and regional areas.

An essential element of the response to this challenge will be to rethink the current assumptions and structures to allow greater flexibility in the workforce, and to reconfigure different health workers’ roles and responsibilities in delivering services.

The successful establishment of the new role of nurse practitioner illustrates what is possible in this regard, as does the expanded role of enrolled nurses in particular settings, and practice nurses working with General Practitioners.

The following reforms are recommended to ensure an adequate supply and distribution of high quality health care workers in rural and regional communities:

Education and Training

a) With close cooperation between the Commonwealth and State Governments remove the monopoly that Medical Colleges have on accrediting vocational training by funding universities to offer such training. Encourage Universities to co-ordinate intake numbers to ensure they accept only as many medical students as they are able to accommodate in their vocational education programs.

b) Private hospitals should be encouraged to develop training programs, producing even more competition. As suggested by Macquarie University’s Vice Chancellor, Professor Schwartz “Competition should drive up training excellence as it has in every other area in which it has been allowed to operate”.

c) Encourage the development of interprofessional education training programs or health professionals in their first years of undergraduate degrees, maximising team based skills development and providing an opportunity to reduce course length.

d) In partnership with Rural Medical Schools, develop a new degree level program to train a multi-skilled health worker with skills across a broad spectrum including nursing, occupational therapy, physiotherapy and podiatry.

e) Provide incentives and payment systems that expand the number of health professional undergraduate and graduate places in rural areas, across all professional areas, thereby making a reality the concept of self-sufficiency with respect to workforce supply in Australia.

f) Expand the Vocational Education and Training (VET) sector health training opportunities to maximise the training and capacity of support staff. By providing a mechanism that gives credit for training experience and on the job skills development, lateral entry to high professional training become available.

Incentive Programs

g) Target the extension of incentive programs for health professionals to maximise their outcome. Programs that have worked effectively for other professional groups or have been evaluated and found to be effective need to be considered. For example, preferential transfers for years of rural service, supported entry and exit into rural positions, leave loadings and incentive payments awarded to teachers, police and professionals in other sector remote locations need to be considered for health professionals.

Flexibility

h) Pilot the development of alternative roles such as anaesthetic assistance, surgical technicians, multi-skilled allied health professionals etc.

i) Overhaul accreditation processes that reinforce professional rigidities.

j) Review professional registration and regulation.

3. Infrastructure:

In many rural and regional areas, physical infrastructure for health service delivery (buildings and medical equipment) has been inadequately funded resulting in hospital staff working in outdated and unsatisfactory conditions in order to maintain services to regional communities. The following recommendations are made to ensure adequate and sustainable health service delivery in rural and regional areas:

a) An investment of $5 billion for health is required over the next ten years to bring the physical infrastructure of health service sites in rural NSW to acceptable standards.

b) Consider consolidation of services in locations proximate to one another to ensure adequate critical mass of health professionals to enhance recruitment and retention. For example, the creation of a rehabilitation or mental health services that cover more than one community, thus enhancing critical mass and increasing the attractiveness of working with fellow health professionals. This is a cost effective model that is attractive to specialist staff; meets community needs (without travelling excessive distance to access care); and makes more sense in terms of physical infrastructure.





4. Information Technology:

Across rural Australia, the tyranny of distance and the lack (or absence) of public transport means that it is imperative to find ways to ensure equitable and timely access to health services across NSW. The distances traveled by both patients and staff in rural NSW are substantial. This means that there are significant lost opportunity costs as highly skilled staff frequently spend time traveling rather than delivering care. To address these problems it is recommended that:

a) An investment of $45 million over 3 years be made to create a co-ordinated high-speed E-health broadband communication network, to enable a safer, higher quality, more equitable and sustainable health system by transforming the way information is used by GP’s and Specialists to plan, manage and deliver health care services to patients in rural and regional communities. It is estimated that the investment to build the E-health broadband network will ultimately achieve savings of $15 million per annum and deliver the following outcomes:

· Provision of technology infrastructure that enables information sharing and protects confidentiality of patient information;

· Increased use of tele-health tools that leverage the time and expertise of health professionals;

· Redesign of processes that use technology to save time and provide clinicians and managers with better information;

· Supply of decision support tools that facilitates evidence-based clinical and administrative decisions;

· Provision of ‘up-to-date’ information about what health services are available, and about treatment options for patients;

· Reduced travel time and costs for both consumers and providers.


5. Transport:

In many rural towns there are often no taxi or public transport services. Links to larger towns are by coach or rail services, some of which do not connect, or require long hours of travel for a medical appointment. For the average rural resident without access to personal transport, a referral to a specialist for further assessment or treatment can become an almost insurmountable challenge. For some patients, it can seem easier to ignore things until the illness or symptoms become so advanced that hospitalization occurs.

The following recommendations are made to ensure a well integrated transport system for rural communities to access health promoting and health delivery services:



a) Information: Investment in an electronic information solution that uses high speed broadband connectivity and links with existing electronic clinical systems (such as eDRS, CHIME, GP systems and the EMR) to manage transport as part of the appointment setting process for patients.

b) Funds: Investment of $3 million annually to establish and maintain an effective transport and information system for rural and regional patients.

c) Integration: With close cooperation between the Commonwealth and State Governments ensure all key health service providers are part of the system, with incentives available to support GPs and private providers to ‘buy in’.



































A. BACKGROUND:

The delivery of health services, both in NSW and nationally are under increasing pressure and struggling with rising demand for health services. The pressures and challenges confronting Health Services are being driven by an ageing population; population growth; chronic disease and its cost to the health system; longer life expectancies; increasing costs for the delivery of hospital and health services; higher consumer expectations of health care; workforce shortages and technological change.

In 2005, the NSW Futures Planning Project identified that we cannot address health needs simply by providing more health services. A coordinated partnership approach with governments, individuals, communities and government agencies and the corporate sector through, a regional health authority approach, has the potential to create an integrated health system that will reform the way in which all health service funders and providers work together to deliver health services to people in rural and remote NSW. Supporting this strategic shift will develop a health service that supports the four goals of NSW Health - to keep people healthy; to provide the health care that people need; to deliver high quality services and to manage health services well.

People living in rural communities in NSW have the right to the same levels of health and health care as their city counterparts. However, rural people in NSW live, on average, five years less than people from the more advantaged metropolitan areas. In addition, rural NSW faces a number of other health challenges – relatively low population growth limited largely to regional centres, increasing difficulties with attracting and retaining scarce health professionals, a necessary concentration of some specialized health services in centres at some distance from where people live, and rural dwellers overall having a poorer health status than the population as a whole.

Developing an integrated approach to human service delivery in rural NSW will play a major role in ensuring the future of many small rural communities.

Health and health care - Major issues for rural and regional NSW

By international standards, NSW has a good health system, with most of the population (except for that portion of the population living in regional and remote areas) having access to high quality medical care and achieving long and healthy lives. But for all its achievements, the NSW public health system – like its counterparts in other Australian states and other developed countries - is also under pressure.
The major challenges faced by NSW Health both now and into the future can be
summarised as follows:
· The state’s population is growing, with most of the expansion projected to occur along the eastern seaboard rather than inland;
· The increasing proportion of older people will place different demands on all
human services as well as informal care arrangements;
· People’s expectations of the health system will remain high, fuelled by information obtained from the media and internet;
· These expectations will both propel and be reinforced by advances in medical technology which offer improved diagnoses, treatments and outcomes while also driving up the costs of care;
· Accompanying the significant improvement in survival rates from heart attacks, strokes and cancers is a rising demand for chronic care services, which will continue to grow with the projected increase in lifestyle-related chronic conditions within the population (such as obesity and type two diabetes);
· The persistent health gap between the most and least disadvantaged members of our society will require redoubled effort to address;
· The current shortage of doctors, nurses and allied health professionals will not be resolved quickly and will place increasing pressure on existing staff and services, particularly in rural and remote areas;
· Many of the above factors will drive up health care costs which, unless they can be contained, will draw funds away from other important government services and place greater financial demands on individual consumers;
· Harnessing the substantial promise of new generation information and
communication technologies – in terms of boosting efficiency and improving
consumer access to information and services – will require timely investment.

These pressures have been acknowledged at both a national level by COAG and the National Health and Hospitals Reform Commission, and by the NSW Government through a range of reviews and reports undertaken during 2007 and 2008 culminating in the release of the NSW Health Action Plan “Caring Together” launched by the Minister for Health and Ageing in March 2009 and the Healthy Future for all Australians handed down by the National Health and Hospital Reform Commission in June 2009. The launch of the National Health and Hospitals Network (NHHN) for Australia’s Future by the Prime Minister in March 2010 highlighted that without major changes to the funding and management of the public hospital system, “State budgets will be at risk of being overwhelmed as rising costs outstrip revenue growth.”
The major structural reforms proposed as part of the NHHN will mean that the Commonwealth Government will:

· become the majority funder of public hospitals;

· take over all funding and policy responsibility for GP and primary health care services;

· dedicate around one third of annual Goods and Services Tax (GST) allocations currently directed to state and territory governments to fund this change in responsibilities for the health system;

· change the way hospitals are run, taking control from central bureaucracies and handing it to Local Hospital Networks; and

· change the way hospitals are funded, by paying Local Hospital Networks directly for each hospital service they provide, rather than buy a block grant from the Commonwealth to the states.




