Rural Health Policy: Meeting the needs of rural communities

Improving acute and emergency services
	The Government is committed to ensuring a safe backbone of acute and emergency services throughout the country. It is an essential requirement of our publicly funded system. To achieve this a significant amount of work is in progress. Acute management system The aim of the 24-hour clinically integrated acute management system is to ensure that people get ‘the right care, at the right time, in the right place, from the right person’. The framework for the acute management system is outlined in Roadside to Bedside, released by the Minister of Health in March 1999. Roadside to Bedside was developed by the Ministry of Health in conjunction with the HFA, the Accident Rehabilitation and Compensation Insurance Corporation (ACC) and the Council of Medical Colleges in New Zealand. The key elements of the 24-hour clinically integrated acute management system are: establishing five regional collaborative networks covering all hospitals and providers involved in emergency work transferring patients with acute health needs to the nearest hospital capable of providing definitive care ensuring appropriate and timely access to resuscitation and stabilisation services for all emergency patients integrating all services involved in the management of acute health needs ensuring an appropriate emergency transport system using nationally consistent and agreed guidelines, protocols and standards developing the workforce to maximise the current expertise and skill mix of health professionals providing hospitals and health professionals with access to opportunities involving telecommunications. The acute management framework is not about centralising the provision of emergency services, but rather aims at ensuring rural health professionals are supported and well linked into a network of providers. The network, once developed, will also provide rural populations with certainty about their ability to access the most appropriate place of care within the optimal timeframe. The HFA is leading the implementation of the framework, supported and guided by a National Advisory Committee comprising health professionals, ACC and the Ministry of Health. The HFA will also be establishing regional teams to develop the backbone of the first networks and a number of clinical teams that will focus on development areas such as pre-hospital care, Emergency Department care and obstetric emergency care. The HFA and ACC is planning to implement the backbone of the first two networks, improve the integration of ambulance contracting and commence the national roll-out of the PRIME scheme by 1 July 1999. The PRIME scheme The PRIME (Primary Response In Medical Emergencies) scheme aims to ensure high-quality access to medical emergency treatment. GPs and practice nurses will be available to attend emergencies and will be provided with extra training and equipment. This scheme is a good example of different agencies working together to provide better services, as it has had the support of ACC, the HFA, the New Zealand Rural GP network, and the Order of St John, which has done much of the training and orientation. The PRIME scheme is being implemented progressively, New Zealand-wide. The scheme, once fully implemented, will give rural people more security about the immediacy, quality and co-ordination of their emergency services. Ambulance services One of the highest priority areas that will be addressed as part of the implementation of Roadside to Bedside is ensuring better co-ordination of ambulance services. The HFA and ACC, with the New Zealand Ambulance Board and the Ministry of Health, will be looking at ways of working together to achieve a more nationally consistent and co-ordinated approach to contracting for emergency ambulance services. Changes will be required from 1 July 1999 in response to the Accident Insurance Act 1998. Special consideration will be given to how the needs of rural populations and those ambulance providers covering rural populations can be addressed through this process. The national implementation of PRIME will also assist in ensuring that volunteer ambulance officers are supported by specially trained health professionals when attending an accident or emergency. Healthline The Government has provided the HFA with the funding necessary to run a pilot 24-hour telephone advice and triage helpline in Northland, the East Coast of the North Island, and the West Coast of the South Island, from the year 2000. The Healthline will provide timely health care advice to callers of all ages about the most appropriate treatment they should seek, or if they can self care at home. The telephone service will be staffed by experienced nurses who are fully supported by computer based algorithms (decision support for triage) which will help ensure consistent, safe and high quality advice is provided. Overseas evidence shows that this type of service has a number of benefits, including guiding patients to the right care, at the right time in the right place. Evidence also shows that this type of service is safe, popular and effective. Nurses would provide triage advice, including assessment of a patient’s condition and directing the patient to the most appropriate level of care, advice on self-care if appropriate, advice on the prevention of illnesses, information about diseases and pharmaceuticals, and information about available services, entitlements and user charges.
