Month: July 2018

Note: This piece was published in Croakey, 13 July 2018. My thanks to Melissa Sweet, Croakey Editor.

In his recent article kicking off the series, Gregory critiqued what the Federal Government is calling its Stronger Rural Health Strategy, describing it as a package of rural medical workforce programs.

In this second piece he makes the case for development of a real National Rural Health Strategy – a document about the principles to be agreed and adhered to by governments at all levels (from all sides of politics) and by the rural health sector itself.

Considerable effort will be needed to put such a document in place, and there needs to be a clear distinction between such a Strategy and Federal/State/Territory rural health plans or road maps. But with an over-arching Strategy in place, rural health can be given the national focus and prominence it deserves.

The ‘Stronger Rural Health Strategy’ announced in the May Budget has none of the characteristics of a real national rural health strategy. It is not bipartisan. And in a sector in which the States and Territories do so much, not to mention local government, it is not cross-jurisdictional.

Nor does it involve or commit the rural health sector itself, or make reference to all of the non-health sectors involved with the social and economic determinants of health.

The Budget’s co-option of the term ‘rural health strategy’ muddies the waters and makes it more important to distinguish a strategy from a plan or road map, and all of those from a bundle of programs.

There are several precedents for production of, and adherence to, a true National Rural Health Strategy.

The most recent was the second iteration of Healthy Horizons, endorsed by Health Ministers and the sector for the period 2003-2007. That document was described as “a framework for improving the health of rural, regional and remote Australians”.

It was approved by the Australian Health Ministers’ Advisory Council (AHMAC) and endorsed by Australian Health Ministers. Accountability was built into the framework, with a requirement for progress reports to AHMAC from all jurisdictions and from the sector itself (through the National Rural Health Alliance (NRHA).

In some quarters it is thought to be ambitious, at a time when rural and remote health is said “not be on the agenda”, to conceive of a national strategic document to which all jurisdictions have agreed.

The counter-argument is that when rural health is not a priority is precisely the time when stronger focus and greater commitment from governments should be sought.

Bipartisan support

There are a number of reasons why it is desirable to have bipartisan support for a high level national document on rural and remote health.

1. The existence of such a document would proclaim that the health and well-being of the one-third of Australia’s population who live in rural areas is a matter of importance.
2. An agreed national strategy would ensure that, irrespective of which party is in power, there would be a consistent approach to the management and prioritisation of rural health.
3. An ongoing, settled, national approach to rural health would be a fixed context in which the States and Territories determine their own plans for rural health. This would reduce variability between jurisdictions in the way rural and remote health is treated, and facilitate work to achieve a uniform national approach in related areas such as professional registration and accreditation, and the setting of occupational terms and conditions.
4. A consistent, documented bipartisan approach to rural health provides the policy context in which national organisations concerned with health and well-being (including but not exclusively those in the health sector) can prosper and optimise their contribution to good health.
5. Such an approach provides certainty about the basic principles and approaches to be taken to rural health, which can be used to keep governments, businesses, researchers and health service providers publicly accountable for what they do and what they may fail to do.

Context

The notion of a National Rural Health Strategy needs to be seen in the context of planning arrangements made at other levels. Each State and Territory health jurisdiction produces, from time to time, its own jurisdiction-wide or rural health plan.

Given the disparate electoral and policy cycles in each jurisdiction, these plans have a variety of timelines so that it is not possible to mandate in a national plan that such-and-such an activity will be achieved by such-and-such a date.

The hierarchy of arrangements sees plans for individual jurisdictions, including potentially a federal rural health plan, sitting at a level below the national strategy. Programs, in turn, sit below the plans. (Some people have a preference for the term ‘road map’ instead of ‘plan’.)

The third piece in this series will attempt to embolden the faint-hearted by detailing the style and content of a new, real National Rural Health Strategy.

• The previous Croakey article.
• See the Federal Parliamentary Library overview of the Stronger Rural Health Strategy.

Note: This piece was first published in Croakey, 9 July 2018.

In the Federal Budget in May, the Government announced what it called a Stronger Rural Health Strategy.

It would be very useful to have a national strategy to guide and inform governments and other agencies concerned with the status of health and health services in rural and remote areas.