B. RECENT REPORTS AND RECOMMENDATIONS - Implications for health delivery in rural and regional areas

i) NSW Rural and Regional Taskforce:
On 25th June 2007, the NSW Premier, Morris Iemma announced the establishment of the Rural and Regional Taskforce to examine and provide advice on key economic, environmental and social issues affecting rural and regional communities across NSW. From August to December 2007, Taskforce members met with and listened to the concerns of the NSW regional and rural communities in relation to government service delivery and received over 160 written submissions before presenting its report to the Premier in March 2008.

In relation to Health, the Taskforce report noted that while rural and regional communities favourably commented upon the core health services provided through large regional hospitals, there was a general concern over a number of aspects of health care generally. In many areas transport to services was the key issue raised.
The Taskforce was made aware of the following issues having significant impacts on the provision of health services in rural and regional communities in NSW:
· The shortage of General Practitioners and the difficulty in attracting and retaining them in small towns;
· Limited availability of Specialists and related services (such as oncology, radiology, paediatrics, renal medicine, obstetrics), even in regional centres;
· Virtual absence of public dental health and acute shortage of private practice dentists;
· Limited local community health particularly in the areas of mental health and aged care;
· Limited availability of ancillary health services such as physiotherapy, podiatry, etc.

a) General Health Care
In relation to the problem of the shortage of General Practitioners a variety of explanations were offered: the ageing of the current medical workforce and the increased workload of the few who remain accelerates the losses; poor remuneration compared to non-rural locations, insufficient numbers of trained practitioners available to meet demand; attracting new and young doctors is made more difficult because of the heavy workloads; the costs of conducting medical practices; the apparent unattractiveness of rural areas due to the absence of other services and facilities available in cities and regional centres; poor employment prospects and education options for other family members.
It was also suggested that like many businesses in rural and remote areas, doctors have difficulty in obtaining the other related skills and services required to operate a business successfully such as practice management, financial management and information technology.
In some towns, local councils and communities have enjoyed success in recruitment and retention by providing incentives such as accommodation and medical facilities to try and attract and retain new providers. The difficulty in recruiting General Practitioners to rural and regional NSW is in spite of data indicating that the total number of doctors is sufficient to meet demand; the problem is in geographic distribution outside metropolitan and regional cities.
As a matter of practicality and economic reality, the availability of specialist and ancillary services is dependent on questions of volume and cost. The concentration of services in regional centres is an essential requirement to achieve the patient loads, sustain the number of practitioners necessary to maintain professional and collegiate standards, provide the capacity to train new medical practitioners, and retain accreditation and currency of practice; and to provide and support the (expensive) facilities and equipment.
This directly conflicts with the ability to provide these specialised services in small rural and regional locations. However, the distances involved and the difficulty of obtaining (transport) access to specialist services, especially for follow up treatment (radiology and dialysis were raised as a matter of specific concern, where travel was a strong disincentive for patients) means that the standard of specialised health care is not equal in all parts of the State.
The cost and access for patients (and carers) to non-hospital accommodation during care and treatment, other than during hospital acute care, was also identified as a major area of disadvantage to rural and regional communities distant from major regional centres with a large base hospital.
Although the Isolated Patient Travel and Accommodation Assistance Scheme (IPTAAS) was recognised as an important form of Government assistance, it was not seen as adequately addressing the wider needs of health care for rural patients, and particularly for their carers. This places children and young people, the aged and those with disabilities at even greater disadvantage. Questions were also raised over administrative arrangements in relation to IPTAAS as to its accessibility and the equity of its benefits.
Although transport access to these resources is only one important element of service provision, the Taskforce noted that hospitals and Area Health Services have tried to respond to this need.
The Taskforce also heard about the demands being placed on the health care system through the demographic profile and changes to it as a result of the movement of young people away from rural and regional areas for reasons of education, employment and lifestyle opportunities.
Matched with this was the impact on families and communities as a result of difficulties in accessing medical and ancillary health care. In particular, the Taskforce heard community concerns over the demands made on families and communities as a result of difficulties in obtaining appropriate support, aged care accommodation and health care for older persons in small communities. Similarly, concern was expressed over the availability of health services for young people with emphasis on issues such as mental and sexual health care.
b) Mental Health
Mental health was raised with the Taskforce as a particular issue. The prolonged drought placed significant pressure on rural families and their communities and mental health became an issue of attention and concern. Concerns over adequacy and access to the specialised mental health care needs of an ageing population and for young people in rural towns and villages was a matter brought to the attention of the Taskforce.

c) Dental health
Dental health care was also raised as a matter of concern. The public dental care system is seen as inadequate or even non-existent for many in rural areas. This is compounded by difficulty in obtaining alternative dental health through private providers, where long waiting lists or unavailability further compromises dental health care.
The consequences of poor service levels in dental health care results in more serious and costly treatment when it does occur (loss of teeth), and there are correlated adverse associated impacts on general health of individuals with poor dental health.
e) Community health care
A key area to support primary health care at a local level is through community health care, where information and preventive health action may be taken. The Taskforce heard about community concern over the limited availability of community health care in local communities

ii) NSW Auditor General’s Report Performance Audit – Delivering Health Care out of Hospitals (September 2008):
This report highlights that with every year, demand for health services is escalating. In the period 2006-2007 the number of admissions to NSW public hospitals increased by 2.8 %, emergency department’s attendances rose by 7.9 % and hospital expenses increased by 6.7 % from the previous year. Exacerbations of chronic disease such as cardiovascular, respiratory diseases and diabetes were responsible for the majority of these admissions (AIHW, 2006) and account for almost 80% of healthcare costs in Australia. NSW Health estimates it will be necessary to open at least 300 new beds per annum to keep up with the predicted growth in demand. Beds are an expensive resource costing between $135,000 and $375,000 each per year to staff and operate. The implications on NSW finances are severe: in 1971-72 health expenditure represented 14.6 % of the total NSW budget, but by 2007-08 this had increased to around 28 %. At this growth rate, funding for health will consume the entire State budget by 2033.

iii) Indicators of Health Performance:
The Australian Institute of Health and Welfare (AIHW) in its September 2008 report on ‘Indicators of Health Performance noted that “Australians living in regional and remote areas generally experience poorer health than people living in major cities”. The performance of the health care system in regional Australia is therefore of particular interest to people living and working in rural and regional Australia. Government and Healthcare policy makers need to develop flexible delivery models to meet the needs of 32% of Australia’s population living outside metropolitan centres, (with 29% based in regional areas and 3% based in remote areas).

The Australian Institute of Health and Welfare’s September 2008 report highlights that people living in remote areas have higher rates of hospitalisation than those living in major cities. Patients in rural and regional hospitals tend to remain in hospital longer due to the lack of support services available to help them recuperate outside of hospital.
iv) Report on the Audit of Health Workforce in Rural and Regional Australia – April 2008:
Following a request from the newly elected Prime Minister (10th December 2007), the Federal Health Minister Nicola Roxon asked the Department of Health and Ageing to undertake an audit of current supply of doctors, nurses and other health professionals in rural and regional Australia and also to identify where health workforce shortages exist. The audit report reiterates that the current supply of health professionals is not sufficient to meet the current needs. This situation will be exacerbated as both the population and the workforce itself age. Distribution of the workforce is poor, declining significantly with greater remoteness and Australia is highly reliant upon overseas trained health professionals. Indeed, there has been reliance in recent years in overseas trained doctors filling the gaps in rural and regional communities.

