People, Places, Possibilities…
WOW – what a massive conference! Thank you to the staff of the National Rural Health Alliance (NHRA) for their hard work in making it such a success. This post is my attempt at summarising just a few of the people, places and possibilities discussed in Darwin over the past few days at the conference of the National Rural Health Alliance (NRHA). I can’t possibly mention every person or speaker, suffice to say that there were 17 different (and excellent) keynote speakers, not to mention the multiple concurrent sessions each day. For more information, the 2015 National Rural Health Conference (NRHC) program can be found here. Croakey, the Crikey Health Blog is also a good place to look for a summary of activity at the #ruralhealthconf.
Some of the main themes that I picked up on were the importance of taking each person and community in their context, the massive impact of the social, economic and cultural determinants of health on outcomes, building on sustainable telehealth, and the self-efficacy and resilience of regional, rural & remote health professionals.
Someone tweeted a few of us during the conference to point out that rural areas received “vast extra funding” for health programs and that health professionals work just as hard in “working class” areas. From my perspective, we at the NRHA conference are not suggesting that regional, rural or remote health professionals or communities are better than or more worthy of funding than others, however there are known clear disparities between urban and regional/rural/remote areas that require attention. There are also major ongoing difficulties in attracting and retaining the health professionals with the required broad generalist skill-set to regional/rural/remote Australian communities. This is why there is often such a focus on regional/rural/remote health. So here we are…
We flew into Darwin on Saturday 23rd May and were treated with an outdoor opera and fireworks display at the Waterfront that night. On Sunday, Dave Townsend (@futuregp) lead an interactive pre-conference workshop, “The rural health guide to social media: learn how to survive and thrive online”. I helped out at this, apparently as a “power” user, along with the lovely Alison Fairleigh (@AlisonFairleigh) and Dr. Gerry Considine (@ruralflyingdoc). The workshop was very well-attended and after an overview of the what, why and how, we divided into four groups to debate social media safety issues, as well as whether social media is efficient, effective and reliable for transfer of information. Sometimes the wading through the vast quantity of information online can be likened to “trying to drink from the firehose”, and Dave suggested that we use “lists” in Twitter to aid with this. He also introduced us to some very useful applications like Buffer or Hootsuite, to manage multiple different social media accounts and schedule tweets, as well as Feedly to manage following multiple blogs, news sites and other RSS feeds. The workshop finished with the establishment of a closed Facebook group to continue the discussion, ideas and learning during and after the conference.
At the opening plenary on Sunday afternoon, Nadine and Tony performed a haert-felt welcome to country on behalf of the Larrakia nation. Charlie King was introduced as our very capable master of ceremonies for the conference, followed by a welcome from the Lord Mayor of Darwin, Katrina Fong Lim.
I was thoroughly impressed by the eloquent and inspiring introduction from 2014 NT Australian of the Year, Shellie Morris, whose grandmother is from the stolen generation. Shellie has been teaching through song for 17 years and can speak in over 14 different Indigenous Australian languages. She encouraged all of the health professionals in the room by repeating “you are valued, you are important”. She wanted us to value the work that we did, and emphasised that “one life you change can change a thousand lives”. After her speech, Shellie joined with two other performers to sing, including an original version of “My Island Home” in the traditional Indigenous Australian language of its author. The conference was then officially opened by the Northern Territory Minister for Health, Jonathon Elferink MLA. Minister Elferink highlighted that what we do is so much a part of our identity, and this is often the second question people ask when first meeting. He asked, “what is your purpose or passion in life”? He also touched on the importance of the social determinants of health which became quite a theme throughout the conference.
Senator Fiona Nash, Assistant Health Minister then addressed the auditorium. Rural health is close to her heart, with a family farm in central NSW, and a mum who was a GP. She discussed aiming for the “right doctors with the right skills in the right places”. Senator Nash also discussed some of the recent federal budget announcements. She explained how fixing the electronic health system is of great importance, as well as trialling an opt-out system. She stated that her department is addressing the fragmented dental system in regional, rural and remote areas, and expanding MBS listings for telehealth. One of the main changes that Senator Nash discussed was the change from the Australia Standard Geographical Classification system to Modified Monash Model for administering programs and allocating funding, for example the General Practice Rural Incentive Payments. This was labelled as a fairer and more common-sense method for implementation based on known data. Senator Nash also touched upon the disappoinmtnet felt by many regarding the loss of the Prevocational General Practice Placement Program (PGPPP) for early junior doctor exposure to rural practice.
