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Presenting a vision for rural and remote health: what are the chances?

Australia’s peak body for rural, regional and remote health, the National Rural Health Alliance, has appointed rural clinician Dr Gabrielle O’Kane as its new Chief Executive Officer, to succeed Mark Diamond in the role.

Dr Gabrielle O’Kane

In a statement, the NRHA said O’Kane, a dietitian, comes to the job with 35-plus years working in outback private and public practice in New South Wales and is also an academic and researcher.

An Adjunct Associate Professor at the University of Canberra’s Health Research Institute, she has most recently been responsible for commissioning and governing drug and alcohol services for the South East NSW Primary Health Network, Coordinaire.

Earlier this year, the Alliance hosted its 15th National Rural Health Conference, seeking to put deep reform on rural health on the agenda in the leadup to the federal election.

Melissa Sweet finalises Croakey’s coverage of the event in the below, which explores opportunities for realising the vision presented by conference delegates in the wake of the election.


Melissa Sweet writes:

It’s 2025, and as people from across Australia gather for the 18th National Rural Health Conference, they are looking back on the past six years with some sense of both satisfaction and surprise.

So many of their aspirations from the 2019 conference in nipaluna/Hobart are coming to fruition. The Uluru Statement has been enacted, and a Makarrata Commission is supervising a process of agreement-making between governments and First Nations.

The Commission’s historical truth-telling processes are supporting healing processes around the country, and there are early signs that the Voice to Parliament is making a tangible difference for Aboriginal and Torres Strait Islander people’s health, by enabling self-determination in policy making and service delivery.

Significant investment in the Aboriginal Community Controlled Health Organisation (ACCHO) sector has been associated with exponential growth in the Aboriginal and Torres Strait Islander health workforce, bringing multi-layered benefits for many communities, especially in rural and remote areas.

Meanwhile, many rural and remote communities are thriving as the result of a series of national, state and territory Wellbeing Budgets that have prioritised action on health equity, including through increased health and social spending, as well as sustainable employment initiatives in communities of greatest need.

Silo-busting

New ways of working across government portfolios, informed by the silo-busting approaches of Wellbeing Budgets in Aotearoa/New Zealand, are supporting action on the social and economic determinants of health through health-in-all policies approaches, with a determined focus on rural, remote communities and other high-need areas.

Rural and remote communities are also benefiting from systemic efforts to address the related problems of poverty, incarceration and housing insecurity, including through investment in early childhood.

Social security payments have been increased so recipients can meet basic living expenses and live with dignity, while governments have heeded the advice from experts like Sir Professor Harry Burns to abandon punitive, controlling policies.

Indicators across a range of health areas, from mental health to rheumatic heart disease (this “disease of poverty” was a major focus at the 2019 conference) and the experiences of people with disability, are improving in rural and remote communities as well as the wider population.

Wellbeing Budgets have also led to significant investments in innovative new models of comprehensive, community-controlled primary healthcare in areas of highest need.

Rural communities at the forefront of developing these new models have learnt much from the example and experience provided by the ACCHO sector, while implementation of the Rural Health Strategy has helped to grow a multidisciplinary generalist rural health workforce.

The Medical Research Future Fund’s dedicated funding streams for Indigenous health, rural health and health equity are also informing the development of innovative primary healthcare models that work to address the wider determinants of health as well as providing holistic services.

But…

It’s not all good news. Climate change is hitting rural and remote communities hard, with extreme weather events increasing in intensity and frequency.

Implementation of the national climate and health strategy, first drafted way back in 2017 by a coalition of health groups, is supporting communities to build their resilience and mitigation and adaptation strategies.

Rural and remote health services receive loaded funding to implement a new National Safety and Quality Health Service Standard for minimising the health risks of climate change to the health of patients and to the delivery of safe, quality care. They have scoped and prepared for risks such as surges in service demand, destruction of infrastructure and equipment, and interruptions to workforce availability, access and supply chain.

The Just Transition Commission has worked closely with rural and regional communities affected by the move away from fossil fuels to develop new economic models, with significant investment in education and training, and support for regenerative agriculture and other sustainable, low-emissions activities.

As predicted, investment in tackling climate change is also bringing wider benefits, through promoting healthier housing, transport, and food systems as well as more socially connected communities. Warnings from 2015 conference delegates that efforts to address climate change must also tackle social and economic inequalities have been heeded.

Reality check?

This at least is how 2025 might start to look if some of the visions presented at the 15th National Rural Health Conference are translated into reality, and quickly.

However, in the three months since the conference, little progress has been made towards creating such a future. Despite the conference’s impeccable political timing, just ahead of a federal election, many advocates were disappointed by the lack of a specific focus on rural health during the election campaign.