v) Final Report of the Garling Special Commission of Inquiry – Acute Care Services in NSW Public Hospitals – November 2008:
In response to a number of events including the death of Vanessa Anderson in 2005 and the experiences of Jana Horska who miscarried in hospital in 2007, Commissioner Peter Garling SC was asked by the NSW Government to conduct a Special Commission of Inquiry into Acute Care Services in NSW Public Hospitals. Garling’s report noted that there are several developments which support the view that the NSW public hospital system has entered into a crisis period. He noted:
· More people are using the public hospital system than ever before, more than can be accounted for by population growth alone. Among these are increasing numbers of elderly patients with complex, chronic conditions who require longer stays in hospital and more specialist teams to treat them. The young also are presenting to public hospitals in greater numbers than was anticipated, especially to the Emergency Departments. Of them, a significant proportion may have mental health problems along with drug and alcohol dependence.
· Demographic changes mean that Australia has an ageing population which will require proportionally more care as the age group survive through their 70s and well into their 80s. In 2006-07 one third of all public hospital patients were aged over 65 years (although that group made up only 13.5% of the state's population). Today, those aged over 65 years make up 45%, nearly half of all public hospital patients.
· Demographic changes also mean that the population no longer lives where the hospitals were built and have existed for many years. The skilled workforce, particularly doctors are not evenly distributed amongst the population. Garling notes that as he calls it ‘the sandstone curtain’ of the Great Dividing Range provides a barrier which the skilled medical workforce finds hard to cross (in reference to shortages of rural doctors and allied health professionals).
· The costs of treatment are also rising alongside the number of patients.
· These developments have also affected the makeup of the hospital workforce. Increasingly newly qualified practitioners have been attracted into work as proceduralists, where the rewards (which are in part driven by the Medicare schedule of fees) are greater, and away from work as generalists where the need is greatest but rewards are considerably less. The problem was made worse during the 1990s when the Commonwealth discourage the entry of more doctors into the workforce through its control over undergraduate places. As a result, there is a shortage of doctors particularly general practitioners, which the experts predict will not be brought back into line for several years (if at all).
· The nursing workforce faces similar challenges with 22% of the entire profession in NSW qualifying for retirement in 2011. The nurses in public hospitals are frequently junior nurses with insufficient senior nurses available to supervise them.

vi) Caring Together – The Health Action Plan for NSW:
In response to the Garling Report, the NSW Government accepted 134 of the 139 recommendations and allocated a further $485 million over four years to the NSW Health budget. Caring Together: The Health Action Plan for NSW was launched by the Minister for Health in March 2009. The Caring Together Health Action Plan proposes a three stage approach to addressing the issues raised by Commissioner Garling.

1. The Action Plan - focusing on the patient;
2. Developing a Sustainability Plan to build a stronger health-care system; and
3. Developing an intergenerational Health-care system plan.

The Action Plan identifies changes geared towards using resources to develop a culture where the patient is both ‘ the heart of the system’ and the ‘ driver’ behind every change.

Currently nurses, midwives and other clinicians are spending too much time doing paperwork. This has added to a sense of frustration and concern about capacity to make good standards of care for patients. The plan aims to improve supervision of junior staff; to ensure the Nursing/Midwifery Unit Managers lead clinical improvements, to have more frequent ward rounds, and to provide ward-based clinical support offices. It stresses that everything must be about the patient. Clinicians, managers and support staff must work together in the interest of patient care. It highlights that infection control must improve and communication with patients about patient care must improve.

The plan commits to a review of hospital roles to ensure that all patients have fast access to the best care and services they need.

vii) Australian Health Ministers’ Conference - National E-Health Strategy
In December 2008, the National E-Health Strategy developed by Deloitte together with key stakeholders (Commonwealth, State and Territory Governments Departments, general practioners, medical specialists, nursing and allied health, pathology, radiology and pharmacy sectors, health information specialists, health service managers, researchers, academics and consumers) was presented to the Australian Health Ministers’ Advisory Council. The strategy provides a basis to guide further development of E-Health in Australia. It adapts an incremental and staged approach to developing E-Health capabilities to:
· Leverage what currently exists in the Australian E-Health landscape;
· Manage the underlying variation in capacity across the health sector and States and Territories; and
· Allow scope for change as lessons are learned and technology is developed further.

A nationally integrated E-Health Strategy has the potential to enable a safer, higher quality, more equitable and sustainable health system for all Australians by transforming the way information is used to plan, manage and deliver health care services. The E-Health strategy reinforces recommendations from the Garling Special Commission of Inquiry into information technology, which recommended a fundamental shift in the way information is assessed and shared across the health system. “Just as a railway system becomes dangerous for passengers when the signal network is old and out-of-date, so too a public hospital system becomes dangerous for patients when information is lost in the clerical maze.”

The E-Health strategy states that “we have to move away from a reliance on tools such as pen, paper and human memory to an environment where consumers, care providers and health care managers can reliably and securely access and share health information in real time across geographical and health sector boundaries”.

Currently the Australian health information landscape is characterised by many thousands of discrete islands of information, many of which are paper-based. This has created significant barriers to the effective sharing of information between health-care participants, an issue compounded by Australia's multiple health service boundaries and geographic distances. It also poses real challenges when trying to understand and report what is really happening in the Australian health care system to support population health surveillance and guide policy, service planning, innovation and clinician and operational decision-making.

The relative lack of maturity of information technology within the health sector has important implications for patient safety. In a complex, multipoint service delivery environment with hundreds of millions of service encounters each year, reliance on largely manual processes and information flows creates the potential for a truly significant amount of errors and inefficiencies. Studies have found that up to 18% of medical errors are due to the inadequate availability of patient information and that adverse events broadly account for as much as 3% of total cost of care each year. This represents approximately $3 billion in avoidable annual expenditure, money that could be better spent absorbing additional health sector demands driven by an ageing and sicker population.

Since 2005, the Commonwealth, States and Territories have been investing, through the National E-Health Transition Authority, in the key building blocks for a national E-Health platform. However at the same time every Australian State and Territory is in the process of defining or implementing some form of jurisdiction wide E-Health strategy (and making significant investments in foundational infrastructure in the health sector), within the private health sector, individual clinicians, professional groups and organisations are also investing in E-Health infrastructure and initiatives. The result is a very large and growing number of disparate E-Health initiatives being delivered within local geographic regions, within acute and primary care settings, and across health sector disciplines in this country.

Without some form of national coordination there is a very real risk of extensive duplication of E-Health effort and expenditure and the creation of a whole range of new solutions that cannot be integrated or scaled across the continuum of care. To avoid this, the National E-Health Strategy recommends that Australia embark on a strategy of national E-Health coordination and alignment focused in four key areas:
· Implementing the national ‘health information highway’ infrastructure and rules to allow information to be seamlessly access and shared across the Australian health system;
· Stimulating investment in high priority computer systems and tools that can deliver tangible benefits to Australian consumers, care providers and health care managers;
· Encouraging health sector participants to adopt and use high priority systems and tools as they become available;
· Establishing an E-Health governance regime to enable effective coordination and oversight of national E-Health activities.

A co-ordinated world class E-Health capability in Australia will:
· Ensure the right health information is electronically made available to the right person at the right place and time to enable informed care and treatment decisions,
· Enable the Australian health sector to more effectively operate as an inter-connected system and overcoming the current fragmentation and duplication of service delivery,
· Provide consumers with electronic access to the information needed to better manage and control their personal health outcomes,
· Enable multidisciplinary teams to electronically communicate and exchange information and provide better coordinated health care across the continuum of care,
· Provide consumers with confidence that their personal health information is managed in a secure, confidential and tightly controlled manner,
· Enable electronic access to appropriate health-care services for consumers within remote, rural and disadvantaged communities,
· Facilitate continuous improvement of the health system through more effective reporting and sharing of health outcome information,
· Improve the quality, safety and efficiency of clinical practices by giving care providers better access to consumer health information, clinical evidence and clinical decision support tools, and
· Support more informed policy, investment and research decisions to access to timely, accurate and comprehensive reporting on Australian health system activities and outcomes.

viii) A Healthy Future for all Australians:
In June 2009, the Commonwealth Government's National Health and Hospital Reform Commission handed down its final report – A Healthy Future for all Australians. This report built on the work of two earlier reports, ‘ Beyond the Blame Game (April 2008)’ and the interim ‘Healthier Future for all Australians’ report (December 2008).

Through the report, the Commonwealth government has effectively put all states ‘on notice’ that they need to lift their game in the delivery of high-quality health care to all communities, or face Commonwealth intervention in relation to the funding and management of primary care and outpatient services.

The Commission's report details more than 120 proposed changes which focus on better preventative measures, improved access for all Australians, and building a more sustainable long-term health system.

The Report found that Australia’s health system is fragmented and inefficient, with hospital productivity at 25% below optimum levels. The report notes the inequities in the health system faced by people in remote and regional communities and suggests that flexible funding arrangements are required to reconfigure health service delivery to achieve the best outcomes for regional communities. To facilitate locally designed and flexible models of care in remote and small rural communities the Commission recommends:
· funding equivalent to national average medical benefits and primary health care service funding (appropriately adjusted for remoteness and health status) be made available for local service provision where populations are otherwise under-served; and
· expansion of the multi-purpose service model to towns with catchment populations of approximately 12,000.

The report highlights that care for people in remote and rural locations necessarily involves bringing care to the person or the person to care. To achieve this, the report recommends:
· networks of primary health care services, including Aboriginal and Torres Strait Islander Community Controlled Services, within naturally defined regions;
· expansion of specialist outreach services-for example, medical specialists, midwives, Allied health, pharmacy and dental/oral health services;
· telehealth services including practitioner-to-practitioner consultations, practitioner- to-specialist consultations, teleradiology and other specialties and services;
· referral and advice networks for remote and rural practitioners that support and improve the quality of care, such as maternity care, chronic and complex disease care planning and review, chronic wound management, and palliative care; and
· ‘ on-call’ 24 hour telephone and Internet consultations and advice, and retrieval services for urgent consultations staffed by remote medical practitioners.
· Appropriate funding mechanisms be developed to support all the above elements.

