author:
David Simmons Professor David Simmons is Foundation Chair in Rural Health, University of Melbourne.

(This article is based on a paper presented to the 2000 National Conference of the Doctors Reform Society in Melbourne, 21 October 2000.)

Background

Health care is becoming increasingly complex, at the same time as the expectations of our patients grow through the power of the media. With increasing patient empowerment and knowledge and increasing demand for the ever limited health dollar, it is easy for us to focus on our own needs and our own sectoral concerns. The traditional health care model had the patient becoming sick or worried about a health issue, visiting the healer, paying for the service in one way or another and leaving satisfied that the healer had been seen. The increasing distance from this approach, through the phenomenal growth in the functionality, diversity and degree of specialization in health systems, continually leads us to ask the question "How and where should health care be delivered?" and "Who should deliver health care and what training should they have received". At the same time, research continually pushes the frontier as to what health care is needed.

Within this setting, it is legitimate for each group within the health sector to ask and to be asked where it should be going. It is even more appropriate that the diversity in ways by which healthcare is delivered be used as a means to provide answers to some of these questions. Rural Health requires health systems and their development to differ from that in the metropolitan setting as a result of geography, demographics, epidemiology and resource availability and allocation.

To extract lessons from Rural Health, we can use a variety of frameworks. The first is the "outcomes" centred approach, and ask what are health systems expected to achieve and whether these goals are being achieved. A guiding principle here is that from a population perspective, we should strive for health outcomes to be comparable in all geographical areas and in all communities (e.g. indigenous vs non-indigenous) i.e. equity in health outcomes. Health systems should firstly be able to address "personal health issues" i.e. symptom relief as has occurred for centuries through the healer system. Modern medicine has now developed and been able to provide evidence that we can minimize premature mortality, morbidity and the social impact of disease. Even more recently, we have focused on the ability to optimize health, quality of life and even happiness. Finally, we have entered into the age of costing and pricing, trying to make sure that we obtain the best value for the health dollar allocated.

Lesson 1: Health outcomes are worse in Rural Australia

How well are these objectives being achieved in Rural Australia? It is now clear from a range of publications that people in rural areas have worse health outcomes than those in metropolitan areas. We are not minimizing morbidity or even mortality.

A good example is with the management of acute myocardial infarction (AMI) (Sexton et al. MJA 2000, 172:370-374). Sexton and colleagues recently used routinely collected hospital discharge data to compare the mortality from AMI in capital and non-capital areas between 1986 and 1996 among those aged 30-69 years. In the non-capital populations, the all cause mortality was 12-18% higher among men and 6-15% higher among women. The coronary heart disease mortality was 13-30% higher among men and 13-21% higher among women. However, the AMI mortality was 24-63% higher among men and 24-38% higher among women. The excess deaths were particularly high among those aged 30-39 years with non-capital men 79% and non capital women 108% more likely to die than their capital counterparts. Of importance to those in the largest states, the greatest excess mortality was in New South Wales with 1506 extra male and 564 extra female deaths and in Victoria with an extra 1015 male and 277 female deaths. These 2 states comprised 64% of all excess deaths.

Another example is suicide (Spillane 1999). Spillane reviewed suicides between 1964 and 1993. The greatest increase in suicides in those aged 15-24 years was in towns of less than 4000. Over the time period, there was an increase of 4.2 fold in Melbourne, but 34.5 fold increase in Victorian small towns of under 4,000 and 31.6 fold in similarly sized Queensland towns. While firearm use for suicides has been decreasing overall, in rural areas this mode has been increasing.

Lesson 1 is therefore that health outcomes are worse in rural, regional and remote Australia. Resources are insufficient (see below), but the extent of the difference suggests that primary health care needs to work closely with those involved in health promotion as well as the secondary and tertiary health care sectors to turn around these differences.

Lesson 2: Primary Health Care contributes to the survival of communities

Although the key goals of health services are the health outcomes outlined, in rural areas such services form a vital part of the very survival of the community. Primary health care represents the bulk of health services in rural Australia. The general practitioners, nurses and others in the primary health care sector and their spouses are a significant part of the community and contribute to local decision making outside of the health sector (i.e. are a source of intellectual capital) and to mutual support in health and non health issues (i.e. are a source of social capital). The importance of health workers and services in the survival of communities is such that closure of health facilities is seen as a threat to the whole community (Egan 1989). The existence of health services is seen as a major factor in the ability to retain and attract families (Wolstenholms 1995) and the existence of small hospitals are important in determining ability to attract and retain GPs and pharmacy services (Humphreys 1996).

Lesson 2 is that the importance of the primary health care should not be assessed simply in terms of the health care delivered but the economic, social and intellectual impact that such services bring.

Lesson 3: Pressures on the workforce are similar independent of discipline

Data from the Australian Institute of Health and Welfare (AIHW) demonstrate the shortage in GP numbers in rural Australia with numbers of patients ranging from approximately 900 per GP to 1800 per GP. Rural general practitioners also often undertake more procedures, in patient work and other additional activities and hence these ratios under-represent the rural workload. However, recently, Alford has shown that nurses and allied health workers are also in short supply, sometimes as much as 53% less per head of population than in a metropolitan area. Indeed, over all, there are 34% less allied health workers than predicted from the metropolitan workforce numbers. Furthermore, such maldistribution is not just between rural and metropolitan areas but patchy within rural Australia, such that some rural areas are well endowed, while others experience major shortages.