“The health of rural Australians, the 28 percent of the population that live in rural Australia, was not top of the agenda with any political party. It defies logic, quite frankly,” says Mark Diamond, who finishes his term as CEO of the NRHA today (28 June).

Diamond said the major political parties seemed to assume that any national health initiatives would benefit everyone equally, not recognising the need for a specific rural focus:

“There was no targeting to address the core reasons why inequity of access occurs in country areas – workforce shortage being the major one.

While the impact sounds as though it will have a uniform per capita equal effect regardless of where a person lives, it actually doesn’t. The services are just not there.

An approach of ‘raising all boats’ does nothing to achieve equality in health outcomes for rural Australians. The 30 percent greater burden of disease will continue.

We need to urgently address the underlying reasons for the inequity before we can expect the same return on investment in achieving equality of health outcomes for all. Inequitable access to healthcare equals unequal outcomes.”

Professor Jenny May AM from Newcastle University, who chaired the conference recommendations committee, also lamented the lack of a specific focus on rural communities in health policy announcements.

She said:

“Rural health did not play well as an election issue for either party although on the ground my sense was that voters were keenly interested in the capacity of the health system to meet their needs

The announcements that were made were about mainstream policy…the difficulty in  application would have related to workforce distribution issues underlying it.

Unless either party chooses to address the issues around underlying workforce distribution and the balance between generalism and specialism, we are unlikely to be able to provide universal healthcare in rural areas.”

Exactly one month after the federal election, the gap between the 2025 vision and the current reality was powerfully underscored by the CEO of the Royal Flying Doctor Service, Martin Laverty, who was in Broome to present to the Royal Commission into Aged Care Quality and Safety.

His presentation highlighted the wide-ranging impacts of systemic primary care failures in remote areas, especially Western Australia and the Northern Territory.

“We are letting older Australians down by a failing primary care system in remote Australia,” he said. As a result, there were high rates of avoidable hospitalisations and elderly people were being removed into care long distances from their communities and families.

“The relevance for this Commission is that where your primary care is failing, you are going to have greater call on aged care services for older Australians and, when they enter, their acuity will be higher such that they will require a higher level of support.”

Laverty urged the Commission to articulate what is a reasonable standard of access to primary care for an older Australian in a residential service, in a community service, or still living independently in their own home. “And once a reasonable standard is articulated, it then requires resourcing to be able to deliver that service access across Australia,” he said.

According to Professor Jenny May, the full impact of the deficits in rural and remote health services will only become apparent in years to come. She said:

“If we’re neglecting prevention at this point and we know we have an ageing population with a higher incidence of chronic disease, the impact of that lack of prevention will not hit our system for ten years.

Those people are in their 50s and 60s now and it’s the quality of their lives when they are in their 70s and 80s where we are going to notice the impacts, such as an increase in hospitalisations that were preventable.”

It’s a reminder of the enormity of the challenge in achieving rural health equity, even if there was an actively supportive political and policy environment. As the Australian Institute of Health and Welfare notes:

“Australians living in rural and remote areas generally experience poorer health and welfare outcomes than people living in metropolitan areas.

They have higher rates of chronic disease and mortality, have poorer access to health services, are more likely to engage in behaviours associated with poorer health, and are over-represented in the child protection and youth justice sectors.”


Ways forward?

The political and policy agenda of the re-elected Coalition Government does not align well with the vision for the future presented at the Hobart conference, and has left many rural health advocates questioning the best ways forward.

The appointment of Ken Wyatt AM as Minister for Indigenous Australians and a member of Cabinet has been widely welcomed, and some rural health advocates are pleased to see an experienced minister, Greg Hunt, remain in the health portfolio. However, others have lamented the loss of Ministers specifically responsible for Indigenous Health and Rural Health.

The Rural Doctors Association of Australia said in a statement it was “very disappointed” that rural health did not have a dedicated portfolio, as it did under the Coalition in its previous term.

Aboriginal health researcher Associate Professor James Ward told Croakey he is optimistic that Minister Hunt will maintain a strong focus on Indigenous health. “Greg has always been reasonable and a very good listener and actions things when you meet with him,” he said.

Ward said Minister Ken Wyatt had shown his ability to get real action on the ground in driving the COAG response to the syphilis outbreak after initial governmental delays lead to its wider spread across affected communities in northern, central and southern Australia.

“Sexual health, mental health and suicide prevention need to be very well supported by the Coalition, given we are in the grip of crisis in all three of those areas right now,” said Ward. “I hope we maintain some of the momentum we have gained with the Coalition over the last while.”

Ward urged the Government to provide effective, ambitious leadership on climate change and to think of generations ahead:

“It would be great if the current Government would think about their great grandkids and their great grandkids. The next seven or 14 generations is what they should be thinking about, not just short term.”

