National Rural Health Commissioner: Putting the rural health agenda back on track
Dr Ayman Shenouda
A rural champion
A visit this week to Wagga from our National Rural Health Commissioner Professor Paul Worley provided a great chance to work through some of our highest rural health priorities.
This new champion for rural patients is exactly what we needed.
He fits the job description well – independent, impartial and “a fearless champion” for rural health. He also has alongside him a strong rural health sector full of ideas for building a strong Australian rural health system.
Getting the agenda back on track
Rural patients are finally getting the focus they deserve and this is our chance to get the rural health agenda back on track.
I think we finally have the policy settings in place for this to occur. But it all has to be orchestrated in a way that sees very specific locational needs acknowledged and addressed.
This is where the new rural commissioner role comes in. We all have a key role here. There’s still a great deal of work which now needs to occur to ensure every instrument in this vital ensemble can be fully utilised.
It is those featured instruments – whether string, woodwind, brass or percussion – each with its own unique qualities that really need to shine. These are the ones that fill in a critical gap and vital if we are going to provide a performance worthy of rural Australians.
National Rural Generalist Pathway
The first task is the National Rural Generalist Pathway.
If we are to get this policy right we will need a broad policy lens with a commitment to needs-based planning encompassing all disciplines.
We know that a sustainable health workforce solution for rural Australia needs to factor in flexibility in policy design. By this, I mean allowing for an optimal skill mix which is capable of meeting the very specific service needs of that community.
Local needs analysis
It is clear that we need reforms that can address maldistribution to meet growing service demand. But to do this we need to look at what is really happening in these communities.
Skills planning through a rural generalist pathway solution must, therefore, encompass a much broader skill mapping exercise. This needs to be steered toward more integrated care and with a focus on the full multidisciplinary skill mix required to keep those services going.
We need to find ways to capture current skill depth so that this can be prioritised better in policy. Reinforcing the importance of primary care and coordination of care so that the policies can follow. But really plotting that essential skill mix required to support rural models of care.
Future supply and demand (against need)
It is about having that critical mass of health professionals to achieve a sustainable service environment.
This not only lifts constraints enabling more equitable access to services but creates a way to mobilise and build on peer support. In turn, reducing burn-out by formalising mechanisms for peer support-support networks. It provides safer working hours and leaves room for internal backfill for relief, as well as professional development or space to take on a supervising role.
There’s been plenty of workforce planning occurring – PHNs, LHNs, and RHWAs – but we lack that common formula.
No-one can see at a national level where the true hotspots are. We need to establish what constitutes a minimum workforce requirement or mix for a particular population size and then apply that across the country.
Matching and forecasting the needs is complex but we have evidence-based approaches to estimating health workforce demand. HWA did years of work around it. I think we must clarify this area of workforce policy as a first key step.
Once we have this formula then we’ll see a situation where training investment meets demand.
There is just not enough aligning in terms of training pathways with workforce planning. This is vital as you can’t have a situation where you have three GP anaesthetists and no GP-obstetrician.
This level of planning would also help in terms of succession planning and reassure those committing to these pathways that there is or will be a position for them. It provides a planned career pathway for them.
Broad skill depth
Broad skill depth is vital to addressing patient need in rural communities. We need to find a way to embed in workforce policy those skills most relied on in meeting this need.
I think the discussion is also broader than the training pathway itself. We have to have an equal focus on the requirements of the existing workforce in meeting shifting community need.
Training solutions need to enable private community-based practice. We really need to ensure we encompass a range of approaches factoring both procedural and non-procedural skills if we are going to align closely to need.
If we support the full skillset required then we are closer to reflecting within the training the full scope of skills practised in rural general practice to meet community needs. This is how we can ensure we produce the next generation of doctors with the skills needed to provide both primary and secondary care.
Past policies have had an impact on both recruitment and retention. It all comes back to securing that critical mass (of students). Early exposure which can establish that community connection early which can continue through to intern, prevocational and vocational training years.
We’ve always said that we need to invest in more localised training solutions to provide for that community connection and rebuild a teaching culture. The hubs are well positioned to facilitate that vital community connection and link the various stages of training in a rural setting across the full training continuum.
The training hubs provide that essential framework now but it is about facilitating those vital partnerships. This is how we can structure training against local healthcare need and service construct and build in those supportive factors so early exposure can be a positive experience.
Nurture rural intention
We need to nurture rural intention through targeted incentives and sufficient rural exposure strategies.
A strong commitment to rural should come with benefits. Capture those wanting to pursue rural through a nurtured pathway and supports which include an investment in mentoring. Truly support RMOs skills and career path aspirations and reinvesting in these years by getting back the PGPPP in its true form.
Newly developed policy offering primary care rotations through the new rural community-based interns is certainly acknowledged but it is a minimised model which really needs to be expanded.
Vertical continuity over time
Focusing more effort on areas that provide both a training benefit and meet a community health need is a way to secure an enduring rural benefit. Realising that a focus on the full multidisciplinary team is key to providing more integrated and improved patient-care strategies.
Building this capacity through vertical integration of teaching and learning which promotes shared responsibilities. It’s that continuity that is needed most – vertical continuity over time to allow for varied exposure which results in the more resilient doctor.
Flexibility is needed to ensure training reflects the local service context with an equal focus on community-based training. It helps develop that understanding of optimal care pathways providing continuity of care and a collaborative integrated care approach.
Team and teaching culture
Developing a strong team culture early has to also be a key focus. Those working in rural Australia know that it takes a dedicated team and an enduring local commitment to tackling the many challenges in delivering regional, rural and remote healthcare.
We need to ensure more exposure to multidisciplinary team environments as well as enabling hospital and community partnerships through supportive policy. This is where the pathway solution has to extend beyond a focus solely on medicine.
Improved support for supervisors has never had the policy focus it deserves. We need to increase the teaching capacity of rural communities while minimising the impact of burnout. Practice viability is a major consideration here.
All these factors need to be considered in terms of ensuring a rural GP can take on a training or teaching role. Succession planning and providing that easy entry, gracious exit is key and would lift the load for many already overcommitted.
A more sustainable future
In designing rural policies which can provide a more sustainable future, the focus clearly has to come back to addressing health disparities between rural and urban Australians. A resilient multi-skilled generalist workforce capable of meeting current patient need now and into the future is all part of meeting that key requirement.
We really need to capitalise on the policy settings we already have in place. The strong planning role of the PHNs and LHNs in identifying local level need. The facilitation role of the new training hubs in ensuring a more positive rural training experience. Existing strong College pathways and well-developed rural skills training program with inter-professional partnerships to build from.
We now have that vital role in the National Rural Health Commissioner to ensure a more coordinated national policy and planning effort can occur. We’re well on our way in putting the rural health agenda back on track ensuring lasting change for rural Australians.
Source: RACGP 2014. New approaches to integrated rural training for medical practitioners. Final Report. Available at: https://www.racgp.org.au/download/Documents/Rural/nrffinalreport.pdf
Dr Ayman Shenouda