The report recommends that a patient travel and accommodation assistance scheme be funded at a level that takes better account of the out-of-pocket costs of patients and their families and facilitates timely treatment and care.

The Commission recommends that a higher proportion of new health professional education undergraduate and postgraduate places across all disciplines be allocated to remote and rural regional centres, where possible, in a multidisciplinary facility built on models such as clinical schools or university departments of Rural Health.

The Commission recommends building health service, clinical and workforce capability through a remote and rural health research program.

The report further recommends that the Clinical Education and Training Agency take the lead in developing:
· an integrated package of strategies to improve the distribution of the health workforce. This package could include strategies such as providing University fee relief, periodic study leave, locum support, expansion of medical bonded scholarships an extension of the model to all health professionals; and
· preferential access for remote and rural practitioners to training provided by speciality colleges recognizing related prior learning and clinical experience and/or work opportunities for practitioners returning to the city, and support for those who plan to return again to remote or rural practice once speciality is attained.

ix) A National Health and Hospitals Network for Australia’s Future
On 2nd March 2010, The Prime Minister announced the Commonwealth Government’s plan to fix Australia's public hospitals, with a $30.9 billion funding takeover as its centrepiece.
The health and hospital reform program would result in the Commonwealth funding up to 60 per cent of all services, infrastructure and research costs in public hospitals.
New "Local Hospital Networks" would pay for services, replacing the traditional model of Commonwealth grants to the States and Territories.
As part of the reforms, the Commonwealth Government would also establish an independent authority to calculate the amount hospitals are paid for each service they provide. A loading would be paid for rural and regional health services to account for the higher costs of providing health services in regional areas.
The government will fund the reforms by redirecting one-third of the GST revenue currently paid directly to the states and territories, to health and hospitals.
The government is planning to implement its reform in the following way:
· Over 2010 - 11, the Commonwealth will work with the states to determine the current and future cost of delivering public hospital services to calibrate the financial transfers required.
· From 1 July 2011, the Commonwealth will increase its funding contribution to 60% of recurrent expenditure on public hospital services, research and training, and planned new capital expenditure.
· From 1 July 2012, the Commonwealth will progressively shift its funding to activity-based funding paid directly to Local Hospital Networks, starting with admitted patient services and progressing to emergency department and outpatient services.
· The Commonwealth will consult with the states on the mechanisms to give effect to its commitment to fund 60% of planned new capital investment.
The Government has proposed devolving decision making to Local Hospital Networks to give communities and clinicians a greater say in how their hospitals are run, and avoid the sometimes rigid management by remote health bureaucracies.
It is proposed that Local Hospital Networks (LHN’s) will be established as separate state statutory authorities. LHN’s will collaborate to provide patient care, manage their own budgets, and be held directly accountable for their performance. It is proposed that LHN’s will comprise between one and four hospitals in most networks, with regional networks potentially including more small hospitals. In consultation with local communities, states will have the flexibility to determine the regional, rural and remote network structure that best meets the needs of these.communities and best takes into account the challenges of managing multiple small hospitals.
To address workforce shortages in regional and rural Australia, the government has announced that as part of a $134 million investment, some 500 communities would benefit from a new initiative which would see around 2400 doctors in rural Australia become eligible for financial support to stay in rural and remote areas.
Under the planned reforms, State health department's will have a different role in the system. They will specialise in systemwide service planning and performance management issues, and work with LHN's to negotiate service contracts, meet unanticipated challenges, transfer good practice and identify and mediate poor practice. LHN’s would-be employers of hospital staff, but with conditions of employment managed by states.

































C. SPECIFIC ISSUES AND TRENDS FOR RURAL AND REGIONAL NSW
Major issues and trends impacting on the planning, provision and delivery of health and hospital services in rural and regional communities can be summarized as follows:-

1 Demographic changes
- major regional centres are likely to maintain or increase their population numbers
- many towns and villages outside major centres will experience a continuing decline in population

2 Profile of health and illness
- experiencing same general trends of increased life expectancy, improved survival rates from heart attacks, strokes, cancers, and increase in level of chronic disease;
- but overall have poorer health status than the total population;
- And there are particular communities (both geographical and cultural) which experience significant health disadvantage.

3 Workforce
- The general shortages of medical, nursing and allied health workers are worse in those rural and remote areas experiencing declining population
- This has a direct effect on the local availability of basic services including general practice/primary health care, community/home nursing, early childhood health services, community-based rehabilitation services, and acute inpatient care.

4 Medical technology
- Local access to certain diagnostic and therapeutic technologies is limited where relatively low volumes of activity do not justify capital expenditure on new equipment, and where specially trained and highly expert staff are required to operate the equipment.

5 Transport
Access issues arising from the above matters raise major transport challenges. Traditional responses have included:
- transporting the patient to the service,
- transporting the service (eg. the medical specialist) to the patient.
These continue to be relied upon, with travel assistance provided to patients via
IPTAAS and the Transport for Health program. Telemedicine offers a “third way” by providing an electronic link between a geographically-distant consumer and provider, and new generation information and communication technology (eg. broadband) will render this a more effective and cost-efficient solution.

6 Costs and benefits – financial, economic, social
- The costs of maintaining services in rural towns are often higher than in larger regional centres and metropolitan areas. In addition to the freight charges added to the cost of goods which have to be transported to rural towns, many small rural hospitals operate with some degree of unavoidable inefficiency because their “critical mass” costs (eg. Safe overnight staffing levels) cannot be reduced to match low volumes of activity. This is accepted as part of the Government’s community service obligation which requires that, as far as possible, communities have ongoing access to basic health services locally even where this results in higher costs.

- Health services also support local economies and communities by providing direct employment opportunities and by purchasing goods and services from local businesses. The presence of health services in a town can also increase its attractiveness as a place to live and may act as a magnet for other government services and businesses to establish or continue operations in the local area.






































D. RURAL HEALTH WORKFORCE REFORMS

Ensuring that the distribution of the health workforce meets the health needs of the community poses significant challenges for government. Distribution issues are heightened when a sector is facing overall workforce shortages.

Difficulties are encountered in recruiting and retaining skilled staff in rural and remote areas, and are exacerbated by changes in the market for health services, that result from increasing difficulties recruiting and retaining sufficient numbers of staff into certain areas of care (such as palliative care and geriatric medicine) and/or in public health services (particularly in areas such as psychiatry, dentistry and pharmacy). Issues such as the level of remuneration, nature of the client base, professional supports, indemnity issues, access to rural training and education experiences, and capacity for private practice have all been cited as factors contributing to this maldistribution.

Education and Training
Research indicates that significant impediments to the development of effective Regional Health Services include:
i. Training places for newly registered Doctors being controlled by specialist medical colleges (for example the Royal Australasian College of Surgeons).
After obtaining a medical degree, graduates work as interns in hospitals for 12 months. They are ineligible for full state registration until they complete their internships. But registration is not the end of medical training; registered doctors are still unable to practise. They are eligible only for further training, first in rotations through various clinical settings, then in specialised vocational training programs.
The right to practise medicine under Medicare requires the successful completion of vocational training and admission to one of the specialist medical colleges.To obtain vocational training, doctors must apply for a hospital registrar position accredited by the relevant medical college or for a training position outside of a hospital, such as a general practice.
In recent time, the Federal Government has funded new medical schools (such as the joint program between UNE and Newcastle University) thereby increasing the number of medical graduates (by 2012 Australian Universities will produce about 3,000 medical graduates every year) but this has created the problem that training places have not expanded fast enough to keep up with the influx of aspirant doctors. “Consequently, some of our brightest students may find themselves unable to further their medical careers” according to Professor Steve Schwartz Vice-Chancellor of Macquarie University in his article ‘Not What the Doctors Ordered’ – Australian Higher Education Supplement (September 10, 2008).
Professor Schwartz highlights the following reasons why training places have not increased to meet the needs of increasing numbers of medical graduates:
a. The States fund the hospitals that deliver vocational training and the Colleges accredit the training. “Alas, neither the colleges nor the hospitals are intrinsically motivated to increase training places. The Fellows of the Medical Colleges may see more new specialists as a competitive threat. State hospitals may be equally unenthusiastic; under-resourced, they prefer to focus on treating patients than on training”.
b. The second impediment to increasing training places results from the nature of medical teaching. “Doctors undergo a hands-on apprenticeship. Registrars learning to be orthopedic surgeons, for example, must perfect their skills on patients with broken or diseased bones. The Commonwealth can double the number of medical graduates but cannot double the number of people with bone problems”.
Responding to concerns from current Medical students and Deans of Medical Schools, the Federal Health Minister has said new training opportunities will be provided in GP clinics rather than hospitals. But according to Professor Schwartz, this raises other questions about planning. He states “with 3000 new medical graduates, not just for one year but every year from then on. Even if no new foreign medical graduates are allowed to immigrate, and if the normal numbers of doctors die, retire or drop out, we still will have about 50 per cent more doctors in 2020 than we have now. If most of them are going to be trained in GP clinics, we will have many more GPs, but unless hospital training places grow we will have about the same number of surgeons, anaesthetists and other specialists”. Schwartz contends that as medicine becomes increasingly hi-tech and customised, “ it is plausible that we will need more hospital specialists and fewer GP’s”.
To overcome shortages of training places Schwartz has recommended the following:
· First, minimise the conflict of interest by removing the monopoly the Medical Colleges have on accrediting vocational training by encouraging universities to offer such training. “Universities would be able to co-ordinate intake numbers to ensure they accept only as many medical students as they are able to accommodate in their vocational education programs”.
· In addition, private hospitals should be encouraged to develop training programs, producing even more competition. “Competition should drive up training excellence as it has in every other area in which it has been allowed to operate”.
ii. Existing ‘medicine centred’ educational training programs provides a barrier to inter professionalism of the rural health care workforce.

