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“One size doesn’t fit all in rural health: 7m people & kids like Max deserve better”

This is the second story in a Croakey mini-series on Fixing Rural and Remote Health, following the launch of the National Rural Health Alliance’s five key priorities for ‘Fixing Rural and Remote Health’.

This post features the speech at the National Press Club by NRHA CEO Geri Malone.

In it, she outlines one case study, where fractures and failings in rural and remote health services that meant it took ten days before a 12 year old boy with significant health issues was able to get appropriate assessment and intervention from a child mental health team.

It also looks at health workforce issues and a superficial sentimentality about the ‘bush’ in Australia that produces only tokenistic responses to the social determinates of health.


Geri Malone speech

I would like to tell you a story.

Imagine yourself in a small remote town, population 250 with a broader district population difficult to quantify, and covering a vast geographical area, predominantly agriculture-based, some mining activities and tourists.

The town has a school and a health clinic, a pub, some other small businesses and a policeman.

The health clinic is staffed by a Remote Area Nurse (RAN)  with fly in fly  out (FIFO) medical and allied health services.

The nearest, more substantial town (population 3,500 ) has more services, a hospital, including birthing services, and is 400 kilometres away.

The Royal Flying Doctor Service provides a weekly Primary Health Care clinic with a doctor and nurse, and responds to emergencies. Allied health services are provided on a FIFO need basis. The capital city is 1,000 kilometres away.

The relieving Remote Area Nurse flew in on the regular, not daily, commercial flight to receive a handover from the nurse  leaving the community on that outgoing flight.

During that face-to-face handover they discussed an ongoing  situation with a specific patient, culminating with the plan that the patient was flying out under the departing nurse’s escort. The situation had been managed over a period of time in consultation with various networks.

The patient was an 12 year boy who I will call Max, who had been exhibiting anti social behavior – disruptive, explosive bursts of anger, had threatened other kids, and also threatened to self harm. He had a history of other similar incidents but never to this extent.

Incidentally the local mental health service has one mental health workers in that closest bigger town,  400 kilometres away,  a solo outreach position from the main regionally-based team another 300  kilometres away again.

This seemed like a good plan, but unfortunately Max was not happy to go,  exhibited behavior which was considered a risk in flight so that was abandoned.

This  left the incoming Nurse to manage the situation and a very distressed mother angry and upset on the day’s outcome, after several days of negotiating and consultation, and with a now sedated son.

The nurse booked another urgent telehealth consult with the city-based team and  was informed that a pediatric retrieval team was being sent out from capital city who would further sedate and transfer Max to the paediatric mental health unit.

However,  that team flew in, assessed him, then they flew out again without Max, deeming it was too much of a risk or they were not prepared to initiate what was required to undertake this safely from everyone’s perspective.

The Remote Area Nurse  a very experienced nurse, by this time, needless to say, felt totally abandoned – not just for herself but for Max  and his family.

Due to her diligence, persistence and her commitment to her patient and the family,  she found some emergency funding that could be accessed to assist the family to drive out – not ideal but a solution.

So it took 10 days from the time of the original incident until Max received the appropriate assessment and intervention from a child mental health team.

Was that a fair result for Max (and his family)?

Unfortunately this is a story which will resonate with many rural and remote based health professionals, clients and families, reflective of the inadequacy of health services – not just a lack of resources but also the fragmentation, a highly time -consuming maze (to navigate) to find a solution.

It is important to mention here the importance of telehealth – the access to the mental health workers through this medium is highly valued and a critical link, but it is equally important to highlight that telehealth is not the panacea that many funders and city based bureaucrats would like to think it is. It only goes so far and is not and must not be seen as a replacement for on-the-ground services, but an adjunct.

Access to appropriate, affordable health services is a basic right

The National Rural Health Alliance (NRHA) is well positioned to inform the discussion on rural and remote health. It has 39 member organisations who all have a common goal to improve the health outcomes for people living and working in rural and remote Australia.

Our members are professional workforce organisations across the spectrum – health service providers such as RFDS, the  key Aboriginal and Torres Strait Islander workforce organisations, important  consumer groups  such as Country Womens Association andthe  Isolated Children Parents Association, reflecting the importance of encompassing all the  elements contributing to health and well being.

Good health is essential for a good productive life, the evidence supports that.

If we can reduce the disparities in health and wellbeing between people in rural and remote areas and people in metropolitan areas, we can dramatically improve participation and productivity, and increase Australia’s economic growth.

Access to appropriate affordable health services is a basic human right. We are not talking about the highly specialised surgical and medical services … but primary health care services, emergency response including mental health care, and being able to birth and die close to where you live.

For a long time now we have been highlighting the fractured nature of the health service delivery that exists between layers of government and provision of service contracts to different organisations that are not co-ordinated and do not meet the needs of communities.

Models that work in urban settings do not necessarily translate to the rural and remote sector: we need flexible arrangements to provide the services communities need.

Going beyond ‘Akubras and moleskins’ tokenism

Access to health services is dependent upon many factors including an appropriate workforce,  and not of any one professional group but a team, whereby the Aboriginal and Torres Strait Islander health worker, the aged care worker, mental health professionals, the optometrist, dentist, ambulance personnel, speech therapist and podiatrist is each as equally vital to health services as is the doctor.

We do not have a health worker shortage in this country at the current time, what we have is a distribution problem – we can’t get them out of the cities.

As a health professional, I  consider myself very fortunate to have worked across rural and remote Australia in variety of nursing and midwifery roles. I am also representative of what we know – that having grown up in rural South Australia, I am more likely to go back and work in that environment. We must focus on growing  our own workforce.

There tends to be a bit of an attitude: that to work in rural and remote health, regardless of which professional group, that you are bit lower down in the pecking order – ‘you couldn’t cut it in in the city so you go bush’.

But we know the reality is quite different, that in order to succeed in rural and remote practice you have to be a special kind of person. As a generalist, you need to be adaptable, resourceful, self motivated, and competent across a very broad scope of practice. You need to be in tune with your community and you need to be resilient. It is a great career.

Australians will attest they have a strong affinity with the bush, they like to romanticise the lifestyle, reinforce the myths and promote the romantic images of the bush, and they wear the Akubras and moleskins to prove they do. Politicians included.

I suggest that that connection is superficial.

Scratch the surface and the actual investment in services be they health,  education, communications and business is tokenistic at best.

We need to do better. One size, one approach does not fit all.

Seven million people and kids like 12 year old Max deserve better. A fair go for rural and remote health.

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