Rural general practitioners have been surveyed to investigate the discordance between what they feel they need for rural practice and what they feel they currently receive (Humphreys. Soc Sci Med 1998;46:939-945). Needed are sufficient numbers, adequate locum relief and access to continuing medical education, support for spouse and family, recognition of practice skills, job satisfaction and an unimpeded career path. In contrast, the perceived circumstances are that GPs receive stress from excessive workload and inadequate locum relief, career path obstacles associated with limited continuing medical education opportunities, inadequate recognition of the distinctiveness of rural practice and variable job satisfaction. While these data have been generated from GPs, it is likely that similar concerns are felt by other rural health professionals.

Lesson 3 is therefore that the rural primary health care team face similar broad hurdles for sustaining their numbers. It is likely that many of the solutions to several of these obstacles are through achieving economies of scale through closer collaboration.

Lesson 4: Shortages in rural GPs are associated with lesser primary health care utilisation

The data above has already shown the poorer health outcomes and larger practitioner workload in rural Australia. The AIHW has also shown that as the ratios of patients per GP increases, the utilization of Medicare, and therefore presumably primary heath care, goes down.

Rural patients are fully aware of what they need and what they are getting (Humphreys. Soc Sci Med 1998;46:939-945). Patients clearly want a doctor, local availability and accessibility to health services, continuity of care, co-ordinated and integrated delivery of care and quality care. Patients report that they have a limited choice due to shortage of general practitioners and difficulties in recruitment, accessibility barriers due to distance from appropriate general practice care, discontinuity of care owing to high turnover, variable co-ordination of care ranging from comprehensive and continuous treatment to periodic treatment from a range of visitors.

Lesson 4 is that the shortage in rural doctors and other health professionals provides a clear expose of the impact of under-servicing and an opportunity to define some of the core principles for the way that primary health care should perhaps be structured from the consumer point of view.

Lesson 5: A more integrated approach to care may not only be good for rural areas

If we pull all of the above together, we can see that the existing framework by which health services are currently structured and funded provides a comprehensive health service, but that this is fragmented in both delivery and workforce management. While it could be inferred that the current approach assumes a flexible and large workforce as in the city, the services in rural areas clearly need to be more efficiently articulated and in sufficient numbers. This integrated approach to care may provide lessons to the metropolitan primary health care teams.

Lesson 6: The costs of tendering, managerialism and cost containment are exposed in rural areas

The introduction of pro-competitive mechanisms to control cost/growth in cost has been a major challenge in health. There are data to show containment of cost in some areas, while in others such strategies have clearly been associated with a reduction in quality and even adverse health outcomes. The cost of such approaches ("managerialism") is large, for example, in the United Kingdom between 1989 and 1994, the approach increased the number of hospital general managers from 4,600 to 23,000 with an associated increase in immediate management costs of £ 25m to £ 251m. Similar approaches in primary health care are also likely to be associated with a major increase in managerial costs. Of course, it could be argued that if this reduced the existing costs and therefore allowed an improvement in quality and range of services this would be beneficial. However, Lesson 6 has been that for rural areas, obtaining managers is often difficult, there are not the economies of scale available for responding to requests for tenders and other administrative activities and that the activities demanded from funders and tenders available relate to issues important in metropolitan areas but are often lesser priorities in the rural sector.

Lesson 7: The current approach to medical work is unlikely to be sustainable

There are a large number of dynamic changes in the health workforce. There is a growth in the "paramedical" professions and at times competition with the medical profession. There is competition between general practitioners and specialists. There is the development of the multidisciplinary approach. There is an increasing "feminisation" of the workforce and changes in career development. The Australian Medical Workforce Committee estimates that the amount of clinical work undertaken over a lifetime by female doctors is an estimated 63% of that by male doctors.

While there is evidence of a gender difference in clinical approaches, the impact of this on outcomes and utilization are currently unclear. At the same time, the proportion of female medical undergraduates is set to increase from 53% currently to over 60% in 2005. Any impact of these changes is likely to be felt earliest in the bush, where only 32% of doctors are female. The current approach to the health workforce and working practices are unlikely to be sustainable and the impact of this in the terms of primary health care service delivery may well be felt in rural areas first.

Lesson 8: Medicolegal pressures will change the face of the scope of the primary health care team

In rural areas, where only 12% of medical specialists work and GPs are more likely to be proceduralists, there is a growing impact upon clinical practice. In 1997 a survey among non-proceduralist GPs showed that two thirds had previously been proceduralists and that 55% had stopped because of rising indemnity premiums. (Rural proceduralists: An Endangered Species AJRH 1998;6:126-131).

Clearly, rural health provides many examples from which the primary health care sector can learn. This paper has not discussed the many positive policies currently in place which support rural primary health care, such as the University Departments of Rural Health policy and the Regional Health Services strategy. This paper has also not discussed the classification systems for rurality and the differences between rural, regional and remote, preferring to use rural for all of the non- metropolitan areas of Australia. The reason for this omission, and perhaps one further lesson from Rural Health, seems to be that action is often delayed and subsequently impeded by debates about classification systems and criteria generation. Perhaps the primary health care sector can learn from the (until relatively recently) slow progress in developing interventions in rural areas. It would be preferable for people to agree upon that which is easy to agree (e.g. areas with clear need) and start work in these areas and let the development of formulae and criteria occur in parallel to help guide work in the areas of disagreement.

Footnote/References

The University Departments of Rural Health are already having an impact upon the rural health sector. If you would like to hear more about the UDRH in Shepparton (or require full references for this article - ed.) please contact the author.

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