Our first keynote speaker was Dr. Carole Reeve from the Centre for Remote Health at Flinders University. Dr. Reeve discussed the delivery of “fair care” and the socio-economic determinants of health were again highlighted, with clear data on increased morbidity and mortality with increasing rurality and remoteness. The circumstances in which we live and work have a huge impact on our life expectancy and productivity. People in regional, rural and remote areas often face poor access and associated delays in diagnosis and treatment, compared to their urban counterparts. However, averages in life expectancy disguise the true figures and their large range. Dr. Reeve stated that despite increasing interest in epigenetics, “for most of us, our post code has a greater impact than our genetic code” on our health. Dr. Reeve fleshed out some of the issues with equity in our health system and the “inverse care” phenomenon, that those who access care are often the least in need.
Dr. Reeve built on this, by asking “why treat people’s illnesses without treating what made them sick in the first place?” There is clear data on increasing multimorbidity with increasing socioeconomic disadvantage. We need to adapt successful public health programs to local areas with minimally disruptive medicine, adding “partnerships” as the 4th P.
Just prior to the welcome reception, NRHA awards and scholarships were presented by Tim Kelly and Ray Taylor. Dr. Kelly spoke on the challenge of having national consistency at the same time as local adaptability and the “slow burn’ to transfer information for increased accessibility, sustainability and effectiveness in health care delivery.
Monday 25th May 2015, Day 1
Megan Davis, Director, Indigenous Law Centre, UNSW spoke on “An international and domestic law perspective on the health and wellbeing of Australia’s Aboriginal and Torres Strait Islander people”. Megan pointed out the link between recognition and improvement in health & wellbeing. She reminded us of some modern history, and that compulsory segregation & the White Australia policy were active until the 1970s. Megan encouraged us to return self-determination and community control to the vernacular, and defined “weak” versus “strong” recognition of Aboriginal and Torres Strait Islander peoples in the Austrailan Constitution. As well all know, actions speak louder than words, but having the conversation is often the first hurdle.
David Butt, CEO of the National Mental Health Commission spoke about how well our current health system is supporting people in regional, rural and remote Australia. Health disparities persist between regional, rural & remote areas compared to urban areas. Access issues continue to be a huge problem, and mental health issues in particular are more prevalent in regional, rural and remote Australia, including increased suicide rates. He implored government for a re-investment in primary care to save healthcare dollars and improve health outcomes. The social determinants of health was again raised as an important issue. Change starts with us. The Australian government can act for change when communities have a collective voice, which was a point of view echoed by Amanda Vanstone later in the conference.
Dr Stephanie Trust, Medical Director and GP at Kimberley Aboriginal Medical Services Council spoke on the challenge of high quality care that is reflective of community need. She recalled her own experiences growing up, knowing her parents were in the Stolen Generation and the generational trauma attached to this. Dr. Trust encouraged us all to be encouraging of our children, whatever background they have, that they can achieve their goals, eg to be a doctor, nurse, pharmacist etc. She recalled the challenges she personally had in dealing with “the tyranny of low expectation” and discrimination as an Aboriginal person, and pushed for training in cultural safety and competence as well as the socioeconomic determinants of health. Following this, Warren Snowdon MP, Shadow Parliamentary Secretary for External Territories, Indigenous Affairs and Northern Australia had only a brief opportunity to address the audience. He spoke of the long way that Australia has to go in addressing human rights in our own country, and that all health professional can and should take on a political (advocacy) role.
Concurrent session A1 focussed on motivation for rural practice with presentations from Narelle Campbell, Vivian Isaac (regarding the FRAME Study), Marie Herd and Greg Mundy (from Rural Health Workforce Australia on #MillenialsGoRural). Vivian Isaac showed us that those who have a rural background, and those who are more self-efficient tended to have more motivation to “go rural”.