In her 2005 paper presented to a rural health conference, ‘Breaking down the silos: interprofessional education and inter-professionalism for an effective rural health care workforce’, Dr Ruth McNair (Senior Lecturer in the University of Melbourne Department of General Practice) argues that “an effective rural health workforce involves a range of health care providers with a range of skills who work effectively together in a collaborative team”. The National Health Workforce Strategic Framework (which developed at the Australian Health Ministers Conference in 2004) recognises that ”a collaborative, multi- disciplinary approach is needed to effectively tackle health workforce issues”. One of the key priority areas for the delivery of the framework was identified as the need to improve links between the health and education sectors.

The collaborative/partnership approach “not only provides appropriate health care, but also provides a sustainable workforce by improving the vitality of the health care providers”. McNair contends that being an effective team worker can and should be learned as part of a vertically integrated education process from the beginning of training. McNair highlights with concern that in Australia “we are not adequately preparing students, and further, that our current education environment creates significant barriers to the development of respectful and effective relationships between different health care disciplines.

McNair’s paper identifies the current education system for health professionals within Australia as a ‘silo’ approach where students (Doctors, Nurses, Pharmacists, Physiotherapists, Dentists, Occupational Therapists, Radiologists, Dieticians, and other allied health professionals) spend the majority, if not all, of their educational experience with students of their own discipline. “Vertical uni-disciplinary streams, (the silo approach) continue from the delivery of undergraduate coursework, through clinical placements and postgraduate training, to accreditation and maintenance of professional standards”.

McNair’s paper highlights that ‘professional stereotypes’ are often reinforced for students through a powerful hidden curriculum, delivered by senior colleagues who can role model negative attitudes and behaviours towards other disciplines. Recently qualified health care professionals in one study, who acquired negative attitudes towards other health care professionals during their courses, attributed this partly to the influence of attitudes expressed by their tutors and clinicians.

McNair also highlights that “the primary care system in Australia has developed within a medical model of care, privileging doctors over other providers”. She highlights the persistent opposition by the AMA to nurse practitioners and suggests “that this powerful group is dedicated to maintaining the status quo”. While expressing concern over the attitude of the AMA, Mc Nair acknowledges that the Australian Division of General Practice has reversed this trend by supporting nurses in general practice and acknowledging their role in encouraging ‘a team approach to care’.

In supporting the notion that the medical model of care is doctor centred in Australia, Mc Nair highlights:
· Rural health workforce policy in Australia has promoted education programs to increase the number of doctors working in rural areas, while largely ignoring the needs of other providers. At the undergraduate level, scholarships are offered for medical students, including the John Flynn scheme, the Rural Australian Medical Undergraduate Scholarship (RAMUS) Scheme and rural bonded scholarships. Rural-origin students are encouraged to enter medical school through targeted access programs, and rural clinical schools have been funded. Only recently have rural nursing and allied health scholarships been offered.
· At a postgraduate level, the needs of the medical workforce have also been dominant. The Australian Rural and Remote Workforce Agencies Group is the peak body for each of the state and territory based Rural Workforce Agencies, formed in 2000. This group and its member groups are specifically funded to support the rural and remote general practice workforce. For example, key projects have been to recruit, train and retain overseas trained doctors; and to provide rural locum relief programs around Australia. There is no equivalently resourced peak body for rural nursing and allied health providers.

Mc Nair argues that those who have worked in rural and remote Australia know that the medical model does not necessarily result in an effective workplace. She states “that if regional doctors are fortunate enough to find themselves in a location with health care, providers of other disciplines, we know that their education did not prepare them for understanding how to work effectively together”.

In recent times, to assist in overcoming these difficulties, University Departments of Rural Health have been established which aim to establish a rural-focused national health network of health professional training. The National Rural Health Alliance (as a peak body of health consumers and service providers) has also been a strong advocate for multi disciplinary primary health care policy. It has prioritised support for allied health and nursing rural workforce, arguing for increased undergraduate placements for nursing and allied health students and scholarships for allied health students. But it is not enough to continue to train providers separately. Mc Nair argues that Australia is lagging behind the UK and USA where ‘interprofessional education’ (IPE) has recently gained widespread political and academic support. “We need more innovative approaches to challenge existing attitudes and improve interprofessional relationships”.

McNair recommends that “IPE and interprofessionalsim should be included as core curriculum to better prepare health care students for rural work“, she also acknowledges that uni-professional education is still required so that students of each discipline can acquire discipline specific skills and knowledge, but recommends that IPE be introduced early in the course where students from different disciplines are brought together to learn with, from and about each other in order to positively influence attitudes towards other professionals and improved group team-work skills.

For McNair, the ideal scenario is for students of different disciplines to learn together in the classroom, and then be periodically placed together in the clinical and community environment through to the end of the courses. Logistically, it is the easiest if different disciplines based at the same university are combined (for example nursing and medical students at UNE; physiotherapist's, dieticians, occupational therapists, dentists, nurses and doctors at major metropolitan universities). In Australia, a number of universities have undertaken rural interprofessional education programs but they have been restricted to small groups of volunteer students, as there have been no compulsory, vertically integrated IPE programs developed. A further logistical barrier has been where to fit IPE content into existing crammed curricular.

Core elements of IPE content according to the World Health Organisation are competencies for effective teamwork such as collaborative sharing of knowledge and skills, understanding of role definitions and boundaries, and development of respect between professionals. Cooperation (with patients, each other and other sectors) is seen to be the central principle in recognition that all of those working in health care depend on each other. The ultimate aim of an IPE curriculum is for students to adopt a value-based perspective, which will then have a powerful influence on professional behaviour.

Health-care provider educators are increasingly introducing explicit learning about professionalism as essential for effective practice. However, within Australia this is largely uni-professional and has the potential to set the values of one profession against those of another.

McNair highlights that despite the potential for University departments of rural health within Australia to introduce IPE they have been slow to take up the challenge. She contends that this relates to a continued dominance of medicine in the rural health-care policy arena and inherent conservatism within medical education within this country. McNair notes that nursing and allied health educators within Australia are increasingly introducing curriculum based on teamwork, however these health care providers cannot hold up the health care team alone. “The doctor is an integral part of the rural health team. It is not enough for co-workers to have developed collaborative skills and values, while doctors grimly hang on to a hierarchical privilege. Doctors must take their place in the multidisciplinary team if the community is to be served well”.

Although placing additional obligations on health services, other studies have shown that clinical placements and access to training and education in a supported environment are an effective way of attracting staff. This may be particularly important in rural areas, where adequate academic infrastructure will likely attract suitably qualified staff and thereby support clinical placements. Training and education reform however needs to be extended to facilitate:

- Generic training of health professionals in their first years of undergraduate degrees, maximising team based interprofessional skills development and providing an opportunity to reduce course length.
- Development of a new degree level program to train a multiskilled health worker with skills across a broad spectrum including nursing, occupational therapy, physiotherapy and podiatry.
- Providing incentives and payment systems that expands the number of health professional undergraduate and graduate places in rural areas, across all professional areas, thereby making a reality the concept of self-sufficiency with respect to workforce supply in Australia.
- Expand the Vocational Education and Training (VET) sector health training opportunities to maximise the training and capacity of support staff. By providing a mechanism that gives credit for training experience and on the job skills development, lateral entry to high professional training become available.

Incentive Programs
Many initiatives developed by governments have targeted geographic maldistribution.
Many have been modelled on interventions operating in the UK, Canada and the USA. They include continuing professional education programs, mentoring, locum relief and scholarship schemes.