But this Budget document is not it.

It is a package of programs for rural medical education, many of them reshaped versions of programs that already exist – and with some questions needing to be clarified about exactly what is intended (for instance, how much money will be allocated).

A Federal Budget program cannot, by definition, be a longer-term, national strategic document: the Budget looks forward over only four years; is about the allocation of funds rather than goals and principles; and is not something that can be endorsed by States/Territories and by both sides of politics.

For much of the period between 1991 and 2007, there was a real National Rural Health Strategy, issued by the Health Ministers’ Conference and jointly approved by all health jurisdictions and the sector itself, represented by the National Rural Health Alliance. The most comprehensive and longest-lasting of these was called Healthy Horizons and was in place from 1999 until 2007.

In the first of three pieces for Croakey, I unpack the current Stronger Rural Health Strategy package, make the case for a new bipartisan National Rural Health Strategy, describe its place vis-a-vis health sector ‘road maps’, ‘plans’ and programs, and illustrate what such a document would contain.

Unpacking the Stronger Rural Health Strategy

Senator Bridget McKenzie, Minister for Rural Health, has described the Stronger Rural Health Strategy announced in the May Budget as “the most comprehensive workforce reform package ever produced in Australia” and as “a comprehensive and transformational rural health package over the next 10 years”.

She continued by saying that The Stronger Rural Health Strategy “resets 29 years of incremental regulatory build-up at every stage of the medical workforce supply, including teaching, training and retention”.

Are these claims reasonable, or is the lily being somewhat gilded?

Close scrutiny of publicly available materials about that Strategy suggests that these claims may be exaggerated.

The first thing to say is that where rural and remote health issues are concerned, the Stronger Rural Health Strategy (hereafter SRHS) is not comprehensive. It concerns only health workforce issues. And in almost all respects it concerns medical workforce issues only.

The fact that all of the Department of Health’s workforce programs now fall under the aegis of the Chief Medical Officer is significant. There are now only vague but fond recollections of the time when there was an Office of Rural Health.

In what way the SRHS is ‘transformational’ is not clear to me. The Minister’s emphasis in her Senate speech on the “resetting” of regulation or red tape is curious. The medical workforce is one of the most heavily regulated there is, and neither the profession itself nor the general public seem to have any objection.

The centrepiece of Australia’s medical system for years has been a regulated market and price for the services of GPs. Through the Medicare Benefits Schedule (Medicare, essentially) a floor price is set for their services, irrespective of clinical need, effectiveness or general quality. Competition between increased numbers of vocationally registered GPs does not reduce the price they charge below the level set by the Schedule.

And the public have a strong interest in regulation. Without it there would be no Medicare.

Let’s not forget too that it is the regulation of overseas trained doctors that prevents them for a period from competing with Australian trained clinicians in the cities, and which provides the mainstay (40-60%) of GP services in many rural and remote areas.

Regulation also plays a critical role in establishing and preserving specific rural programs such as those funded through the universities and the Rural (Health) Workforce Agencies.

The next thing to note is that a Budget commitment over 10 years is meaningless given the uncertainties about who will be in government in that period, what their view will be about the importance of rural health, and what their capacity will be to fund essential services like health. Governments will always face the trap of spending too many of the fruits of economic growth for political purposes, mainly through unwise tax cuts.

The Government’s consistent messaging about the SRHS is that it is “a $550 million investment to support improved rural health services”.

Questions abound

Where the $550m comes from is a mystery – and is likely to remain so, given that the Budget papers only deal with the period until 2021-22.

One thing that can be said is that, over 10 years, that’s an average of $55m a year. Given that the primary health care deficit with which people in rural and remote areas have to live has been estimated at over $2 billion each and every year, $55m a year is really not a lot.

It is to be hoped that current and future Australian Governments give more priority to rural and remote health workforce issues than is indicated by $55m a year.

The Budget papers show that the SRHS will be provided with $83.3 million over the five years 2017-18 to 2021-22. The funding over those five years is concentrated in the second and third years (2018-19 and 2019-20) and valued at $150m. In the other three years there are savings against the program, valued in total at about $70m. This surely needs explaining. It would be good to know which of the programs will have reduced funding in the fourth and fifth years.

