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Saving rural health services

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Matt Smith:

Many medical professions have been experiencing shortages and nowhere is this problem felt more profoundly than in regional communities. How to solve these problems, or at least how to work around them is something these communities must face. I'm Matt Smith and you're listening to La Trobe University podcast.

Professor Jane Farmer is the head of the La Trobe University Rural Health School. She has been studying the problem in Northern Europe and is now it's quite similar around the world.

Jane Farmer:

Many rural areas internationally, you've got ageing populations. And you've maybe got the whole nature of rurality changing as well. So some communities are quite static, some are declining in size. That makes a whole kind of complex dynamic I think for health services. So one of the issues, is just as populations age then your health professional are ageing. So how do you regenerate new generations of health professionals and I think that's one issue.

So I think we really need to look at what resources we have in communities that can be developed rather than looking constantly at putting things in. I suppose another issue is just this changing nature of the people that are in rural communities. So you're moving from populations who maybe work in agriculture or primary industries to these populations of older people. There's a different set of health conditions that are pertaining there.

So you're moving from people who maybe would have had accidents or orthopaedic kind of situations, back ache that kind of moving to these older populations with complex, chronic illnesses you know who want to stay a living in their communities. So the kind of rural health professionals this pretty much more this kind of generalist sort of almost pastoral care but obviously with the capacity to deal with these emergency situations if they come along. And also to make rural areas the kind of places that you do want to live as a younger person.

So what can health professionals do? They need to be giving good care to mothers and babies, that kind of thing. So in a way you've got quite a complex kind of a problem of what health professionals can actually provide in there and how health services themselves are going to provide it. From their point of view, they're looking at these dispersed populations with chronic illness, with difficult to actually recruit health professionals to work there or to live there and that becomes a really expensive and complex situation for the health services themselves to try and work out.

And at the same time, you've got a whole kind of regulatory apparatus going on that says in order to deliver babies you have to deliver X number of babies a year or in order to operate on patients or provide anaesthesia, you have to be doing X volume of cases. And that can be quite difficult in the rural area because you just don't have the volumes of patients.

So you're having to comply with regulations that are set up for big metropolitan high volume almost factory-like situations in small rural settings where you maybe get infrequent numbers of these types of cases.

Matt Smith:

So you're dealing with very much decentralized kind of services where a limited number of health care professionals are covering quite a large catchment area. How do you think communities could be better engage in solving these sorts of problems?

Jane Farmer:

OK, well I think what often happens certainly in Scotland as you would get to situations where there was a bit of a crisis. So the Health Service would be saying, "We can no longer sustain or provide the kind of service that you've been used to", this kind of service where you've maybe got a GP which is actually quite an expensive highly-trained resource, and in Scotland often in rural communities for quite small numbers of people. So you get situation where health professional would retire or they would move on.

The community would say, "Right, obviously we need another doctor or another district nurse." And the Health Service would be saying, "No, wait a minute there's 300 of you" or whatever. A GP cost £200,000. If we're looking at per head, that's a huge amount of money and actually it's also difficult to attract someone to work here. It's difficult to keep them professionally up-to-date. They also have to provide locum so they kind of get off the island. So to them that kind of get into this protest situations that's often the sort of situations that I've worked in in the past almost kind of like a marriage guidance role or whatever like a mediation situation. And in those situations, what we try to do is get a community to look at what it wants to do in the future, where is it going as a community, where does it want to be? And then a really useful thing to do is try to channel in as much information, data as possible around the situation.

So you're not working on anecdote and story, you're working on facts. So you can actually get quite a lot of data if you're working at it for individual communities.

You can tell communities, things like how much their services cost, what services are actually using at the moment. So communities often have the perception that there's lots of emergency situations. People always have accidents. They always need doctors out of hours. So you can actually provide that data that shows that actually over the last year there was only two GP calls light or something like that. You can also show them what actually are the health issues for their community, it tends to be things that are related to lifestyle, things like smoking, obesity-related conditions, things like high blood pressures and so on. People actually really quite surprised when they look at health rather than ill health or conditions or illnesses or acute illnesses or things that are very visible. The health things are often things that they could do something about or socially it's more of an issue.

So those are the kind of things that we've done is really around treating the community or people in the community like they're a manager, giving them the same kind of information that the managers would use to make decisions, trying to get everybody together and kind of having this quite frank discussions and then kind of negotiating it out. And often that ends up with slightly different models.

All parties and their creation have to think a little bit differently. They have to start thinking about doctors and nurses and then maybe think more about what skills do we need in this community? Quite often it involves the community themselves in the overall project, which we did in a lot of countries in Northern Europe.

