Time to fix inequity in rural health care

  5 November 2020  NWMPHN

This article was originally published in VicDoc and has now been republished in The Health Advocate.

 

When it comes to access to high quality health care, not all Australians are equal.

If you live in a major population centre, chances are you have ready access to the hospitals, health services and health professionals you need. If you live in a regional area, not so much.

For a country that rightly prides itself on its system of universal health care, there remains a distinct and distressing gap between outcomes for those who live in the big cities and the one-in-three Australians who don’t.

In 2019, the Australian Institute of Health and Welfare reported that on average, Australians in rural and remote areas had shorter lives, higher levels of disease and injury, and poorer access to and use of health services. Rates of potentially preventable hospitalisations were 2.5 times higher than in major cities and the total disease burden 1.4 times higher.

In cancer care, regional patients generally have a 7 per cent higher mortality rate than their urban counterpart and for some cancers the discrepancy is up to 84 per cent. Even accounting for risk factors such as the generally higher alcohol and tobacco use in regional areas and the dangers of workplaces such as farms and mines, these are damning statistics. And for marginalised and vulnerable groups such as Aboriginals and Torres Strait Islanders, they are much worse. How has this happened? It does not make health, social or economic sense to have health care services concentrated in major population centres to the point that patients must go to cities to access most of their health care.

The costs to a community are also more than the discrepancy of health outcomes. Patients are forced to travel, take more time off work and caring responsibilities. The loss of comprehensive health care infrastructure and services costs a community in its ability to attract and retain citizens—and doctors—and there is a loss in the economic and community benefits of hosting health care facilities.

Alongside this, we have all political parties wanting to regionalise our population and decongest the city and move doctors to the country. Without adequate health care, it just makes no sense and it is unjust. Ironically, in some cases restricted services have been exacerbated by a black-and-white view of quality and safety. If a service in a regional centre struggles in areas of safety or quality, the quick and risk-averse reaction is to close or limit the service. It’s a much harder proposition to increase, upskill, connect and support the workforce, upgrade local infrastructure, and develop systems and services to meet the standards and population needs. Yet this is what is needed.

To see where the current mindset leads, consider the recent high-profile case of maternity services in Yass, a regional NSW town with a population of more than 6,000. Since 2004, women in Yass have had to drive either 70 km to Canberra or 90 km to Goulburn to access maternity services—leading to several women giving birth on the roadside on the way to hospital. Many women in Victorian towns have even worse access than this.

Consider too the uncertainties posed by the current pandemic. As I write, Melbourne is in stage four lockdown, with coronavirus cases surging among health care workers. What does that mean for an immunosuppressed patient from country Victoria who needs to travel for treatment? And what would an outbreak look like in a region without ready access to comprehensive care? Bring the service to the people Contrary to popular belief, the population of regional and remote Australia is growing. According to the Australian Bureau of Statistics, it increased by 10% between 2007 and 2017, and has been forecast to grow further still.

The approach of forcing people to go to the service rather than bringing the service to the people needs to change. Three recent developments mean that this could well be the ideal time to do it. The first of these, radically accelerated by the pandemic, has been the acceptance and adoption of telehealth.

This means that rural hospitals and practices can have realistic, real-time and visual access to the best specialist expertise. An existing example of this is the Victorian Stroke Telemedicine Program, which has been running since 2011 and gives regional hospitals 24-hour access to a roster of stroke neurologists. According to the Florey Institute, interim results show that ‘Eligible patients are being treated more quickly and more safely’.

There is no reason this could not work in other fields such as obstetrics, dramatically improving access to local delivery options for regional women.

The second development is the Rural Generalist Program, a federally-funded scheme to help recruit and train more doctors with a broad scope of practice to work rurally — from delivering a baby to emergency surgery. It is designed to attract many young doctors to rural areas, provide a more sustainable workforce and increase the provision, capacity and viability of services.

The third, and potentially most transformative, is the recent update to the National Health Agreement. What I hope this will do is drive a complete change in mindset, where larger hospitals think beyond their own four walls and consider what people, health professionals and smaller services in their region really need. If it works as I believe it should, it will see Local Hospital Networks working with GPs and Primary Health Networks to minimise duplication and fragmentation and put services back into the places that need them most.

Right now, Australia suffers from a damaging and persistent maldistribution of health care services. This inequality has been growing for years, but now we are presented with an opportunity to fix it. An opportunity we must take, for the sake of equity and common sense. For too long we’ve had a system that serves the needs of those who administer it in cities. The time has come for it to serve the people that use it across our entire land.