Rural health inequities: less talk, more action

WHILE the rest of Australia prepares for a welcome 12 days of Christmas, New South Wales rural communities and health professionals are preparing submissions against the 12 terms of reference for the inquiry into health outcomes and access to health and hospital services in rural, regional and remote NSW.

Sadly the inquiry has been triggered by some unsavoury media reports (here, here and here). The latest was a 60 Minutes report on Sunday 6 December called Sick and tired.

Preparing submissions is not the usual Advent activity of writing Christmas cards and stuffing stockings but it is certainly important and relevant to all rural health services across Australia.

So, in contrast to my usual light-hearted Christmas opuscules, I shall briefly comment on the 12 terms of reference of the inquiry.

Health outcomes for people living in rural, regional and remote NSW

Surely NSW politicians already know the answer to this question? Why are rural communities and health providers having to run over the same thing over and over? At the federal level there has been intense investment in rural medical schools, relocation and retention grants. Rural communities and clinicians would like to see a similar energy and commitment at a state level.

A comparison of outcomes for patients living in rural, regional and remote NSW compared with other local health districts across metropolitan NSW

Again, NSW Health is the peak organisation that collects and owns these data. What can they expect submissions to show over and above their own data? With the adoption of electronic medical records, NSW Health knows all the diagnoses, all the treatments and expenditure in all their Local Health Districts.

A perusal of the Australian Institute of Health and Welfare reports gives some information on the differences between urban and rural health outcomes. I daresay NSW Health would have even more specialised data.

Therefore, the public should be asking this of the politicians, rather than vice versa.

Access to health and hospital services in rural, regional and remote NSW including service availability, barriers to access and quality of services

NSW Health has the data relating to who they employ and contract to their facilities, so they can see that the towns are poorly staffed and serviced. It is hard to provide quality service when you battle each day to simply offer the basics to as many patients as possible. With more workforce, more time could be spent on each service.

Access and quality makes me think of ambulances arriving at hospitals in full knowledge that there is no medical cover. Why take a patient there and expect miracles from the nurses, instead of doing the right thing and taking the patient to where there is a doctor?

What about patients turning up to small emergency departments in good faith expecting to see a doctor, only to be told that the best they will get is a telephone or video consultation?

It is about time that NSW Health and the politicians be open and honest with rural communities. Please tell us clearly what hospitals have doctors and at what times the doctors are available.

For the hospitals with doctors that suddenly become unofficial referral hospitals for the doctorless hospitals, provide the extra staff and resources needed to take on the extra work.

Patient experience, wait times and quality of care in rural, regional and remote NSW and how it compares with metropolitan NSW

Again, NSW Health have these data already. Why are they wasting time asking us for it again?

An analysis of the planning systems and projections that are used by NSW Health in determining the provision of health services that are to be made available to meet the needs of residents living in rural, regional and remote NSW

Calling all internet hackers and unemployed spies! How is anyone to know the planning systems and projections of NSW Health, let alone analyse them?

We the rural doctors would love to see such data, for it may explain why so many obstetric, surgical and other services have shut in rural NSW hospitals in the past 30 years. And it may explain why our pharmacies are often missing the basics, our equipment is threadbare etc.

An analysis of the capital and recurrent health expenditure in rural, regional and remote NSW in comparison to population growth and relative to metropolitan NSW

Again, NSW Health already has these data.

An examination of the staffing challenges and allocations that exist in rural, regional and remote NSW hospitals and the current strategies and initiatives that NSW Health is undertaking to address them

There appears to be an increasing reliance on agency nurses and locum doctors in rural NSW.

NSW Health has a Settlement Package with the Rural Doctors Association of NSW, which remains reasonably generous for many rural Visiting Medical Officers (VMOs). The Settlement Package, like anything, needs regular review. It would be improved for the doctors in the smallest towns by offering a minimum pay for on-call days, rather than risking sitting around all day without getting called and without getting paid.

NSW Health is often doing deals with doctors and medical corporations outside this package. I know of cases where such deals have displaced doctors from towns. Doing such ad hoc deals also muddies the waters for the bulk of NSW VMOs, as it creates uncertainties about tenure and income. There have been occasions when NSW Health does a deal with a corporate entity to effectively take over a number of towns. Putting all the eggs in one basket may create its own problems.

The current and future provision of ambulance services in rural, regional and remote NSW

An honest discussion about ambulance services is overdue. This is a positive.

The discussion should include taking patients to appropriate facilities, obstructionism when isolated rural doctors are trying to get patients to higher level care and the way ambulance coordinates rosters and call-outs.

The access and availability of oncology treatment in rural, regional and remote NSW

The last thing a patient with cancer wants to do is drive a few hours to a regional centre for 30 minutes of chemotherapy, then drive all the way back again.

All the major NSW regional centres have multidisciplinary oncology services, with only Dubbo lacking radiation oncology (a situation which is soon to be fixed).

Chemotherapy and immunotherapy for cancer is overdue for demystification. What we have achieved in my small town of Coonabarabran should be an example of what can be achieved elsewhere.

The access and availability of palliative care and palliative care services in rural, regional and remote NSW

In my view, palliative care is best delivered by the rural GP and local nurses, who have intimate knowledge of the patient, the patient’s carers and loved ones and the services available in town.

Palliative care is not rocket science. Rural hospitals and rural residential aged care facilities can offer palliative care as well as anywhere else.

An examination of the impact of health and hospital services in rural, regional and remote NSW on indigenous and culturally and linguistically diverse communities

Again, medical and health journals are replete with evidence about such things.

The phrase “closing the gap” has regrettably become part of Australian daily parlance. So, I simply say to the politicians, “just get on with it rather than ask questions”.

Any other related matters

Is this inquiry going to have teeth? Is it going to listen to the right people or simply be an echo-chamber for NSW Health managers?

We are still waiting for these key points of the 2008 Garling Report to be actioned:

“1.73 During the course of this inquiry, I have identified one impediment to good, safe care which infects the whole public hospital system. I liken it to the Great Schism of 1054. It is the breakdown of good working relations between clinicians and management which is very detrimental to patients. It is alienating the most skilled in the medical workforce from service in the public system. If it continues, NSW will risk losing one of the crown jewels of its public hospital system: the engagement of the best and brightest from the professions who are able to provide world-class care in public hospitals free of charge to the patient.

“1.74 So serious is this problem that I have approached it at each level of the public hospital system. At the state-wide level through a Clinical Innovation and Enhancement Agency. At the area level, through an Executive Clinical Director who should be a recognised clinical leader able to speak on behalf of doctors and other clinicians and who is to be consulted by the area chief executive on all matters affecting clinical procedure. At the hospital level by reconnecting clinicians with management through devolving more power from the area chief executive to local managers, including program, stream and unit leaders. At the clinical unit level by involving clinicians (along with allied health professionals and patient representatives) in the re-design of clinical practices and by involving them in the monitoring of all safety and quality of care data for the individual unit or ward.”

After the 2020 of bushfires and COVID-19, we all need to take some time out, relax and regroup before tackling 2021. Merry Christmas to all InSight+ readers!

Dr Aniello Iannuzzi is a Visiting Medical Officer at Coonabarabran District Hospital, a GP, and a Clinical Associate Professor at the University of Sydney and University of New England. He is Chair of the Australian Doctors’ Federation.

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.