Communities were coming to us and saying that, "We're really worried because our older people are getting taken off to residential care when they can't cope." And we were kind of saying, "What do you feel you could do yourselves to keep people in the community?" And that's where that project kind of start from. So people started up things like good neighbour schemes, so just visiting people can be a huge, huge thing for keeping people living in their community.

And also people would get involved in saying that kind of transfer a lift giving scheme that kind of thing. So I suppose on the work that we've done, the message would be really kind of like looking at what actually is needed in the community and then looking at all the resources you have and all the potential resources you could have to address it rather than just looking at what you had before.

Matt Smith:

While it mightn't be cost effective in some of these communities to have a GP for example, you said that in some cases you'd look at it not only get like two emergency call outs in a year. If an area doesn't have a GP what happens in those two situations, in some ways aren't you putting monetary value in human life?

Jane Farmer:

That is the kind of thing that people will see they'll kind of see well it's all very well you saying there was only two situations but in each of those situations that was somebody's life that could be at risk. One of the things that came up as well as this idea of monitoring and surveillance was that they really wanted someone who could tell what was an emergency or not and what to do in that situation. And that really surprised us.

They weren't saying what we want is someone here who can deal with all possible emergencies. They were saying that for them, the biggest question and most difficult question is what do I do? How serious is this issue? I live two hours from the nearest hospital. I need to know, is this something I should take myself off in my car or I should call an ambulance or I should call the air ambulance, or I should get somebody to take me to hospital? It's that kind of knowing how serious the situation is, that's the problem. There are various ways of addressing that which depends on your element of willingness to look at the evidence I think. In Scotland, they've introduced this kind of call centre scheme where people call up in an emergency first and they talk through their symptoms and their situation and then they get advice.

I don't know if there's a similar situation here in Australia a sort of out-of-hours call centre type thing but that thing actually pertains in quite lots of rural Scotland now. And so, what that does is it goes through like kind of algorithm of what might be your condition and then it tells people what to do so it might say you probably need to come in to hospital. So let's call an ambulance for you.

Matt Smith:

Are you talking to a person there though?

Jane Farmer:

Yeah, yeah, absolutely.

Matt Smith:

OK, so it's not like now, if you're feeling chest pain, press one.

Jane Farmer:

Yeah. No at the front end of it there is an element of that. You know like how much of an emergency is it? You do talk to a person and I've used it myself. So I know what it's like. So you go through quite an extended conversation and then quite often if they say to you, "Actually, I think you could permit to take some paracetamol and see what happens. They will call you back in an hour as well. So they're kind of looking after you. So there's now sort of thing but also I think the other thing is that there are other people in the community who can triage if you like an emergency situation or if you understand that that's a particularly crucial issue for your community then you skill somebody up or more than one person up in your community to deal with it.

It's a bit like what I've been saying to you in terms of you look at what resources you've got in the community and you look at how you can apply them to what your situation is and if you have gaps then you look at who you could skill up in your community to deal with that.

Matt Smith:

You said earlier that a GP doesn't need to be responsible for everything and most of the things that a GP does do are things that could be managed by other people, in that sort of situation I think that more knowledge is needed by the community. You got problems with smoking or things like that you know go to the local counsellor, counselling service maybe and get help from them and not the GP.

Jane Farmer:

I mean I'm not anti-GP and I think there's quite a substantial argument that sees at the end of the day a GP might be the most cost effective way of dealing with everything. The idea of a medical person is that they are highly trained, highly experienced professional who can deal with any medical problem or challenge.

In rural communities there often aren't counsellors you know they're often isn't very much at all. One of the other things that communities ask for when we're doing this work was some sort of community health leadership, people or training or leadership in the community that was around health awareness, health literacy if you like, kind of looking at the up and coming issues for communities, what are the conditions, the health problems of communities and where do we actually come from? Because often it's not about taking a pill or having an intervention, it's about something that's much more basic. These are really social issues rather than health issues.

Matt Smith:

One of the problems as well is just attracting the needed health professionals to rural communities, what sort of things could be done in that area and what benefits do a rural community get from a health practitioner that people don't usually know about?

Jane Farmer:

OK, so in terms of attracting professionals to rural communities. I mean, that again needs to be tackled from various perspectives. So one is obviously a real kind of societal thing just in terms of governments and regional development agencies and locally they themselves actually advertising that you get really good quality of life in rural areas. You know, you only have to sort of leave Bendigo and drive in to Melbourne and hit that traffic and you kind of think, "Oh thank God, I live in Bendigo" or some other kind of rural place. So we always contrast rural with urban. We should maybe start contrasting urban with the quality of life that we have in rural areas. Another issue is around the profession themselves, and professions themselves over the last 30 years have developed such that the value and put stasis on people who become specialists. In the rural area you may have a special interest you may even be able to do what your specialist thing but you have to deal with a lot of generalist issues. There needs to be kind of a message from the professions themselves as well but it's valuable what health professionals can contribute in rural areas.