Extension of these programs needs to be effectively targeted to maximise their outcome. Programs that have worked effectively for other professional groups or have been evaluated and found to be effective need to be considered. For example, preferential transfers for years of rural service, supported entry and exit into rural positions, leave loadings and incentive payments awarded to teachers, police and professionals in other sector remote locations need to be considered for health professionals.

Because of the inter-dependence between clinicians, incentives need to be offered across the range of professions including allied health, key nursing positions and medical practitioners if a critical mass of service providers are to be attracted and retained in a rural area.

Flexibility
Despite some changes at the margins which for example, have seen limited prescribing rights introduced for a small number of allied health providers and nurses, the current roles and responsibilities of professional groups within the health workforce have largely remained as traditionally defined rather than evolving to meet modern day client needs or emerging service models. The impact of rigid professional boundaries are greater in rural areas where health services cannot offer specialty services and professional groups at every site.

Increasing flexibility is essential for rural areas. This can be achieved by:
· Piloting the development of alternative roles such as anaesthetic assistance, surgical technicians, multiskilled allied health professionals etc.
· Overhauling of the accreditation process that reinforce professional rigidities.
· Reviewing of professional registration and regulation.

Rural Health Workforce Recommendations

The following reforms are recommended to ensure an adequate supply and distribution of high quality health care workers in rural and regional communities:

Education and Training

a) With close co-operation between the Commonwealth and State Governments remove the monopoly that Medical Colleges have on accrediting vocational training by funding universities to offer such training. Encourage Universities to co-ordinate intake numbers to ensure they accept only as many medical students as they are able to accommodate in their vocational education programs.

b) Private hospitals should be encouraged to develop training programs, producing even more competition. As suggested by Macquarie University’s Vice Chancellor, Professor Schwartz “Competition should drive up training excellence as it has in every other area in which it has been allowed to operate”.

c) Encourage the development of interprofessional education training programs for health professionals in their first years of undergraduate degrees, maximising team based skills development and providing an opportunity to reduce course length.

d) In partnership with Rural Medical Schools, develop a new degree level program to train a multi-skilled health worker with skills across a broad spectrum including nursing, occupational therapy, physiotherapy and podiatry.

e) Provide incentives and payment systems that expand the number of health professional undergraduate and graduate places in rural areas, across all professional areas, thereby making a reality the concept of self-sufficiency with respect to workforce supply in Australia.

f) Expand the Vocational Education and Training (VET) sector health training opportunities to maximise the training and capacity of support staff. By providing a mechanism that gives credit for training experience and on the job skills development, lateral entry to high professional training become available.

Incentive Programs

g) Target the extension of incentive programs for health professionals to maximise their outcome. Programs that have worked effectively for other professional groups or have been evaluated and found to be effective need to be considered. For example, preferential transfers for years of rural service, supported entry and exit into rural positions, leave loadings and incentive payments awarded to teachers, police and professionals in other sector remote locations need to be considered for health professionals.

Flexibility

h) Pilot the development of alternative roles such as anaesthetic assistance, surgical technicians, multi-skilled allied health professionals etc.

i) Overhaul accreditation processes that reinforce professional rigidities.

j) Review professional registration and regulation.


















E. INFRASTRUCTURE

In many rural areas of Australia it is becoming evident that the physical infrastructure for health service delivery has not been the recipient of adequate physical infrastructure (buildings and medical equipment) funding. The reasons behind this are complex and involved and are strongly linked to the fact that in NSW, the majority of the population is located in three main coastal areas; therefore these coastal areas have had to build and rebuild to meet the growing population demands. Additionally, in recent years it has become apparent that overall sustainability of health service delivery from multiple sites, in some rural areas is questionable due to declining population, significantly changed health service demands, the age of the work force and the continuing inability to attract and retain young people to some rural areas.

It is apparent that many hospital sites are suffering from a long standing process of non investment in infrastructure maintenance and many are now not suitable to deliver acceptable care. It is not uncommon for staff and surgeons to be working at sites where the hospital’s design and functionality is outdated. Therefore staff are working in unsatisfactory and below common standard conditions in order to maintain services.
There are several pockets of population growth in NSW where the current infrastructure will not meet the needs of the current and growing population. An example is along the NSW coast where the aged population is growing fast and yet there are not enough facilities to support the health needs of this group.

For rural NSW it is estimated that some $5 billion for health will be required over the next ten years to bring the physical infrastructure of health service sites to acceptable 2010 standards.

For rural NSW there are also issues about service sustainability, both in terms of physical infrastructure and workforce, in some of the smaller sites.

· The solution may mean some consolidation of services in locations proximate to one another to ensure adequate critical mass of health professionals to enhance recruitment and retention. For example, the creation of a rehabilitation or mental health services that covers more than one community, thus enhancing critical mass and increasing the attractiveness of working with fellow health professionals. This is also cost effective, attractive to specialist staff, meets community needs without travelling excessive hours to access care, and makes more sense in terms of physical infrastructure.

Infrastructure recommendations

The following recommendations are made to ensure adequate and sustainable health service delivery in rural and regional areas:

a) An investment of $5 billion for health is required over the next ten years to bring the physical infrastructure of health service sites in rural NSW to acceptable standards.



b) Consider consolidation of services in locations proximate to one another to ensure adequate critical mass of health professionals to enhance recruitment and retention. For example, the creation of a rehabilitation or mental health services that cover more than one community, thus enhancing critical mass and increasing the attractiveness of working with fellow health professionals. This is a cost effective model that is attractive to specialist staff; meets community needs (without travelling excessive distance to access care); and makes more sense in terms of physical infrastructure.












































F. INFORMATION TECHNOLOGY

Across rural Australia the tyranny of distance and the lack (or absence of) public transport means that we need to find ways to ensure equitable and timely access to services across NSW. The distances traveled by both patients and staff in rural NSW is substantial. This means that there are significant lost opportunity costs as highly skilled staff, are traveling rather than delivering care. To change will require the following:

· Creating a common high speed communication infrastructure, using broadband Technology infrastructure that enables information sharing and protects confidentiality
· Increased use of tele-health tools that leverage our time and expertise
· Redesigned processes that use technology to save time and provide clinicians and managers with better information
· Decision support tools that enable evidence-based clinical and administrative decisions.

Advances in information and communication technology will fundamentally shift how we provide care, how patients and providers interact and how providers work together. Technology has the potential to both improve access to information at the point of care in the current system and to serve as a tool to redesign and improve how and where care is provided.

Fundamental to this vision is the creation of a broadband network which will enable high speed communication, resulting in increased patient access through tele-health and greater interface between GPs and Specialists. The whole of rural NSW will require an investment of $45 million over 3 years to build the broadband network which will achieve savings of $15 million per annum.

Communication infrastructure strategies will support rapid and secure communication, the establishment of “virtual communities” to share knowledge and enhanced ability to disseminate health care information to providers and the public.
This will change the way we deliver care by allowing health care providers greater mobility in where they can deliver care and where they can access important information. The use of broadband technology will enhance and enable these activities.

Electronic Health Record (EHR) strategies will help enable the sharing of patient specific clinical information with providers across the area. The EHR would enable efficient and timely exchange of health care information and will support increased patient safety. Broadband technology deployment is a prerequisite to the EHR.

Integrated corporate systems, as a state-wide strategy, will result in significant cost reductions in providing these services, allow timely access to important business information, and provide detailed and integrated data to support efficient business processes. Again, broadband technology deployment is a prerequisite to achieving totally integrated corporate systems and exploiting the active benefits.


Community/small business/uptake of broadband technology
Once health and education provide the role of ‘anchor tenants’ of high speed broadband technology in rural NSW small businesses and local households will be able to avail themselves of this essential service at significantly lower cost (reduction of 40% estimated) than currently available.

Information Technology recommendations

To address rural and regional information technology needs in the health system, it is recommended that:

a) An investment of $45 million over 3 years be made to create a co-ordinated high-speed E-health broadband communication network, to enable a safer, higher quality, more equitable and sustainable health system by transforming the way information is used by GP’s and Specialists to plan, manage and deliver health care services to patients in rural and regional communities. It is estimated that the investment to build the E-health broadband network will ultimately achieve savings of $15 million per annum and deliver the following outcomes:

· Provision of technology infrastructure that enables information sharing and protects confidentiality of patient information;

· Increased use of tele-health tools that leverage the time and expertise of health professionals;

· Redesign of processes that use technology to save time and provide clinicians and managers with better information;

· Supply of decision support tools that facilitates evidence-based clinical and administrative decisions;

· Provision of ‘up-to-date’ information about what health services are available, and about treatment options for patients;

· Reduced travel time and costs for both consumers and providers.














G. TRANSPORT

In smaller rural towns there are often no taxi or public transport services. Links to larger towns are by coach or rail services, some of which do not connect, or require long hours of travel for a brief appointment. Ambulance is only available for emergency transport and some specific treatment services, such as renal dialysis, and now that access is also being eroded. Many Area Health Services are providing patient transport services from their general operational funds in order to improve access for patients to inpatient services but this does not assist access to early intervention and community-based treatments.