I was also interested to discover that I am considered to be a “Millenial”, a term that I had not yet heard. With good humour, Greg Mundy presented how there is a new generation of health professionals coming through the ranks, and we need to adapt to this generations’s views in order to ensure a proportion of them will choose to become rural practitioners. Afterall, over 45% of the Australian workforce will be made up of Millenials by the year 2020.
John Wakerman, Assistant Dean, Flinders Northern Territory delivered a talk on research excellence & the new Modified Monash Model as an example of research informing policy. Bruce Bonyhady, Chair of the National Disability Insurance Agency detailed the history of the National Disability Insurance Scheme and its challenges and opportunities going ahead. Dr Mark Wenitong, Senior Medical Officer, Apunipima Cape York Health Council presented the rural and remote Aboriginal and Torres Strait Islander health narrative. He pointed out that we can’t disinvest in remote Australia, because that is Australia! In the discussion of life expectancy data and attempts at closing the gap, Dr. Wenitong said that a focus on risk factor management over-simplifies things and ignores the social determinants of health, epigenetics, the poverty trap, poor food security, economics and adverse childhood experiences, amongst other complex factors. Self-determination and empowerment were again felt to be extremely important to make lasting change in the health of Australia’s Indigenous population.
Concurrent session B1 was about the latest news in medical education. Tarun Sen Gupta spoke on some successes of the Queensland Rural Generalist Pathway, and John Togno on workplace-based assessment and the use of simple and cheap technology for off-site assessment. Emma Kennedy described the Flinders Northern Territory medical program and the need to be flexible for sustainable course delivery. Teresa O’Connor spoke on integrated rural placements to maximise student learning, and finally Dr Jenny May discussed the broad scope of GP practice in rural & remote Australia.
That night there was the gala dinner for the conference, which was entitled “A Taste of the Tropics”. An energetic live band fuelled the dance floor antics for many. It was lovely to have the opportunity to meet and mingle with people from all walks of life, from all over Australia, with different rural health roles. I think however, that some misinterpreted the dress code, ‘tropical rig’…
Tuesday 26th May 2015, Day 2
Amanda Vanstone, Chair of the Royal Flying Doctor Service explained that the RFDS is so much more than emergency retrievals; it is flying generalist health care, with the admirable aim of delivering the “finest care to the furthest corner”. It is sad to hear that the mortality rate is 35% higher in rural compared to metropolitan Australia. She pointed out that the RFDS has the biggest primary care “waiting room” in Australia, with about 40 GP & primary care clinics running daily. The RFDS assists with overcoming geographical and remoteness barriers. This is hugely important, as all Australians deserve access to high quality healthcare, wherever they may be.
Kathy Burns, Artistic Director of Barkly Regional Arts presented the multiple exciting projects they are working on, including music, story plates, painting, dance and healing through video documentaries to name just a few. She suggested that we all need to slow down & connect. “Let dis be light” sounds like a wonderful program that Barkley Arts are currently running, in order to shine a light on people with disabilities. Arts & health really can align; take a look at desertharmonyfestival.com. Another aspect of the NHRA conference was the poetry and photo competition – well done to everyone for their wonderful entries.
Lindsay Cane, Chief Executive Officer of Royal Far West charity in NSW then spoke about “the country charity in the city”, established in 1924. They have had to adapt over time to focus on different disorders which were most prevalent at different times – from congenital deformities to polio, and now to more of a focus on mental health or learning disorders. Their aim is to assist those children who may have otherwise “fallen through the cracks” in our health system. Hopefully this sort of charity can be expanded to other areas in Australia.
Dr. Alan Cass, Kidney Specialist & Director, Menzies School of Health Research spoke about research in remote Australia, and doing what really matters in our communities. With a 75% higher risk of markers of early kidney disease for babies of low birth weight, we need to ensure food security. He demonstrated how we are failing in this at the current time, by showing a photo of an expensive ($6.50) mouldy head of lettuce in a remote town, and comparing this to a fresh, affordabe ($1) head of lettuce in a city Coles supermarket. Prevention is better than cure. It costs $80-100,000/year to keep someone in renal dialysis. Clearly, we need to work harder on prevention.