So we used the thing called the Capital's Framework and it looked at social capital, economic capital, human capital, and how people respond in terms of the natural environment and we devised a measurement tool. So health professionals, they're obviously reasonably well paid. If they spend money on the local community, that's a good thing for the community. In terms of social capital, there's quite a lot of evidence that health professionals often involved in a lot of community activities.

Some of them they get caught up in through their health professional rules so there's a little bit of a gray area between the health and the social rule. They often are community leaders. So they're called upon to lead certain initiatives and they're seen as a credible voice for the community. They often have good connections like side of the community that they can use to get resources into a community. And then in terms of human capital, I think this is a crucial thing in that a lot of rural communities have over the last 40 years become depleted in terms of human capital.

So just the difficulty of running a business, the difficulty of being a lawyer just not viable anymore and actually the main people that you have left, that have professional qualifications are health professionals and they potentially are providing the real backbone in terms of human capital in that community and what happens if they're not there and I think it really interest into study communities for health professionals go in and out rather than actually living there and see what kind of difference that makes.

And so, when I say you know maybe communities don't need doctors, I think you've then got to turn it on its head and say that look at all the other things these professionals are bringing into communities as well as their health service role maybe that's a hugely valuable to these communities as well. And so, I think of communities' protest about losing a health professional, potentially losing one. They're talking about more than health services. They're talking about something about sustaining their community.

Matt Smith:

You've been drawing all these information together into what I assume is going to be quite a sizeable book. Tell me a bit about that.

Jane Farmer:

OK, so the book largely looks at some work that we've done over a period of three to four years in a number of Northern European countries, so Sweden, Finland, Greenland, Scotland, and Northern Ireland. And I guess it looks at similarities and differences and working with involving communities and health services in those different countries. Government policy says you should involve communities more but how do you do that? What sort of things are communities prepared to get involved in? What effect does it have on communities and what things will communities actually produce? When you go into communities to do that, there are certain number of or group of people who will get involved. One of our challenges was that we wanted to see if we could involve other people as well. So enlarge the group of people and communities who get involved and get more volunteers and that was actually really difficult.

The second thing was around what will people actually do in communities and we found that people were largely much more interested in doing social things, transport schemes. They're really interested in meeting places. They're interested doing heritage projects but they weren't particularly interested in doing things like care.

So they didn't want to get into kind of formal situations where they had to provide care for other people. So I think there's kind of a limit to what you can expect people to do. And there's also a limit in terms of what you could do as a volunteer and what you should be doing as an actual trained professional and I think that was going on as well. In the different communities we worked with many of the outcome range from sort of setting up voluntary groups but some community actually set up social businesses but just quite amazing. One community did actually set up its own care scheme and another set up a transport scheme. People would get involved. They much more valued being supported in that involvement. They needed some kind of umbrella or structure which would help them to get involved and then for them the challenge is not having started this kind of social businesses, it's how do they keep that sustainable.

Matt Smith:

You did those studies in Northern Europe and in Scotland and Wales. How do they translate to Australia is there a lot of differences between those communities and Australian rural communities?

Jane Farmer:

Yeah. In the UK I think people have become quite paternalised by the welfare state and also lots of people have moved in to rural communities from urban communities. So they're quite disoriented and while I think is there's an element of that in Australia, I mean it's certainly in some communities that are maybe nearer urban areas I think it's more of a traditional of helping each other and doing things for themselves. I don't think there's quite the same almost kind of neoliberal policy urge that there is in Europe and particularly strongly in the UK where governments are actually really retrenching on service provision and saying to particularly rural communities, "OK, you guys if you want to continue living here, you have to participate in producing services."

They're looking at mixed service delivery model as concept of co-production and really the rhetoric is kind of forcing people rather than nurturing people into this sort of situation almost with the kind of fright, if you don't really enter into this and you don't really do it and you don't do with any enthusiasm, you might just get left. I don't sense quite such an extreme policy situation here but then that's maybe because people are more able to fend for themselves here in the first place. I don't know. Obviously, these things are hard to measure.

Matt Smith:

That's all the time we've got for the La Trobe University podcast today. If you have any questions, comments, or feedback about this podcast or any other, you can send us an email at podcast@latrobe.edu.au. Professor Jane Farmer, thank you for your time today.

Jane Farmer:

Thank you.