Improving health outcomes in rural, regional & remote NSW

Barriers to healthcare access in rural, regional and remote NSW are multifactorial, but tackling workforce challenges must be a priority if we are going to improve outcomes in these areas.

From the beautiful beaches of the North Coast to the rolling fields of the Riverina Murray, rural, regional and remote NSW has much to offer. But beneath the beauty lies some stark realities for residents, including shorter lives, higher levels of disease and injury and poorer access to and use of health services, compared with people living in metropolitan areas.

An Upper House Inquiry was established last September to look into the health outcomes and access to health and hospital services in rural, regional and remote NSW.

In addition to examining health outcomes, the committee is investigating patient experiences, wait-times and quality of care for people living in these areas, and how these measures compare to metropolitan communities, including examining service availability, barriers to access and the quality of available services.

Furthermore, the Committee is analysing NSW Health’s planning, systems and projections in determining the provision of health services, as well as capital and recurrent funding.

The review also includes a look into staffing challenges, ambulance services, access and availability of oncology treatments and palliative care.

Submissions to the Inquiry close mid January.

To help inform our submission, we surveyed members about their experiences and conducted research interviews with individual members and the Medical Staff Councils of rural, regional and remote hospitals.

We had a huge response from members, which spoke to the passion and dedication many members have for working in rural, remote and regional Australia and their commitment to seeing improvements in healthcare for their patients.

The challenges faced in rural, remote and regional areas across NSW are not uniform. Healthcare service and access is highly varied across the State in many respects, but residents face similar issues of disadvantages relative to their metro counterparts in relation to their health and welfare.

HEALTH OUTCOMES

Many health outcomes are worse for regional and rural populations. Regional and rural communities also have a proportionally higher Indigenous population, whose health risks and outcomes across all measures are significantly worse than non-Indigenous Australians. 

These disparities include:

• Higher incidence of death from all causes, resulting in a lower overall life expectancy with the greatest gap in life expectancy experienced by the Indigenous population

• Higher incidence of low-birth weight neonates and perinatal mortality

• Increased incidence of death, injury and disability amongst the Indigenous population and young adults in regional communities due to higher rates of violence, accidents and suicide

• Higher incidence of many chronic conditions that together with later diagnosis and limited treatment options impact survival rates of patients 

WORKFORCE

The number of medical practitioners has increased in recent years on average across Australia. The number of medical practitioners registered and employed in NSW in 2019 was 31,817, according to Health Workforce Data.

The NSW Rural Health Plan: Progress Report (2017-18) indicates there was a 15.8% increase in medical practitioners between 2015 and 2017. 

However, as indicated by the significant number of regional areas that are classified as ‘Districts of Workforce Shortage and/or Areas of Need’ there continues to be considerable service shortages access the State.  

It is not possible to accurately ascertain distribution of the specialist workforce by speciality from published statistical measures, which makes assessment of the (in)adequacy of the workforce difficult to quantify. 

It is understood that NSW Health, together with Colleges, are currently improving data collection and transparency in relation to the specialist workforce and unmet need, a task that is critical for targeting specialities and communities and as a benchmark to assess the success of existing and future policies. 

The low number of specialists in regional areas is particularly concerning, as these areas are not only serving their own populations but also rural and very remote areas.

By contrast, the number of GPs (including GP proceduralists) per 100,000 population is slightly higher in regional areas, reflecting their broader scope of practice and provision of services to smaller populations over larger distances. 

The Rural Doctors Network gathers statistical data for GP workforce planning and policy development.

According to the RDN, as of 31 December 2018 there were:

• 2,061 rural NSW GPs (excluding registrars)

• 2,562 rural NSW GPs including registrars in 651 practices in Australian Standard Geographical Classification – Remoteness Area (ASGC-RA) 2-5

• 515 rural NSW GPs who are Visiting Medical Officers (VMOs) in rural hospitals in MMM 2-7

• 266 GP vacancies registered with RDN in rural towns

The RDN NSW points out that despite an increase in the number of rural GPs over the years, the average hours of patient contact has decreased as more doctors are working part-time and doctors have gradually reduced their  hours. There are growing concerns about an aging GP population. About 33% of GPs are over 55.

