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To improve rural health, we need to move beyond the hospital focus

The PM is pushing hospitals to centre stage in the health reform debate, but questions are being widely asked about the wisdom of his priorities. Smart politics does not necessarily make for smart policy.

Professor Lesley Barclay, who spent five years as a health services development academic in the NT before taking up a position as director of the Northern Rivers University Department of Rural Health in NSW, is particularly concerned about the impact upon rural health. She writes:

“The Prime Minister’s recent announcement of plans for a national health and hospitals network is keeping much of the public focus and debate centred firmly on hospitals, as if they are the most important agents for health.

There is a downside to this, particularly for rural areas where we need to be developing new models of care that move way beyond the traditional role of the country hospital.

Small rural hospitals were often built by local communities at a time when communication and transport were difficult. Buildings were often paid for by local people who were justifiably proud of their achievement. They were built to standards and designs now out of date using materials such as asbestos – which is often still there.

Many of these hospitals now need major remedial work and are unsafe.

Small country hospitals remain powerfully symbolic however of a community’s achievements. They were built when country GPs came and stayed for life, townspeople were young and country towns still growing. The focus was on treating illness.

Local services cannot provide contemporary standards in acute health services. There are now risks to under resourced acute care or emergency services provided in small towns.

At the same time, we have become too preoccupied with the achievements of acute care and large hospitals. Too many resources are channelled into expensive specialists, technology and drugs and too little effort has gone into rethinking or restructuring services for rural people.

For example, we see increasing avoidable admissions to acute hospitals of elderly people from small rural towns because of drug errors. This has worsened their health, reduced their quality of life and increased unnecessary costs attached to health care.

Large hospitals cannot provide primary care services for conditions such chronic disease, terminal illness or mental health, support for frail aged, mothers and new families. These are all areas where research shows we need to provide better quality local services.

One hundred and thirty birth facilities have closed across rural Australia in recent years without evidence or consistent rationale for this. This has reduced levels of antenatal care, increased rates of expensive intervention at birth and increased numbers of babies being born on the side of the road or in small hospitals no longer staffed to support birth. There are increased costs for families in transport and accommodation in far distant large towns.

Regional hospitals are often creaking at the seams with overloaded beds and clinics, the consequences of unnecessarily exacerbated poorly managed chronic disease. There is no time, staff or continuity of care for prevention or harm minimisation services. We are introducing new risks by not restructuring local care and relying inappropriately on acute regional services.

While regional hospitals offer a range of life saving treatments in an emergency they are expensive and not appropriate for managing chronic illness, problematic for mental health, produce poorer outcomes for normal birth and are not suitable for the terminally ill or frail aged. GPs, skilled nurses, midwives and Aboriginal Health Workers who live locally and operate out of multipurpose clinics provide optimal services for these conditions.

Contemporary health services need to be conceived of differently as a network – not one place. These networks would enable country people to get the best of both worlds.

Networks should be designed around health needs, geography, access to services and providers. This must occur with well informed local leaders participating and representing their community. Links to specialist services support local professionals and are crucial to good networks.  Social support services such as meals on wheels combine with a range of locally employed staff working with GPs, such as nurse practitioners and care attendants, are essential to contemporary rural health systems. They allow people to receive much care locally and stay at home.

Acute hospitals cannot provide long term healing or maximise and promote health. This is not their purpose. Far distant hospitals can be frightening and lonely places to give birth or die. Local care is more economical and satisfying except in acute illness or trauma.

It is long overdue that informed debate helped us create the best and safest model of health care for the 30% of Australians who live in rural and remote Australians areas.”

Comments 2

  1. margo says:

    Does ‘avoidable admissions’ because of ‘drug errors’ refer to problems arising from incorrect prescribing or from patient error? Is this is an example of the need to improve health literacy?

  2. Croakey says:

    Lesley Barclay asked me to post this response on her behalf: Medication errors and adverse drug reactions can occur as a result of errors at each level of the system. The initial prescription by the doctor may be for an inappropriate medication or at an incorrect dose or it may not allow for drug interactions. The pharmacist may make an error in dispensing, not check drug interactions or provide insufficient advice to patient. And as Margo mentions there may be patient error. This includes lack of compliance, lack of understanding and overdosing or under dosing. The cases I am talking about that lead to avoidable admissions are often patient level problems with understanding and insufficient explanation or support with often complicated medication regimes. Solutions are more complex than just patient literacy but better support and systems as well. Home medication review can be particularly helpful for these people.

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