1. IMPROVING HEALTH CARE IN RURAL AUSTRALIA New models for training and care in rural communities and their evaluation Critical strategies for improving health outcomes for Rural Australians The “Western Alliance” initiative Deakin University November 2014

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

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

4. What about Rural Health Care? More than 33% of Australians live in Rural or Remote communities They produce 65% of the Nations wealth There numbers are growing and feature many retirees!

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

6. Unacceptable Health Outcomes “Australians living in rural and remote areas have much poorer access to local health services” 2 billion dollar Medicare gap “Significantly worse health outcomes” “A significantly shorter life expectancy than Australians living in metropolitan areas”

7. The Chronic Disease burden “The prevalence of chronic disease is troubling” “data shows the incidence of cancer is about 4 per cent higher than in major cities” “Significantly higher incidence rates for preventable cancers”.

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

9. Disease Burden “Compared with their city counterparts rural residents tend to exhibit: 10 percent higher levels of mortality; 20 percent higher rates of injury and disability; 32 percent higher rates of risky alcohol consumption; and 10–70 percent higher rates of peri-natal death”.

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

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

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

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

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

15. Current Government Policies Medical Education----- 25% medical students “Rural” Have lived in a rural post code for five years !!! Establishment of Rural Clinical Schools All students spend a minimum of 4 weeks in a rural clinical setting.

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

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

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

19. What does the evidence suggest? Training many more rural medical students A return of the GP proceduralist Selected “Rural” students should have an intention to practice in the country Rural students to be trained in rural universities with a rural specific curriculum featuring Inter-professional learning Inter-professional learning

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

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

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

23. Primary Care? Once we have settled on a clear vision for the model of care desired we must train/assemble the clinicians who can provide it

24. Evidence based reforms “Rurality” not postcode all important “Affirmative action” selection Six year undergraduate program Problem based learning featuring IPL Rural specific curriculum Early and extended acquisition of procedural skills

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

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

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

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

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

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

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

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

33. No vision or commitment to these structural reforms in Canberra. Minister Crean advised------- ‘We listen to proposals that enjoy really strong community support’ “Don’t be whiners, bring us solutions to your problems” Rural apathy must be reversed Community and University Advocacy

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

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

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

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