Bronte Martin, Nursing Director at the National Critical Care and Trauma Response Centre gave an engaging talk on their disaster-response training and team based at Royal Darwin Hospital. They have an impressive 25 tonnes of equipment ready to go within 12 hours, to sustain a 60-bed field hospital for 14 days. Bronte highlighted the synergy between rural and remote health & disaster response work, where clinicians need to be highly skilled, independent, with a broad generalist focus, and flexible in a resource-poor environment.
Concurrent session C8 was entitled “Sexual and Reproductive Health”. Lisa Bourke, Rural Sociologist talked about her research into rural young people’s perspectives of sexual health. It was interesting to hear the findings of her focus groups, and the dichotomous judgements made by the youths invovlved, e.g. if another person was “dirty” or “clean”. Older respondents, GLBTIQ respondents and women were generally more comfortable having the conversation. However, she found that young people wanted more information from health professionals about safe sex, sexualy transmitted infections (STIs), and the like. She suggested that we need more youth-friendly GP clinics available for young people to access.
Ingrid Rowlands, School of Public Health, University of Queensland, spoke on rural women seeking health information online. She presented data from the Australian Longitudinal Study on Women’s Health (ALSWH). This study has collected information about women across the lifespan, with the aim of informing government & influencing policy. They have found that around 50% of people go online to seek health information – before or after seeing a doctor. It was also found that the major sources of health information for these women was their doctor, their family, and the internet.
Jill Davidson, the CEO of SHine SA talked about using technology to improve health indicators & to improve access for young South Australians, with the example of the online chlamydia initiative, Get Checked Now. As a side note, she encouraged us to look around the room – there were only 2 guys out of about 40 people in total in the room. Jill pointed out how sexual health is important to guys AND girls!
Genevieve Dally, Registered Nurse at the Family Planning Welfare Association of Northern Territory Inc. presented “I’m here for my women’s health check up” – health promotion in the context of cervical screening. She explained that with the introduction of the National Cervical Screening Program (with biennial screening in ages 18-70), in 1991, there was a 50% reduction in cervical cancer. Her community has high rates of STIs and unplanned pregnancy, so she has found that these appointments are a good chance to combine cervical screening with full women’s health checks. She therefore posed the question, “what will happen with the upcoming change of cervical screening to 5-yearly checks”? Possibly, there will be less STI screening, preconception or contraception counselling, breast checks, etc. But of course money will be saved, so we then need to consider where this will be directed – perhaps a good area could be addition of new MBS item numbers for comprehensive sexual health checks, or similar.
The Tuesday afternoon Keynote speakers addressed the nutrition situation in the Asia-Pacific region. And how there are still major problems with malnutrition & high maternal mortality rates, resulting in many childhood developmental issues. Tuesday afternoon concurrent session D4, was entitled “Health training that works”. Dr. Rod Omond, Northern Territory representative on the RACGP National Rural Faculty (NRF) board presented on multidisciplinary rural training hubs – partnerships for sustainable rural training.
A few of the points raised from the NRF’s research paper were the need for:
– a broad generalist skills focus
– a focus on community need
– flexible training with multiple entry & exit points (including allowing for established GPs to upskill to meet community need)
– rural training integrated throughout medical training
– caution not to value certain skills over others
– building on existing training networks and expertise (e.g. rural clinical schools)
– multidisciplinary rural training hubs to help address both recruitment and retention aims, to nurture rural intention & support the existing rural workforce
Wednesday 27th May 2015, Day 3
The final day of the conference kicked off with keynotes focussing on the broad issues of economics, tax policy and reform, as well as techology to support regional, rural and remote communities.
Julian Disney , Director of the Social Justice Project at the Unirversity of NSW discussed the need to build on regional centres to have flow-on positive effects for rural and remote areas, increasing access to services closer to home. It was suggested that the geographic distribution of poverty in Australia is influenced by distortions in government policy which aggregate people into urban areas. Perhaps we need to be reminded that we need our rural communities, after all, where would we be without our farmers?
Another topic broached in the plenary was the need to build on technology and technology infrastructure for telehealth. However, many in the audience were concerned that we also needed to recognise the limitations of telehealth, keeping in mind that it doesn’t suit all situations or people. Rural people still deserve access to face-to-face health professionals, as well as an improved, sustainable and widely accessible eHealth system.
