How will our two-speed economy constrain efforts to improve rural and remote health across the various states and territories? How can we get the balance right in rural and remote health policy between national uniformity and local flexibility and appropriateness?
How can we ensure that the many agencies involved in addressing rural and remote health inequalities deliver timely, effective action?
These are some of the questions raised below by the National Rural Health Alliance’s Gordon Gregory, in welcoming today’s launch of the National Strategic Framework for Rural and Remote Health (available here).
A warm welcome (with some pointy questions) for the National Strategic Framework for Rural and Remote Health
Gordon Gregory writes:
Health Ministers from all jurisdictions have today launched the National Strategic Framework for Rural and Remote Health. The Alliance unequivocally welcomes this new National Strategic Framework, in the hope and expectation that it will lead to stronger and more coherent national action to improve health and wellbeing in rural and remote areas.
The principles, goals and outcomes areas of the Framework generally reiterate those previously established in Healthy Horizons, an indication that it represents a sustained approach to acknowledged priority work areas, notably access, service delivery and workforce.
The major strengths of the new Framework are that it provides a succinct account of current health issues in rural and remote Australia and challenges the perception that success in the health care system can be assessed solely on the quality and outcomes of services in urban areas. It also accepts the need for flexibility and for a focus on local ways of addressing local problems.
The major uncertainty associated with the Framework is that its effectiveness depends very much on how it is used by eight Governments operating in very different political, fiscal and geographic environments.
To prove any doubters wrong there will need to be strong leadership and financial commitment at both national and State/Territory levels.
This immediately raises the issue of capacity, with the Commonwealth under great fiscal pressure (some of it imposed by that pervasive variable: ‘global confidence’) and the States/Territories in quite diverse fiscal circumstances. Western Australia, including in particular through its Royalties for Regions program, is investing heavily in health-related services and infrastructure, whereas Tasmania is finding itself unable to build investment at this time.
These different circumstances clearly illustrate the most significant constraint on the sort of coherent directions agreed in the new Strategic Framework.
They highlight the implications for rural and remote health of the so-called ‘patchwork’ or ‘two speed’ economy and therefore emphasise the importance of the Federal Government’s fiscal stance and the critical role to be played by its redistributive financial activity.
The new National Strategic Framework for Rural and Remote Health is a good document – perhaps even better than Healthy Horizons – but, like any good strategic framework, it will only prove to be as useful as the actions that flow from it.
The Alliance believes that jurisdictions should now move to the development and agreement of a National Rural and Remote Health Plan, with quantitative performance indicators which can be used to determine annual progress and to provide annual accountability.
With such a Plan in place, the urgency of fiscal equalisation across jurisdictions will become even more transparent, as will making real progress towards greater equity and quality of health outcomes between major city and rural/remote areas.
Who will make it all happen?
Much of the national leadership on issues identified for action in the Strategic Framework is in the hands of bodies such as the Australian National Preventive Health Agency, the National Health Performance Authority, the Independent Hospital Pricing Authority, Health Workforce Australia, and the COAG Reform Council.
A critique of real action and progress on the strategies to realise the five goals in the Framework might therefore be based on progress made by these national organisations. To date action by and through the ANPHA and the NHPA has been slow. The work of the IHPA has been more visible and impressive.
Health Workforce Australia is engaged on very many fronts but is still to convince all constituents that its work will make the necessary difference in the immediate future. The Alliance has developed confidence in the COAG Reform Council (more a reporting agency than one leading action), because it has been adaptive and responsive to the needs of the rural and remote health sector.
Patient Assisted Travel Schemes
The treatment in the new Strategic Framework of Patient Assisted Travel Schemes (PATS) is instructive of the challenges for a national approach to progressing action on rural and remote health.
It is very encouraging to see the document include not only a description of the current PATS situation but also, perhaps for the first time (and not too early, given the time that has elapsed since the Senate’s report), specific acknowledgement that one of the shared strategies of Commonwealth and States/Territories will be: “facilitate developing national standards for patient travel and assistance”.
The indicated action on the matter is welcome but the practical difficulty is confounded by the tension between national uniformity and the desirability for local appropriateness. No one would expect the PATS scheme to be identical in States the size of Tasmania and Western Australia, but greater uniformity and equity for the people of both those jurisdictions is clearly both fair and sensible.
The new Strategic Framework deals sensibly with the critical issue of the relationship between its agreed objectives and strategies and those of the States and Territories, as well as with other national strategies.
Leadership needed at multiple levels
When it comes to action on the ground, a great deal of work relating to the individual strategies will necessarily be undertaken by the Local Hospital Networks and the Medicare Locals. There is considerable concern about the continued lack of clear understanding and good communications on the expectations of these agencies and how they can be met. (Last week a Think Tank organised jointly by AHHA and NRHA canvassed several of the issues in relation to these new agencies.)
On the one hand there is uncertainty, especially about how sufficient funding and other resources will be provided for those bodies to meet the expectations of them; on the other hand, there is broad recognition of the opportunities provided for greater local engagement, management and accountability.
A great deal of national and jurisdictional leadership will be necessary to convert these opportunities to real improvements in rural and remote health outcomes.
The new Strategic Framework provides a major opportunity for a ‘whole of government’ approach to improving rural and remote health outcomes. The endorsement of the Strategic Framework by all jurisdictions is an important first step towards this.
At each jurisdictional level, what is now required is a serious effort to have Health Departments lead understanding and work by non-health agencies to improve the social and economic determinants of health and wellbeing.
At the national level an appropriate agency to lead this work has been established. Operationalisation of the new Strategic Framework should be the de facto strategic plan for Rural and Regional Health Australia, with development of a new National Rural and Remote Health Plan to be, in effect, its triennial work plan.
The existence and strength of equivalent bodies focusing on rural and remote health within State and Territory Health Departments has waxed and waned over the years. Now is an opportunity to ensure that there is a strong body for this purpose in each jurisdiction.
The National Strategic Framework for Rural and Remote Health is the first significant national document to give appropriate meaning to the words ‘rural and remote’. This in itself is a valuable contribution, providing greater clarity than so many other documents which use the ambiguous term ‘regional’.
So with the nomenclature now clarified, ‘all that remains to be done’ is to produce a complementary National Action Plan for Rural and Remote Health that all jurisdictions can endorse; balance fiscal capacity of the jurisdictions; convert the ‘whole of government’ thrust of the Strategic Framework into action; and look to the key national agencies to effect without delay the leadership that the Commonwealth must exercise in order to achieve greater equality of health outcomes soon, rather than continuing only to recognise that such inequalities exist.