Replacing doctors as they retire will be a significant challenge, which is compounded by the fact that these doctors often take an active and critical role in training registrars and medical undergraduates.

Regional and remote areas are also heavily reliant on international medical graduates, and more transient workforce short term placements, visiting staff and FIFO workers.

RECRUITMENT AND RETENTION

It is imperative that we explore initiatives to ensure that regional practice is an attractive option. 

The majority of current initiatives focus on the important issue of provision of primary care services to rural and remote populations, with fewer initiatives targeted specifically towards either the regional workforce or non-GP specialists.

Programs that have specifically targeted regional areas include expansion in GP Training and Specialist Training Program placements (STPs), as well as the creation of academic centres such as the Rural Clinical School (RCS) and University Departments of Rural Health Program (UDRH). 

What can be done? Through our consultation with members, AMA (NSW) identified these solutions.

SOLUTIONS

• Supporting the rural and regional pipeline: Recruiting rural/regional students and creating opportunities for rural/regional immersion throughout medical training has provided a long term but effective strategy to maintain and increase the rural and regional medical workforce, especially the GP workforce. Some advances have also been made in developing the specialist pipeline, such as increasing STPs. However, further STPs and more generalist training options are needed to cater for the numbers of junior doctors wanting to train and practise regionally.

• Bundled initiatives: Not all doctors with a rural background will practise in regional/rural areas, and because of the smaller number of medical students with a rural background, the majority of regional/rural doctors have an urban background. This emphasises the fact that multiple bundled initiatives – professional, organisational, personal and financial – that target other key driving factors in a doctor’s choice of geographical location, such as regional training and support, streamlined recruitment processes, succession planning, reviewing family needs, and financial initiatives, are required to recruit and retain doctors in regional and rural settings. 

• Critical mass: Building and retaining ‘critical mass’ (multiple doctors with the same specialty in a popular location) is imperative for recruitment and retention. A critical mass ensures seamless high-quality services to the community and partly counteracts the professional, organisational, and social disadvantages or remoteness. 

•  Appropriate infrastructure:  The non-GP specialist workforce is in many ways a more difficult problem than the GP workforce, requiring adequate infrastructure and hospital appointments. Adequacy of health infrastructure, including availability of long-term certainty of theatres and lists, diagnostic services, access to specialist drugs, specialist nurses and staff, access to private hospitals as well as connections to metropolitan colleagues, are all key issues for recruitment of specialists and maximising their benefit to their community.

• Engagement and planning:  Doctors on the ground are often keen to be involved in succession planning and recruitment and more broadly in planning and service delivery decisions. Engagement of clinicians by hospital administration in workforce planning is critical to the success of recruitment and retention drives in regional and rural areas. 

• Standardised contracts and working conditions for VMOs: Members have highlighted the inadequacy of standard contracts. These contracts do not take into account 24/7 on-call requirements of some specialists who have no back-up. This makes it difficult to attract new specialists to the area. LHDs need more flexibility to be able to address these individual demands. 

•  Improving Health IT: There are several practical concerns with the existing rural eMeds EMR program. The current software has not kept pace with versions available in metro LHDs. The limited features and support create delays in treatment and an inability to access information after hours.

• Rural / regional bonding: It was consistently expressed by our members that there is a lack of surgical specialists as well as nursing staff. High need exists for specialists, such as rheumatologists, neurologists, dermatologists and psychiatrists. Rural / regional bonding for some advanced training positions or enhanced Medicare funding for areas of need to attract specialists to rural areas might alleviate some of these shortages.

You can read AMA (NSW)’s full submission to the NSW Parliamentary Inquiry into Regional, Remote and Rural Services after submissions close on 15 Jan 2021 here: https://www.parliament.nsw.gov.au/committees/inquiries/Pages/inquiry-details.aspx?pk=2615