Concurrent session E3 was entitled “Overcoming workforce shortages”. Chris Mitchell of Health Workforce QLD spoke on “Doctors in remote QLD: they don’t stay, do they?” He highlighted how retention aims were not being met in remote Queensland, with high turnover and poor retention after only 2 years. Most agree that this sort of discontinuity is not healthy for communities. Deborah Russell of the Centre of Research Excellence in Rural and Remote Primary Health Care presented research data on retention aims of a range of rural and remote healthcare workers. There were similar outcomes of poor retention for allied health professionals in rural and remote areas, as for doctors. Factors that impacted upon retention included remoteness and population size, professional factors like being procedural or non-procedural, having geographical restrictions and return-of-service obligations (which acheived only short term retention, not long term retention), and Australian versus overseas graduates (Australian graduates were found to be more likely to stay in rural or remote areas in the long term).
The final plenary included an energentic a performance from the African Gospel Choir, an energetic auction and another three keynote speeches. John Paterson spoke on the impact of current funding policies on the provision of Aboriginal primary health care, again highlighting the importance of the socioeconomic determinants of health. Jacki Schirmer, Senior Research Fellow at the University of Canberra presented on “Creating healthy rural places”. She says that we need to be more holistic, and prioritise place-based (community-focused) interventions. She echoed Dr. Reeve’s idea of the need for partnership to be the “4th P”, as rural communities are enthusiastic, but have limited resources to make positive health changes.
Stephen Jones, Shadow Assistant Federal Minister for Health presented Labour’s approach to regional and remote health, followed by a brief video message from Prime Minister Tony Abbott. Mr. Jones discussed a desire to focus more on harm reduction relating to illicit drug use and abuse in Australia, as well as working harder on food security for our rural communities. Mr. Jones talked of building a rural training pipeline extending from early health and medical student days through to the established rural health workforce. He said that we need to get the balance right between primary care, which is the most efficient and effective part of the health system, and acute and hopsital-based care. Mr. Abbott said that all australians should have fair access to health care, and that the Australian Government is committed to ensuring there are “the right people, with the right skills, in the right places”. Over the next 2 years, the Australian government has committed an extra $20 million to fund the RFDS. He also stated that he is committed to closing the gap for Indigenous Australians, with $1.4 billion allocated to community-controlled Aboriginal health services.
The final keynote speaker for the conference was Jawoyn woman Kylie Stothers from Katherine, who spoke about “living where I like, and loving where I live”. Kylie did a brilliant job bringing it all together, and summarising some of the main points from keynote speakers throughout the conference. Kylie has worked as a social worker in the Northern Territory for 17 years, but says that her professional role is only a small part of her identify. Her cultural, family and community background are also important. Her exposure to the health system started with her grandmother when she was only about 12 years old in her rural community. Australia is a rural and remote country so we need to have this discussion, and turn our attention to the next generation of rural health workers. We need to have higher expectations of our young people and help them to see that “anything is attainable”. Our rural and remote children and young people deserve to have dreams, but in order to allow this, we need to change policy and language. “We need people and partnerships to enable change”; it can’t just be a talk-fest. We need to have a “strength-based, solution-focused” culture. We also need more incentives and encouragement for our allied health professionals to “go rural”, not our just doctors.
After all of this I was thinking, “it’s great that we can all get together to discuss issues around regional, rural, remote and Indigenous health in Australia, however how do we ensure positive change comes of conferences like this, rather than just saying nice idealistic things?” How do we ensure “the finest care in the furthest corner” of Australia as the RFDS aims to do? Well the first step is always going to be to talk about it, and hopefully reach some sort of consensus or common goal with which we can approach government to lobby for policy change. The Sharing Shed was one way that the NRHA attempted to do this throughout the conference. Sharing ideas at conferences like this, including research outcomes about the things that motivate young health professionals to “go rural”, helps us to tailor our universities, training programs and health services to maximise the chances of positive outcomes. The 2015 National Rural Health Alliance conference recommendations from the Sharing Shed can be found at the NRHA conference website.
Let’s all take an active role in working towards the positve health outcomes that we hope to see in our regional, rural and remote communities. Let’s look positively on the people, places and possiblities of our sunburnt country!