For the average person without access to personal transport, a referral to a specialist for further assessment or treatment becomes an almost insurmountable challenge. At times it can seem easier to ignore things until the illness or symptoms become so advanced that hospitalisation occurs. The human and service cost associated with this is unacceptable.

It is not appropriate to provide specialist health services in every small rural community in NSW. These communities require local delivery of a well-funded and planned generalist primary care service with generalist aged care, community nursing, allied health and child health services (including residential aged care and, where appropriate some levels of emergency care and inpatient service) associated with access to a sustainable and effective transport system, which links people to appointments for other health services available in larger towns and cities. Rural Area Health Services currently receive funds from NSW Health through the Health Related Transport program.

Transport coordinator positions have been created in rural NSW to facilitate local strategies to make best use of existing transport opportunities in a co-ordinated fashion. There have been some excellent initiatives, using these resources, to improve access to transport for small rural communities. However as the cost of providing specialist services increases, and as the population ages and requires more ongoing and complex care, the need for coordinated and readily available transport will increase.

There are some key requirements for a well-integrated transport system for rural communities to access health promoting and health delivery services. These are:

· Information: An electronic information solution that uses high speed broadband connectivity and links with existing electronic clinical systems (such as eDRS, CHIME, GP systems and the EMR) to manage transport as part of the appointment setting process.
· Funds: Rural NSW would need $3 million recurrent annually to establish an effective transport and information system.
· Integration: All the key health service providers – both Commonwealth and State funded would need to be part of the system, with incentives available to support GPs and private providers to buy in.




Transport recommendations

The following recommendations are made to ensure a well-integrated transport system for rural communities to access health promoting and health delivery services:

a) Information: Investment in an electronic information solution that uses high speed broadband connectivity and links with existing electronic clinical systems (such as eDRS, CHIME, GP systems and the EMR) to manage transport as part of the appointment setting process for patients.

b) Funds: Investment of $3 million annually to establish and maintain an effective transport and information system for rural and regional patients.

c) Integration: With close cooperation between the Commonwealth and State Governments ensure all key health service providers are part of the system, with incentives available to support GPs and private providers to ‘buy in’.



































H. VISION FOR RURAL & REGIONAL HEALTH SERVICES IN NSW

The Commonwealth Government’s reform paper ‘A National Health and Hospitals Network for Australia’s Future” (March 2010) outlines that one of the greatest challenges facing government today is to ensure that future generations will enjoy world class, universally accessible health care – the quality of care that has helped deliver Australians the third longest life expectancy in the world. The future direction of the public health care system requires reform to ensure it remains sustainable in the future.
The future vision for health services can be informed by answers to questions such as:
· What do we as a society want for ourselves when it comes to the future of health?
· What vision do we have for the health care system in rural and regional areas?
· What values do we want it to be based on?
· What do we want to achieve?

It’s not hard to set out broad ideals that we would all like to see realised. These can
be expressed as the four goals for NSW Health:

Ø To keep people healthy
Ø To provide the health care that people need
Ø To deliver high quality services
Ø To manage health services well

Guiding Principles and Values
Supporting these goals are a set of values that we want to see embodied in our health system. Sometimes these values may be in tension with one another, but they are all important if we are to create a high quality, efficient and sustainable health care system for rural and regional communities.

Health and wellbeing
Being healthy gives us a greater capacity to enjoy life and fulfil our potential, and societies should therefore protect and promote the health of their citizens

Care and compassion
Every individual in need deserves to be cared for - irrespective of their circumstances.

Quality
Health care consumers and staff should be confident of quality and safety in all circumstances.

Access
Everyone should have fair access to health advice and services that are affordable, timely and appropriate to their needs.

Shared responsibility
People should take responsibility as far as possible for their own health, and should be offered help and support in doing this.

Participation
Individuals and communities should have the opportunity to participate fully in decisions relating to their health and health services.




Stewardship
Available resources should be allocated fairly in accordance with need, and should be used wisely and accountably to maximise the return on investment.

Efficiency and effectiveness
Services should be offered efficiently to avoid duplication and waste, and effectively, based on evidence of what works.

It is generally understood that improving our health and addressing our health needs cannot be achieved simply or solely through the provision of more health services. It requires coordinated action by government, individuals, communities, non-government agencies and the corporate sector.
It is therefore logical that we should aim for partnerships in health, underpinned by a set of principles which will guide our actions over the next 20 years.

Six operating principles have been developed as drafts for consultation.

1. Empowering people to make healthy choices
A good health system will encourage people to be more aware and active in managing their own health, will help promote healthy environments, and will work with others to mobilise community support for healthy choices.

Implications for rural NSW:
Many rural towns have a strong sense of community, and a willingness to focus on projects which benefit all local residents. There is significant scope in rural towns for joint action at the local level by government services, local businesses, schools, sporting clubs, community and cultural organisations, and the media, to reduce health risks and create healthy environments.

2. Working together to create better health care experiences and outcomes
A good health system will provide services that are matched to people’s needs, and will enable the whole community to participate in creating the best possible experiences and outcomes for those using the system.

Implications for rural NSW:
Because of the increasing difficulties in maintaining some local health services due to a worsening shortage of doctors, nurses and allied health professionals, it is imperative that increased efforts are made to engage local rural communities in discussions about what services can and should be available locally, and what services need to be provided on a more centralised basis and will therefore necessitate patient travel. Information and Communication Technology (I&CT) solutions will need to be pursued to improve consumer access to:
Up-to-date information about what health services are available, and about treatment options
Quality health care services which can be provided via remote electronic communication, and which reduce the need for travel (by both consumers and providers).
At the same time, as part of a statewide effort, planning for rural health services must also very deliberately shift its focus more towards protection, prevention, detection and early intervention services, and services provided in the community (all of which will reduce the need for acute hospital admission over the longer-term).

3. Integrating regional planning, funding and services
A good health system will use an integrated approach to planning, funding and service provision which considers health care within the broad range of factors affecting health and wellbeing.

Implications for rural NSW:
Developing integrated networks of health and human services within local rural communities and regions will be absolutely vital to maintaining adequate and appropriate services in those areas, and could play a major role in ensuring the ongoing viability of many rural towns.
In particular, a more integrated approach to the delivery of human services at a regional and community level would reduce overall infrastructure costs through cost-sharing arrangements, address some of the “critical mass” problems which each agency faces when working independently, and allow joint planning and service delivery which more efficiently and effectively addresses the community’s priority needs, and improves the coordination of care. Such an approach also allows the development and implementation of strategies that are customised for a particular place and/or group of people.

A prerequisite for integrated regional service delivery is a governance framework that ensures accountability and funding arrangements and infrastructure (including I&CT) which support new ways of doing business.

4. Improving value, economy and sustainability in health care
A good health system will make the most effective use of the available resources and ensure that costs are kept under control to promote sustainability. The services provided to meet the health needs of the community will be appropriate and cost-efficient.

Implications for rural NSW:
The costs of maintaining services in rural towns are often higher than in larger regional centres and metropolitan areas. In addition to the freight charges added to the cost of goods which have to be transported to rural towns, many small rural hospitals operate with some degree of unavoidable inefficiency because their “critical mass” costs (eg. safe overnight staffing levels) cannot be reduced any further to match low volumes of activity. This is accepted as part of the Government’s community service obligation which requires that, as far as possible, communities have ongoing access to basic health services locally even where this results in higher costs.
The development of new models of care such as Multipurpose Services have maintained local access to services and reduced net infrastructure costs through collocation of primary, acute and aged care services. Increased investment in health protection, illness prevention, early intervention and chronic disease management in the community will also pay long-term dividends in reduced demand for hospital services.
Continue to pursue efficiencies that have been delivered through the consolidation of corporate and business support functions across a number of rural health services. These sorts of initiatives must continue to be pursued as the health needs of rural NSW continue to change.
Ongoing advances in high cost technology for diagnostic and therapeutic purposes is likely to lead to an increased consolidation of such services into fewer centres. However, the effects of this will be mitigated by improved information and communication technology which will connect rural communities with regional and metropolitan hubs and facilitate remote access to quality advice, service and support (while at the same time supporting more efficient work practices).

5. Ensuring the availability of a flexible, skilled health workforce
A good health system will plan and use its workforce creatively and intelligently to ensure an adequate supply and distribution of high quality health care workers. Health workers will be equipped with the right education and skills for the different roles they are asked to perform.