Community-based initiatives
	Government health agencies will continue to work in partnership with local communities to find solutions to the problems they face. These solutions are likely to focus on organising services around patients, better relationships between providers, local solutions to local problems, and having decisions about resources made as close as possible to need. The HFA Localities Teams approach rural health issues by looking at community needs and identifying gaps in service provision. The HFA wants to work with communities in making decisions on how best to meet these needs with available resources. Rural community consumers, groups or health care providers wanting to discuss health and disability support services for their community should contact the HFA Locality Manager. (Contact addresses are provided on page 35.) Health centres The health centre (or health clinic) model is becoming more common in rural areas. Health centres range from the very small to those that cover a significant range of services. Some go to the extent of having inpatient facilities. Typically, this type of facility provides an integrated range of services including primary and community health services. Health centres usually have a community service base (for example, providing public health nursing, district nursing, home help and mental health teams) with facilities for visiting specialists, and for treatment (for example, physiotherapy, public health and pharmacy services). Sometimes it will also have general practice and/or maternity beds. There is a wide range of ownership structures. A number of health centres are run by public hospitals. In some places, local community groups or groups of health providers have developed health centres to replace small hospitals that were once run by the public health system. Some have been developed using the Community Trust Assistance Scheme (CTAS). There are also partnerships between the public hospital and the local community. Despite initial community concern regarding this development, experience is increasing widespread support for these new health centres. A good example of a higher level health centre in action is the new community hospital that opened in Dannevirke in 1997. While the hospital itself is owned largely by local health providers, the services are publicly funded by the HFA. The new hospital works with the town’s GPs to provide medical inpatient care and includes x-ray and ultrasound facilities, physiotherapy and a medical laboratory. MidCentral Health also provides a range of services from the facility. Dannevirke’s solution ‘The best advertisement for the Dannevirke Community Hospital is that staff are happy in their work’, says manager Sharon Wards. ‘My philosophy is, if you keep your staff happy, then your patients will be happy too. ‘Originally Dannevirke wanted its hospital on the hill come hell or high water but that was not happening. We rallied for the new service through constant public relations, talking to the public and working through the issues that arose. Dannevirke Community Hospital opened its door in September 1997 and now the community is right behind us. ‘It’s worked well with all services being utilised. ‘We had the opportunity to make this place work, and everyone’s attitude and time has made it the success it is. It was a huge change in thinking for many of the staff from big hospital bureaucracy to a small, patient-focused environment. But it did not take long for staff to make this their own baby. ‘What we have is a purpose-built facility with no wasted space. Administration costs are kept to a bare minimum and most resources are going towards staff and patients. We have tried to design services that are focused on the needs of the community.’ For example, Dannevirke Community Hospital has GP-managed beds to provide convalescence following surgery and for medical problems which don’t require specialist intervention. The hospital houses eight GP beds, three maternity beds, x-ray facilities, Medlab and Homecare 2000. MidCentral Health also operates public health, district nurses, specialist outpatients, and mental health and occupational therapy in the building. Over time, more health centres will develop as community initiatives come forward. The HFA is continually looking at developments in this area including, where appropriate, trials of new services with associated evaluations. Integrated care Many integrated care initiatives are now developing up and down this country. There are a range of initiatives that come within the understanding of what is meant by integrated care. At one end of the spectrum is the emphasis on improved co-ordination between services; at the other end it means taking the available budget and using it to purchase a whole range of services for a whole population so as to get the best outcome overall. Integrated care in its various forms seeks to deliver health services to people and to communities in a co-ordinated way. It looks at the bigger picture when providing health care, so that the community’s need for preventative and educational services are worked on as part of a constructive overall package. Integrated care aims to give both better co-ordinated and more health and disability support services with existing resources. Integrated care services may have the following features: coverage of a particular population a range of services more than one provider well developed, effective collaboration between providers the use of a single pool of funding. The Government is encouraging communities and local providers to consider a variety of integrated care arrangements, thus allowing local people to take the initiative in developing their own local services by working out the solutions that serve them best. Such approaches are expected to help communities to resolve some of the issues in maintaining effective health services experienced by rural communities. Because rural communities tend to be small, they often already have some important ingredients for successful integration, such as existing relationships between key groups. Unfortunately, sometimes strong parochialism and existing health provider relationships can run counter to regional attempts to develop integrated solutions. In small communities where the community and health professionals are able to work co-operatively, initiatives seem to have moved forward faster than in cities. Kaitaia Maternity Service The Kaitaia Maternity Service incorporates all the maternity services in the region spreading from Mangamuka to North Cape. The majority of the region’s roads are unsealed and access to some areas is difficult during the winter months. The service has to deal with these problems, as well as significant population factors like having a high percentage of Maori women (45% of the women aged 15–44 years) and a high proportion of young families, many of them on low incomes. ‘We didn’t want to create competition in this area,’ says Donna Mayes, Kaitaia Maternity Services manager. ‘GPs and practice nurses have a long history of working together and we wanted to continue that relationship, ensuring that our service met the needs of rural women. We wanted to make a service where the midwives and GPs had security of income, collegial support working as a team, and flexibility in how the services were delivered.’ The midwives provide antenatal care, and do home deliveries as well as look after the maternity service at the hospital. GPs provide the medical backup throughout the pregnancy as need and choice demands. The maternity service provides senior midwife cover at the Kaitaia hospital maternity unit and Northland Health provides support staff. The service also works in closely with community groups such as Plunket, Ringa Atawhai and iwi-based health groups. ‘We are too isolated to operate in a competitive environment. Our drive was to get focused on how to meet the needs of women and we made a decision to leave the politics behind. Our satisfaction is in seeing women in the region receiving good care,’ says Donna. The formation of Independent Practitioner Associations and other groups interested in integrated care, such as Healthcare Aotearoa and Maori Integrated Care groups, have also encouraged the development of integrated care. The earliest rural integrated care initiative was in Hokianga. This is not a typical initiative because Hokianga has a special area status but it has been accepted as a very successful development for the local community. Developments have also moved quite rapidly in some small community towns with outdated existing facilities that were confronted with change. Examples are Balclutha, Ranfurly and Gore in the south, and Dargaville and Kaeo in the north. Balclutha looks to the future Balclutha’s integrated Healthcare Facility opened its doors to the community in December 1998. Brian Dodds, the chairman of the board of Clutha Health Incorporated, says it has been a challenging task bringing the community around to accepting the new facility as the key health service. In December 1991 a campaign to fight for the retention of surgical services at Balclutha hospital started. Three years later these remaining surgical services closed down and the Hospital Support Committee rallied to find alternatives which would secure sustainable health services in the Balclutha. ‘In the beginning we were all fighting for what we had; then we stepped back and thought, “shouldn’t we be looking to the future?” There was divided opinion on it. Concern about whether or not, as a community, we should be taking on the responsibility for the provision of health services,’ says Brian. In August 1997 the group presented a business plan, centred on a new facility in Balclutha, to the community and members of the committee spoke to as many community organisations as possible to gain the support they needed to get the project under way. ‘It’s been a big change for the community to accept but we are confident that the quality and range of services which the new facility offers will do much to overcome the remaining opposition.’ Now the focus is on ensuring the continuing provision of the best health services by drawing together local health personnel and through better co-ordination and co-operation improving the services to the community. Clutha Health Incorporated has been formed to own the facility on behalf of the community. It is an incorporated society with a board membership of 10 (five of whom are elected, while three are appointed by the people who work in the facility, one by the Clutha District Council and one by the Minister of Health). The incorporated society, in turn, has appointed a board of five directors to the Clutha Community Health Company Limited, which holds the contract to provide health services. The facility includes seven general inpatient beds, two observation beds, four inpatient beds with specialist geriatric supervision, a maternity facility ward, two postnatal beds and two more beds to cope with overflow, five suites for general practices, x-ray services, a laboratory, physiotherapy, and an outpatients department where visiting clinicians and speciality nurses will conduct clinics. District nurses, occupational therapists and a medical social worker will also work from the facility. There are a number of other rural-based integrated-care projects under way. One of these is with Kaipara Care in Dargaville for the multi-disciplinary management of diabetes, child asthma and frail elderly in a rural bicultural environment. There is also interest from communities such as West Coast, Gisborne, Eastern Bays and Southland to find ways for community-based providers, the hospital and local government to work together. The Government is keen to foster a variety of different approaches that may serve to integrate care in rural communities. Some of these arrangements could mean changes to people’s choice of service providers. Generally this will have community and provider support. However, that may not always be so. Because of this, care will be taken to ensure the following: if an arrangement will cover everyone living in an area, then very careful and responsive consultation will be needed if people will have to make a choice of which arrangement to use, it will be crucial they know what they are signing up to and are able to make free choices people must be protected against organisations refusing to enrol individuals purely because of their need for services the aspirations of Maori for more control over their health services need to be addressed accountability and monitoring of access will be needed provision needs to be made for ensuring that national policies are complied with any extra costs for an integrated approach must be evaluated against the benefits. Family health teams Family health teams are currently being piloted in Waitakere, Eastbay and Otago. The pilots aim to provide a comprehensive family health team concerned not only with specific health problems, but also with broader social and cultural factors. This would involve, for example, assisting parents to get help from the appropriate services. It would also involve supporting and speaking for families, and co-ordinating different services for them if necessary. This concept, once evaluated, could be a useful model for application in rural areas.