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How to improve oral health in rural and remote areas

Efforts to improve oral health in the bush should learn from the history of rural medical workforce initiatives, suggests Gordon Gregory, executive director of the National Rural Health Alliance.

And this should happen quickly – in time for the forthcoming Federal Budget to start work on improving the availability of an oral health workforce in rural and remote areas, he says.

 ***

Learn from rural medical history

Gordon Gregory writes:

The Report from the National Advisory Council on Dental Health was released last week. The Council’s priority task was to provide advice on dental policy options and priorities for consideration in the 2012-13 Budget.

The Report confirms that people in rural and remote areas, particularly children and adults on low income, bear the brunt of poor oral health.

One of the main reasons for this is the dreadful distribution of oral health professionals.

“The geographical distribution of the dental workforce is concentrated in urban areas. The majority of the dental workforce practise in Major Cities: 81.0 per cent of dentists; 87.4 per cent of dental hygienists; 62.2 per cent of dental therapists; 74.7 per cent of oral health therapists; and 67.5 per cent of dental prosthetists.

 There are three times as many dentists practising per 100,000 population in Major Cities (59.5 per 100,000) than in Remote/Very Remote areas (17.9 per 100,000).” (Report from the National Advisory Council on Dental Health)

In releasing the Report, Minister Plibersek referred to workforce and infrastructure constraints, and in the Letter of Transmission, Mary Murnane, Chair of the Advisory Council, writes as follows:

“Foundational activities, such as investments in oral health promotion, infrastructure, and workforce, are integral to all options, and without advancement on all of these activities the policy objectives of the service delivery options cannot be met.”

In preparing for special programs to improve the supply of oral health professionals to rural areas, lessons need to be learned from longstanding programs for general practice.

After years of too few medical students, we now have more medical students graduating than ever before: some 3000 in 2013 – double the number of 10 years ago. These junior doctors then need quality postgraduate training for the first three years after graduation – learning to put their theoretical learning into practice with gradually reducing supervision.

However, it is now apparent that there are not enough quality training places, particularly in rural areas, to enable all of these new graduates to hone their skills. For this reason the Australian Medical Students’ Association (AMSA) has come out against further increases in medical student numbers.

In an endeavour to help address this problem, the Alliance has been promoting a plan to diversify the settings in which junior doctors can complete three postgraduate years of training with supervision and mentoring. These additional training places could be in community health centres, Aboriginal Medical Services, private hospitals, with the RFDS or in small accredited general practices in rural and remote areas, thus exposing these new doctors to the advantages and challenges of practice in country settings where workforce numbers are still insufficient to meet need.

Health graduates who come from a rural background are more likely to take up practice as a health professional in a rural area. However, rural students are poorly represented in tertiary studies, especially in dentistry. Currently the bulk of students in Australia’s dental schools are from metropolitan areas; others are from cultural groupings with little natural affinity with rural Australia.

This was precisely the situation that applied in medicine before the introduction of the Rural Australia Medical Undergraduate Scheme (RAMUS). The RAMUS program has helped to turn around the number so that a greater percentage of those who complete medical studies are from rural areas. (Some 1,300 rural people have completed medicine in the past 11 years with the help of a RAMUS scholarship.)

Other programs that are available for medical students include the medical rural bonded scholarships, which provide scholarship funding during the student years in return for a period of service in rural or remote areas following registration, and the bonded medical places scheme, which funds extra medical school places (for students who would otherwise not have a place) in return for a similar period of service.

Medical graduates are also entitled to forgiveness of their HECS debt if they practise in a rural or remote area for a period of time. The HECS reimbursement is on a sliding scale based on the remoteness and duration of their rural practice.

The Alliance consistently argues that this sort of attention should also be given to other health professions such as nursing, for example, where there are also greater numbers of students graduating in the next few years. And now there is a clear opportunity to give similar attention to oral health students.

The rural and remote health sector is a very strong supporter of a better oral and dental health system – by whatever means it is to be delivered. A start needs to be made on the “foundational activities” in the forthcoming Federal Budget – especially workforce availability and distribution.

There needs to be a mix of carrots and sticks in the programs to encourage a greater number of young health professionals, including dentists and oral therapists, to practise in rural and remote areas.

Hopefully a system can be devised for oral health professionals that includes the best approaches learned from general practice, including scholarships for students from rural areas, access to rural and regional training, support for rural infrastructure, HECs reimbursement, fly-in, flyout dental services, an expanded Foundation Year for dental graduates, and perhaps an expanded scope of practice for oral therapists.

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