Three decades ago, in late 1990, an officer of the Commonwealth Department of Health and Community Services travelled from Canberra to Gundagai to meet with eminent rural GP Paul Mara.
Steve Catling was a UK civil servant on exchange in the Department. It was the first week of his placement, so who knows what he thought of the curious countryside through which he passed.
After his return from the trip Steve famously said to colleagues in the Department that the only solution to Australia’s rural health problems was to move everyone to the cities. That view did not stop him from working hard to help manage the 1st National Rural Health Conference in Toowoomba that took place a couple of months later (Feb. 1991).
Paul Mara chaired the Agenda Forming Committee for that conference and in that capacity had oversight of a draft prepared by Commonwealth, State and Territory officials of the very first National Rural Health Strategy. It was discussed, amended and adopted by those who attended the conference.
One of the outcomes from Toowoomba was the conversion of the Conference Committee to what was called “an ongoing advisory group on rural health”. That became the National Rural Health Alliance (NRHA).
The purpose of the NRHA, then and now, has been to challenge the view that the only solution to the nation’s rural health problem is to move everyone to the cities. It is possible, goes the argument, that by various means people living in rural and remote areas can be provided with good access to health services which gives them equity if not equality with those living in the major cities.
Thus it is that the NRHA promotes action to have health services in rural areas that are fit for purpose for such areas. This quite often requires changes to financial, regulatory and workforce arrangements compared with those that apply in metropolitan areas.
But how important are improvements to health service access compared with, say, regional development in non-metropolitan areas and the demographic change that results?
In working towards better (more equal) health for people who live in rural or remote areas it doesn’t take long to realise that what matters is not a person’s relationship with health services as much as their educational and employment status, their social and cultural background, and their genetic make-up.
This is the stuff of a social determinants approach to health – one that sees health services narrowly defined as being little more than repair shops:
Except for a few clinical preventive services, most hospitals and physician offices are repair shops, trying to correct the damage of causes collectively denoted ‘social determinants of health’. Donald Berwick, The Moral Determinants of Health, JAMA Network (on line), June 12 2020.
Towards the end of my time with the NRHA, Martin Laverty (at that time CEO of the RFDS) led work to bring agencies together into a social determinants of health alliance. That group pointed out that, in Australia, a multi-party Senate Committee had unanimously recommended that the Government should adopt the recommendations from the World Health Organisation’s Commission on Social Determinants of Health.
Nothing has happened. The distribution of wealth in Australia has worsened. Over a million children are living in poverty.
The Marmot Review published in the UK in 2010 asserted that work towards six objectives would reduce overall health inequalities:
- Give every child the best start in life
- Enable all children, young people and adults to maximise their capabilities and have control over their lives
- Create fair employment and good work for all
- Ensure healthy standard of living for all
- Create and develop healthy and sustainable places and communities
- Strengthen the role and impact of ill-health prevention.
So it is clear why the NRHA has to work on such an enormously wide range of matters, which some have interpreted as having the organisation skate on thin ice. Falling through has usually been avoided thanks to the fact that the NRHA is such an inherently good idea that it has proved feasible to enlist the support of experts in particular topics to join with it in its work.
The Regional Australia Institute reported this week that regional centres attracted more people aged 20-35 than the capital cities during the last two Census periods. While 180,000 millennials moved to capital cities between 2011 and 2016, more than 207,000 moved between the regions, resulting in a net inflow to regional centres of 65,204 people. From 2006-2011, this number was 70,493.
In total 1.2 million people moved to and around areas outside the capital cities between 2011 and 2016. The places concerned included Cairns, Toowoomba, Ballarat, Maitland, Bendigo and Lake Macquarie. (The big movers: understanding population mobility in regional Australia, Kylie Bourne et al, Regional Australia Institute, June 2020.)
Overall, the population of regional cities with more than 50,000 people grew 7.8 per cent, industry and service hubs with more than 15,000 residents grew at 3.3 per cent, and smaller regional areas increased 1.6 per cent. On top of this existing trend, the COVID pandemic has strengthened people’s belief that location may not be a barrier to where they choose to work.
So which is more important, telehealth or demographic change?
As a result of COVID-19 there have been very welcome extensions of Medicare benefits for telehealth consultations – the scale of which has the heads of rural health advocates spinning. But it may be that the kind of demographic changes reported by the RAI will do even more in the long run to deliver health equity to rural areas. The former improve services in the repair shop. But demographic changes are producing more central places in rural areas with the population and service characteristics necessary to stave off, for some, the time when repairs are needed.
But the real answer is both: the ice looks thick enough for a twirl.