Implications for rural NSW
The current and worsening statewide shortage of medical, nursing and allied health providers is most pronounced in rural and remote NSW, with many towns struggling to maintain even basic primary health care in the form of a General Practitioner and a Community Nurse. It is clear that urgent action is required on a number of fronts, to: support, retain and develop the existing workforce; encourage additional students to undertake health provider education, and; attract skilled staff to work in rural and regional areas.
An essential element of the response to this challenge will be to rethink the current assumptions and structures to allow greater flexibility in the workforce, and to reconfigure different health workers’ roles and responsibilities in delivering services. The successful establishment of the role of nurse practitioner illustrates what is possible in this regard, as does the expanded role of enrolled nurses in particular settings, and practice nurses working with General Practitioners. The education and employment of “technical assistants” to support certain allied health professional groups is also gaining support. Education and training options for health care workers will need to be remodeled to support new models of service delivery and the consequent new workforce demands.

6. Staying at the forefront
A good health system will be alert to the changes in the world around it, and quick to respond to new issues as they emerge. It will be flexible enough to adapt to new circumstances, and robust enough to sustain itself in the face of external pressures.

Implications for rural NSW:
For these, amongst other reasons, rural NSW also offers considerable scope and impetus for trying out innovative ideas and new ways of doing business. Active pursuit of whole-of-government and intersectoral approaches to planning, funding and service delivery is an obvious example. Harnessing the potential of new generation communications technology also holds great promise for addressing the tyranny of distance. The platform for action should be a sound assessment of costs and benefits, taking into account evidence and experience of what works.




I. ESTABLISHING REGIONAL HEALTH AUTHORITIES

Currently, in rural Australia and indeed throughout Australia, the complexity of differing levels of Government at Federal, State and local government levels impacts on the ability to truly deliver integrated health care. This is not solely related to funding mechanisms, although they are also truly complex. The differing level of government involvement in health care currently creates a system which does not readily allow for integration at the point of service delivery. Indeed it could be argued that the current structures enable bureaucratic complexity, but may fail the patient.

The diversity, duplication and complexity of the differing levels of government must also result in increased costs to maintain multiple governing bodies. It is postulated that in order to overcome this multi-layered approach and to truly form health partnerships, the most effective route would be to consolidate Federal, State and Area Health service funding in a regional approach and to direct it towards coordinated networks of services tailored to specific areas and communities. The vision of delivering services close to home could then be fully realised. This approach has now been announced by the Commonwealth Government as part of its National Health and Hospitals Network for Australia’s Future. A regional approach has also been used in Canada, and although there are acknowledged problems that have been encountered (all related to funding structures), overall the evidence seems to support a regional approach for large rural areas. According to Romanow (2002), regional approaches have enabled the actualisation of empirical values within the health care system, thus turning rhetoric into reality.

Rural health care is not the same as urban health care. There are specific needs and
problems which require a specific focus of attention.

· There should be development and implementation of national rural health strategies to encourage local community and clinical engagement. Many clinicians and citizens are not adequately involved in decisions about the delivery of health services in their local community. The establishment of Regional Health Authorites, supported by Commonwealth and State Governments would facilitate cooperative involvement of communities, doctors and other health professionals, hospitals, medical schools, professional organisations and governments at all levels.
· Government must centrally develop and adequately fund Rural Health Authorities which deal with the specific health service needs of the rural areas and develop rural friendly approaches to health issues.
· There should be development of appropriate ‘needs-based’ and culturally-sensitive rural health care resources with local community involvement, regional co-operation and government support.
· Policies and requirements of governments should be tailored to the capacity and needs of rural areas, decreasing multilayered bureaucracies and targeting health care in to the community.
· Creating an integrated health system requires significant shifts in how we work together to meet health needs and how we deliver care. Supporting these strategic shifts requires a change in structure to develop a foundation that supports population health, integration of care and teamwork.

In moving toward an integrated Regional Health Authority system, it will be important to focus on both planning (creating an integrated continuum of care) and service delivery (improving population health and improving care). A Regional Health Authority approach would enable the following:
Ø Reduction of service fragmentation and the development of more holistic person /family/community centred approaches to health care delivery.
Ø Establishment of co-ordinated and collaborative processes for the delivery of multiple cross program services to residents of rural and regional NSW.
Ø Over-arching planning approaches from primary to tertiary care to further an integrated approach to achieving better quality, safe and sustainable health care goals.
Ø Knowledgeable health care professionals being pivotal to the services provided to patients. In Australia and throughout the world, it is anticipated that the current shortage of health care professionals will be exacerbated by a lack of training capacity and the escalating demand for health care services.
Ø Development of a sustainable health care system that anticipates and advocates for the training of health care professionals to meet tomorrow’s demand for health care services. This will involve not only ensuring that the proper number of health care professionals are being trained but also ensuring that they have the skills required to work in a health care environment that is constantly evolving with the identification of better practices and introduction of new technology for more effective and efficient health care delivery. To do this, we must first make the health professions more attractive to prospective students by providing a healthy and attractive work environment with an emphasis on attracting prospective professionals into rural areas. We must also ensure capacity to provide the necessary training in rural areas. A Regional Health Authority approach will enable the increased flow of personnel and development of a more integrated educational and collaborative approach to delivering health care in regional communities. A Regional Health Authority linked with Universities providing programs in rural medicine and nursing will attract specialists and enhance overall training opportunities, within both the tertiary areas and the primary care arena.
Ø Increased opportunities to partner with other large organizations enabling structural re-organisation to support integrated service delivery across rural and regional NSW
Ø Integration (and reduction) of financial, information and administrative processes.
Ø Development of a ‘one layer’ system in health across NSW, with a truly integrated approach from primary to tertiary care.


Regional Health Authority recommendations

It is recommended that as part of the Commonwealth Government Health and Hospitals Network Reform agenda, that the NSW Government, supports the establishment of Regional Health Authorities in rural and regional NSW (referred to as ‘Local Hospital Networks’ by the Commonwealth Government) to manage State, Federal, Local Government and Private sector health funding. The Regional Health Authority for each geographic area would:
Empowering regional communities
a) Work with local councils, other health service providers, other government agency service providers and local communities to develop holistic local models for health care to attract, support and retain general practice doctors and procedural specialists in rural and regional locations (this can include practice facilities and resources, training for non-medical support, ancillary heath care, and connection with community health facilities for health promotion/preventive action within local communities);
Meeting needs by working together
b) Develop, in conjunction with local councils and other health service providers, models of locally based integrated community health care connected with local medical practitioners, broader community health care services (particularly mental health, aged care and post hospital care) and preventive health care activities within rural towns and villages, linked to regionally based hospitals and the development of networks of local health care providers (doctors and ancillary health care) to enhance local support for local primary health services;
Integration
c) Implement a governance framework that includes a Board comprised of local health, management and finance professionals with an appropriate mix of skills and expertise to ensure transparency and accountability in the financial management and administration of the Rural Health Authority;
d) Develop integrated networks of health and human services that reduce overall infrastructure costs through cost sharing arrangements and allow joint planning and service delivery between local hospitals which more efficiently and effectively addresses the community’s priority needs, and improves the coordination of care;
e) Implement plans to shift the focus of health services more towards protection, prevention, detection and early intervention services to reduce the need for acute hospital admission over the longer-term.
f) Enhance access to post acute hospital care and ancillary health services for those in rural localities, including working with the Ministry of Transport to address community transport options to meet needs, where such an option is viable;
Matching needs with financial resources
g) Enhance support to post hospital acute care and support to carers and family support through appropriate and affordable accommodation strategies;
h) Support the development of new models of care in rural and regional areas such as Multipurpose Services that maintain local access to services and reduce net infrastructure costs through the collocation of primary, acute and aged care services
Workforce
i) Implement actions (outlined in recommendation 2 below) that support the development of greater flexibility in rural and regional health workers roles, as well as to supporting, retaining and developing the existing regional health workforce and encouraging additional students to undertake health and medical studies in order to work in rural and regional areas;
Staying at the forefront
j) Be responsible for assessing and implementing cost effective and innovative practices to provide a high standard health system that is responsive to the needs of its local communities.
Specific Needs
k) Develop accessible and appropriate health care services in rural and regional locations (particularly in the areas of mental health, aged and geriatric care, sexual health, drug and alcohol abuse, ancillary health care) including options such as transport and mobile local service provision to meet local needs, especially for young people, older community members, and those with disabilities who are unable to readily access services in large regional centres;
l) Work closely with Aboriginal Medical Services to determine the feasibility of developing culturally sensitive Obstetrics/Midwifery services in locations other than regional centres;
m) In line with Priority 4 of the State Plan, review the scope and the accessibility of primary health care services for Aboriginal clients with a view to proposing innovate methods to further improving outcomes.
n) Work with the Commonwealth and State Government and the relevant dental health professional association, to enhance the provision and accessibility of dental health practitioners in rural and regional locations, including the availability of public dental care services to meet the needs of rural and regional communities;
o) Work with the Commonwealth and State Government to encourage the development/establishment of dental schools/programs in association with regional universities to assist with the training of additional dental health practitioners in regional communities.












Richard Torbay, MP
Member for Northern Tablelands

11/03/2010