Ward urged the rural health lobby to continue supporting the Aboriginal health sector, and to “stand aside” when opportunities in service delivery arise, to ensure that the ACCHO sector is prioritised.

“Make sure they are on the same page as our peak representative bodies, such as NACCHO, and keep those partnerships very strong and tight over the next little while, as we will need it,” he said.

On a similar note, Aboriginal health advocate Mrs Janine Mohamed, who was one of the MCs at the Hobart conference, also stressed the importance of the wider rural health sector supporting ACCHOs, noting the importance of their work in supporting the cultural determinants of health.

“…advocate for Aboriginal dollars to go to Aboriginal community controlled organisations, whether we are talking about the health sector or legal sector or community sector,” she urged health equity advocates in a presentation in Canberra just a few weeks after the federal election.

Leanne Wells, CEO of the Consumers Health Forum of Australia, advises the rural health sector to work hard on maintaining strong alliances and clear messaging. “As the NGO sector, all we’ve got to trade in are partnerships and ideas, strong alliances, good arguments and good research,” she said.

The CHF is planning to establish a rural consumer health forum to develop a deeper insight into rural health, “so we can strengthen our commentary in that area”.

Rural health advocates faced “a hard slog”, Wells said. “There seems to be very little response or acknowledgement across the board in health that this matters. We’re up against it.”

The contraction of rural and regional media, at the same time as populism and fake news is on the rise, is another factor for rural health advocates to consider.

WIN’s closure of regional TV newsrooms across New South Wales and Queensland is the latest blow to local news across Australia, as Dr Margaret Simons and Gary Dickson wrote recently in Inside Story:

“At the same time as local news in the regions declines, right-wing commentary not watched by most urban Australians is becoming freely available to rural viewers.

The long-term effect of declining local news will be more fractured communities and less national consensus. Increasingly, we can expect to be taken by surprise by the views of our fellow Australians. We should all be concerned.”

When Mark Diamond reflects on why rural health advocacy is not cutting through, he looks back to his own upbringing in a country town, and his career spent in rural communities.

He has come to the conclusion that many country people simply accept their lot:

“I think they have resigned themselves to the fact that they are going to experience less access to healthcare and they have rationalised that in some way.

Therefore they don’t feel compelled to complain about it even though they’re experiencing some of the worst health outcomes of anyone in Australia.

There is not the grassroots movement that this is unacceptable.”

Inspiration from Indi?

Perhaps the grassroots movement that has transformed politics in the once-conservative Victorian electorate of Indi over the past several years offers some wider lessons for rural health advocacy.

Dr Helen Haines, a midwife, nurse and researcher with more than three decades of rural service, was elected as an independent, albeit with a slim margin, after running a values-based campaign with progressive policies on climate action and anti-corruption.

The first independent MP to succeed another independent MP, Haines was selected as Cathy McGowan’s successor in an open, consensus-based process decided by community members.

At the recent Progress 2019 conference in Melbourne, members of the Voices for Indi campaign described their seven-year history in building a grassroots movement based on community-based participatory democracy.

More than than 1,600 people signed on as volunteers and supporters for Haines’s campaign.

Once they had signed up to the campaign’s values – respect, inclusion, diversity, listening,  recognising the power within communities – and undertaken training, they were empowered to develop local messaging and activities as part of the campaign’s philosophy of having “radical trust” in supporters.

The presentations at Progress 2019 suggested the Voices for Indi campaign is likely to bring many benefits for rural health beyond the obvious political representation.

It helped to develop shared values, forged powerful social and community connections, and generated considerable social capital and community development. As suggested by the orange cockatoos that came to symbolise the campaign, many participants found the experience enjoyable.

“Indi is a connected community with three independent wins under its belt. It’s a really exciting time and it’s a great place to be,” one of the campaign team members told the conference.

Haines’s statement about why she was running for election said she had not planned on entering politics but realised that regional communities “rely on people showing up and pitching in”.

She said: “Working in healthcare means you see the very best and worst impacts public policy can make on people’s lives and after decades of working to improve this on a local level, I am ready to take that fight to Canberra.”

The Indi model appears a useful model to gain wider leverage for rural health, says Professor Fran Baum, who was one of the keynote speakers at the Hobart conference.

It also offered a helpful prescription for improving rural health more generally, to shift the focus from service delivery to building cohesive, thriving communities, she said.

Baum suggests that perhaps the Indi story offers a pertinent theme for future rural health conferences: “Creating healthy communities: what does that mean socially, environmentally and economically?”.

Alternatively, conferences in the future may be examining: “Can rural and remote communities survive in an era of climate breakdown?”

Thanks to Mitchell Ward for photographs from the Indi campaign presentation at Progress 2019.


This is the final article in our coverage of the #RuralHealthConf. Its publication was delayed to include analysis of the implications of the federal election for the conference recommendations.

 

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