This piece was first published in Croakey on 5 June 2017. It was edited for Croakey by Jennifer Doggett.
In a political climate where rural health issues are struggling to be heard, the creation of a new role of a National Rural Health Commissioner is a promising move. But will this new position deliver the improvements in access to health care that rural and remote Australians deserve?
In the second of his series of articles for Croakey (read the first one here), former National Rural Health Alliance CEO, Gordon Gregory, discusses the new role and provides two relevant examples of previous attempts to change the focus of government departments.
In this article he argues that, to be effective, this new position needs to be a standalone role, outside of the Department of Health, and with its own independent support staff and resources– a model more like the Mental Health Commission than the current Chief Allied Health Officer. He also highlights the importance of ongoing political support to ensure the position achieves maximum influence.
Gordon Gregory writes:
The Bill to provide for the appointment and functions of a National Rural Health Commissioner (NRHC) is expected to be debated in the Senate between 13-22 June.
All political groupings support it.
Some of the more significant comments from the debate on the Bill in the House of Representatives can be seen in this piece from my blog. And in a piece published on 10 August 2016 (it’s been eleven months since the Election in which the Commissioner was promised) I wrote that, for it to be effective, the NRHC should be modelled on the National Mental Health Commission and not on the Health Department’s Chief Allied Health Officer (CAHO).
Having worked for a long time to help to improve the wellbeing of people in rural and remote areas I am loathe to do anything that might set back an initiative that could help. However, I am concerned about the likely ineffectiveness of the NRHC as it is currently defined.
The Chief Allied Health Officer model
I may be accused of looking a gift horse in the mouth.
My view about what might come to pass is based not only on the known plans for the establishment and role of the NRHC but also from the situation relating to the Chief Allied Health Officer and the (by now) forgotten phenomenon of the Rural and Provincial Affairs work of the Department of Primary Industries and Energy (DPIE).
When the position of Chief Allied Health Officer was announced by then Health Minister Tanya Plibersek in March 2013 it was widely welcomed, in the belief that it would strengthen the role of allied health professionals in health, aged and disability care, lead allied health workforce initiatives, and facilitate better integration with medical and nursing services.
There is little evidence of such developments. Allied health is still the forgotten professional grouping in health policy matters, particularly at the national level.
The limited effectiveness of the CAHO is a structural or systemic issue, certainly not one attributable to the personnel involved. The position as Chief Allied Health Officer was allocated to an already-busy Deputy Secretary in the Department. The Department has reported that, in the role, the Deputy Secretary/CAHO has engaged closely with allied health stakeholders through a number of speaking engagements at allied health meetings.
There is no reference to the sort of work expected of the NRHC, including providing advice to the Minister, being involved in policy development and workforce distribution, and pro-actively strengthening relationships across the professions.
Lessons from DPIE
Turning now to earlier evidence. Thirty years ago DPIE was an industry Department, concerned with the critical issues relating to productive inputs, natural resources, terms of trade, and export and domestic markets for the products of its industries. Today’s equivalent Department still is:
“The Department of Agriculture and Water Resources develops and implements policies and programmes to ensure Australia’s agriculture, fisheries, food and forestry industries remain competitive, profitable and sustainable.” (from the DAWR website)
But for a brief period from 1985 DPIE had some formal carriage of policies and programs relating to the people in rural areas – not just as human resources necessary for production but as individuals and communities whose welfare was affected by the policies and regulation affecting primary industries.
DPIE’s work on what was then called Rural and Provincial Affairs was concerned with the human and community consequences of what was happening with agricultural, forestry, fishing and resource extraction (mining) sectors of the economy. What might normally have been thought of as ‘unintended human consequences’ of industry policy became, albeit in modest form, one of the arbiters of what industry policy should be.
The special Unit established in the Department managed information programs for rural people, including farm families, on welfare, transport and educational programs. Its staff were involved as leaders in inter-Departmental work on such things as rural education, health, transport, women’s affairs, local government and environmental protection.
To the extent that they succeeded at all these endeavours were dependent on leadership and support from the Prime Minister of the day and his Primary Industries and Energy Minister. Following personnel changes in those key positions, within five years the Department was able to return – like droplets of gallium recombining into one perfectly-shaped drop – to its natural state as a hard-nosed, economic industry agency
I mean no disrespect to the politicians and public servants who oversaw or permitted that return to a normal state of affairs. Australian Government Departments have plenty to do. The Administrative Arrangements Orders mandate the areas they are required to cover. Their staff are busy. Inter-departmental collaboration takes time, energy and strong political commitment.
Impressive leadership
The leadership currently being provided for the National Rural Health Commissioner is impressive. In fact it sometimes seems as if the Assistant Minister for Health, David Gillespie, and peak bodies in the rural and remote health sector think about little else.
But if it is modelled on the Chief Allied Health Officer it will fail. Giving the additional responsibility as Rural Health Commissioner to a Deputy Secretary of the Department of Health would mean that little would change: he or she has little capacity for extra work.
So at the very least it must be a new, stand-alone position. If it is a position within the Department of Health two issues of concern will arise. The first is the resources at the disposal of the Commissioner. Second is the question of their independence. The Member for Indi Cathy McGowan was surely right when, in the debate in the Reps., she said she could not accept that a person working in the Health Department would be ‘independent’.
The all-Party all-sector enthusiasm for the NRHC initiative is based on an assumption that it will mean valuable, sustained and effective change in rural and remote health.
The need for change
And things do need to change. The special needs of rural and remote health are not high on the Government’s or the Health Department’s agenda. There is no longer a Rural Health Branch in the Department. The Rural Sub-Committee of the Australian Health Ministers’ Advisory Council no longer meets. There has been no contemporary, updated National Rural Health Strategy and Plan since 2011. The Minister, David Gillespie, no longer has the word ‘rural’ in his portfolio title.
All of this can and should be put right with the establishment of a Rural Health Commission, not a Commissioner.
To be effective it needs staff and other resources. It could be modelled on the Mental Health Commission, with a requirement to report to Parliament and the public. The amendment moved by Cathy McGowan for an annual report to Parliament was accepted in the Reps and is a critical improvement.
Numerous expectations
The numerous and extensive expectations of the NRHC have already been listed by the Government (these are all from speeches and/or Releases from Dr Gillespie):
- the first and most pressing duty of the RHC will be to address the issue of the medical workforce and coordinate with all the various stakeholders, which are numerous, in the development of a Rural Generalist Pathway;
- the Commissioner will provide advice in relation to rural health beyond the Pathway;
- the RHC will have to be involved in policy development and championing causes;
- the needs of nursing, dental health, pharmacy, Indigenous health, mental health, midwifery, occupational therapy, physical therapy and other allied health stakeholders will also be considered;
- the Commissioner will be a member of the Workforce Distribution Working Group and could use the group to take advice on other of the Commissioner’s functions;
- the Commissioner will be a member of, and can draw on the advice of, the Rural Stakeholder Roundtable;
- the Commissioner will provide advice in relation to rural health to the Minister responsible for rural health on matters relating to rural health reform;
- in order to help address the economic and social determinants of health the Commissioner will form and strengthen relationships across the professions and for all the communities; and.
- the Commissioner will be an independent advocate, giving the Government frank advice on regional and rural health reform and representing the needs and rights of regional, rural and remote Australia
It could be exciting times for rural and remote health, with a real prospect of having equivalent health for people in those areas very soon.
But the right structure, appointee and continued political support are essential for the National Rural Health Commissioner to play a leading role in the improvements that need to be made.
This is the second in Gordon Gregory’s ongoing series of articles for Croakey (read the first one here)