Of the $150m allocated in total for 2018-19 and 2019-20, only $122m is current expenditure for the Department of Health.

Several elements of the package are augmentations or re-arrangements of existing programs, such as extension of the Rural Health Multidisciplinary Training Program, updating the geographic eligibility criteria for rural bulk billing incentives, amending return of service obligations under bonded medical training programs, and streamlining the GP training arrangements provided through the two Colleges.

From 1 July 2019 the General Practice Rural Incentives Program and the Practice Nurse Incentive Program will be combined and re-named the Workforce Incentive Program. This is just the latest iteration of general practice incentive programs that have existed for at least 25 years. Extension of the program to support nurses, Aboriginal and Torres Strait Islander health professionals and allied health workers is welcome.

Incrementalism

One of the higher profile initiatives in the package is establishment of the Murray-Darling Medical Schools Network, credited with “creating end-to-end medical school programs that take school leavers straight to rural medical schools”.

This is an incremental addition to what has been happening in medical education and training for twenty years, but is not ‘transformational’. The Integrated Rural Training Pipeline for medicine (IRTP) was announced in December 2015.

The Murray-Darling Medical Schools Network will receive $95.4 million over a period not specified in the Budget papers. There will be no additional medical Commonwealth Supported Places (CSPs) in the universities. Rather, 2 percent of the existing CSPs (up to 60) will be subject to competition between university providers, including the new Murray-Darling Network.

The amount allocated to the SRHS includes an extra $84.1m for the Royal Flying Doctor Service, bringing total Commonwealth funding of the RFDS to $327 million over the next four years. (Inclusion of this $84.1 and its extrapolation through to year ten may help explain the difference between the Budget paper’s five-year $83.3m and the headline $550m over ten.)

The continued seriousness of the bottleneck at the Registrar stage of training for general practice is recognised by a couple of means.

From 2021 there will be an additional 100 places for junior doctors in training for rural generalist practice. To provide more registrar positions away from the metropolitan hospitals, the pathways through the RACGP and ACRRM will be ‘rationalised’. There will be a Rural Primary Care Stream and a Private Hospital Stream. Both will be very welcome, with the latter providing salary support for junior doctors working in private hospitals.

Further additions to the number of doctors working in rural areas will come from encouragement to those who currently do not have Vocational Registration (VR) to obtain it by enabling them to directly bill Medicare if they work in a place classified 2-7 in the Modified Monash Model.

Moves are foreshadowed towards the situation in which all bonded medical students will have a three-year bonding period, and there will be some changes to the regulation of their return of service obligation.

Presumably the key selling point of the SRHS – that it “will deliver 3,000 specialist GPs to the regions over the next 10 years” – is based on an estimate of the extra number who will adopt rural practice in order to obtain VR, to acquit return of service obligations, to train in the Rural Generalist Pathway, and/or in response to more closely targeted place-based incentives.

Partly as a response to Health Workforce Australia’s 2014 report that projected health workforce supply and demand through to 2025, there will be a new planning tool for health workforce and services data. It will help the Department to anticipate workforce shortages among professions registered with the Australian Health Practitioner Regulation Agency and tweak incentives and training funding as appropriate.

Overall the SRHS continues the Australian Government’s positive engagement with an issue that is top of the mind for many people: having access to a doctor. It includes some incremental moves down a familiar track but is no more than a partial treatment for the ills of people and communities in rural and remote Australia.

Further explanation needed

However, some of its elements warrant further explanation. For example, one of the SRHS Fact Sheets informs readers that there is to be continued funding for the Australian Primary Health Care Nurses Association and “an independent review of nursing preparation and education”.

Both of these initiatives are welcome but the particular Fact Sheet includes no mention of the words ‘rural’ or ‘remote’ so that inclusion of these elements in the SRHS may be bogus.

Medicine is still front and centre where the Federal Government’s consideration of rural health is concerned, and strong advocacy must continue to try to extend its role to other disciplines, health care settings and health-related sectors, and to topics other than the workforce.

A centrepiece of this advocacy should be work on a new, real National Rural Health Strategy that would be approved by both sides of politics, governments at all levels, and the rural and remote health sector itself.

• See the Federal Parliamentary Library overview of the Stronger Rural Health Strategy.