Introduction by Croakey: With days to go before the New South Wales state election, major parties are being urged to consider strengthening community-based primary healthcare, especially in rural and remote regions.
As discussed by CEO of the Healthy Communities Foundation Australia Mark Burdack below, the NSW Greens are the only major political party to commit to improving the public community health sector. Both the Liberal and Labor Party’s plans are focused on staffing and hospital infrastructure.
Burdack also urges the Federal Government to do more to centre communities’ voices and needs in policymaking, which he says tends to be dominated by industry groups representing the health professional workforce.
This is the first in a two-part series about community-based healthcare. Also read: How Community Hubs could contribute to better health for rural and remote Australians.
Mark Burdack writes:
The 2023 NSW election has descended once again into a contest between the major parties over who can promise the most new or refurbished hospitals and additional hospital beds (here, here and here).
Never mind that we cannot adequately staff our existing metropolitan hospitals, and that the 30 percent of Australians who live in rural and remote communities routinely have no local doctors.
The NSW Greens are the only major political party to publicly commit to strengthening community-based primary health care, and refocus our system on keeping people healthy, to reduce the need to build even more expensive hospitals.
We all know that our health system is failing, in rural and remote NSW in particular. Yet if the promises made by political parties are any guide to how our politicians see the issues, you would be forgiven for believing that the system is fine, “nothing to see here”, we just need to build a few more hospitals and it will all be sweet.
When politicians are confronted with the uncomfortable reality that our health system is not “fine” at all, the response is often that we have the best health system in the world. If you argue otherwise, you face marginalisation, stigmatisation, defamation and exclusion for not being a “team-player”.
Yet, the claim that we have the best health system in the world strains credulity.
The recent NSW rural health inquiry found that “rural, regional and remote New South Wales have inferior access to health and hospital services, especially for those living in remote towns and locations and Indigenous communities, which has led to instances of patients receiving substandard levels of care”.
Rural and remote people can no longer be dissuaded from believing that which they can see with their own eyes. Glib one-liners can no longer be used to dismiss their lived experience.
Even city folk are now realising that the health crisis, like COVID-19, is a virus spreading into once healthy parts of the body corporate – as ambulances pile up in our emergency departments, people die because the ED is overwhelmed, elective surgery lists blow out, aged care residents die needlessly for want of basic primary health care, and bullied and burnt-out staff leave the system.
If our leaders cannot even recognise that there is a problem, how on earth are we going to solve it?
Every time the crisis rears its head in public, we invariably turn to the same people for answers expecting that by doing so we will get a different response.
Strengthening Medicare Taskforce
The Federal Government recently appointed 17 members to the Strengthening Medicare Taskforce. Almost every one of them is an industry representative.
This is not a criticism of the expertise and eminence of the members of the Taskforce. But it does challenge the notion that we are genuinely committed to community engagement in health policy.
The Taskforce lacks any representation from local government, a community sector organisation like the CWA or Rotary, a local health action group, a rural health practice, a housing department officer, the media, a survivor or a family member of a victim – the people who deal with the consequences of our failing health system every day.
By and large, industry groups represent the interests of the health professional workforce that are their members.
Of course industry must be represented as a stakeholder at the table, and workforce must be a central part of any discussion, but when industry is the only people we truly listen to it sends a very clear message that we are not interested in the experiences or wisdom of communities.
Health policy
This has two direct implications for how we conceive (or misconceive) health policy.
First, ‘if all you have is a hammer, then every problem looks like a nail’. If all the decisions about health policy are effectively made by people with an interest in workforce (industry associations, universities etc), every problem quickly becomes a workforce problem.
Second, if every problem only has a health workforce solution we limit the scope of potential inquiry, and therefore the responses we can consider, according to a predetermined idea of what constitutes the health workforce.
The health crisis in Australia, as elsewhere in the world, has arisen because we have ignored the myriad people engaged in helping to keep people healthy, and forgotten who the health system was designed to help.
For two decades governments were warned by rural and remote people that our focus on medical workforce alone was misconceived, and policies designed in our cities would strangle the supply of rural GPs and worsen the maldistribution.
The workforce mindset blinkers our ability to think about what people actually want and need from their healthcare system. People want help to remain healthy, not a nice hospital in which to die from an avoidable illness.
Yet our health policies suggest that if we can just build more hospitals, and train more specialists, then the needs of people will naturally be satisfied.
Social determinants
But we all know that the reason people become chronically unwell in Australia, as elsewhere in the world, has very little to do with the ability to access a hospital.
As argued by former Treasurer Wayne Swan, in his book ‘Postcode: the splintering of a nation’, health and life outcomes in Australia are largely determined by when and where we are born, live and grow. Depending on the research, these social determinants of health account for between 50-80 percent of life outcomes.
And herein lies the whole problem of Australia’s health policy. The professional workforce that is engaged every day working directly with communities and individuals to address the social determinants of health are not considered part of the health workforce at all or given an appropriate voice in decision making about health policy.
They are teachers, social workers, police, personal carers, disability workers, family counsellors, volunteers, employment agents, planners, financial counsellors, GPs, practice nurses, allied health professionals, disability workers, rugby league and netball coaches, meditators, practice managers, Aboriginal community safety officers, aged care workers, urban planners, local government officials and so forth.
Despite the determinative and positive impact that these professions have on human health and wellbeing, and the key role that they play in reducing the cost of health to state and federal budgets, they are rarely seen or heard when it comes to decisions about health policy in Australia.
Community leadership
Despite the research that shows that community-led health planning leads to outcomes that are more responsive to local needs, rural and remote based health organisations or consumers are never at the table.
The words of former Prime Minister Scott Morrison about Aboriginal health and development ring true about the way we treat rural and remote people:
Despite the best intentions, investments in new programs and bipartisan goodwill, [there] has never really been a partnership with…people. We perpetuated an ingrained way of thinking…that we knew better…We don’t. We also thought we understood their problems better than they did. We don’t. They live them.”
Genuine community leadership of health requires an acknowledgement that all health expertise does not lie in Canberra or a capital city.
I understand that this is not easy to hear if you have spent your life believing that you alone have the expertise to fix the “problems” of rural and remote people, and that rural and remote people simply lack the intellectual capacity to understand the complexity of the health system or challenges it faces.
As a result, rural and remote communities are forced to navigate fragmented and disconnected services designed by people removed from the every-day realities of their lives.
The lack of genuine community leadership undermines the ownership that is essential to long-term systemic improvement in the conditions driving poor health and life outcomes. The failure to engage with the experts in rural and remote health means we are fighting a battle with one hand tied behind our backs.
Whether at a state or federal level, the contemporary model of remote development of policy and remote management of care for remote communities delivers exactly what the word implies – remoteness.
See previous Croakey articles on the NSW state election.
