Rural Health Policy: Meeting the needs of rural communities

Developing and maintaining skills in rural areas
	Appropriate and well-maintained local skills for front-line care are critical to rural health. Rural health and disability support service providers must be innovative and flexible in their efforts to develop and maintain skills. This requires, firstly, that health professionals with the right training are recruited and retained in rural areas. Practitioners in rural and provincial areas need to have a wider range of skills than their city counterparts. This is a large part of the enjoyment and the challenge of rural practice. They need to have, for example, an understanding of community health systems, skills in initial assessment and emergency care and understanding of chronic disease management and disability support. Once health professionals have been recruited to rural areas, it is important that they be able to continue their professional development. Ongoing professional development is needed for the safety of their practice, and also helps overcome any sense of professional isolation. Isolation raises other issues, such as the need for locum support, and whether the lifestyle is attractive for the rest of their family members. The recruitment, retention and ongoing education of rural health professionals have all been difficult issues for many years, and they are being faced directly and positively. There are a variety of ways the current situation can be improved, and the Government is keen for these improvements to happen. There are already a number of local and national initiatives aimed at supporting the needs of local communities, including improvements in rural practices and the development of nurse prescribing. These generally involve improving training available for GPs and nurses in rural health centres, giving more attention to ways of retaining health professionals in rural locations, and making sure locums are available for them. Clinical education, training and ongoing support Undergraduate medical and nursing education includes attention to the basic knowledge and skills required in rural practice. This level of education imparts a general experience. More specific training for practice in rural areas is a focus for postgraduate study. Universities and polytechnics vary in the extent to which they take account of the needs of rural communities when they select medical and nursing students. Health care funders, providers and communities need to express their requirements to these education providers. However, it should be noted that rural health is already an area of increasing focus in medical and nursing education. Ongoing support and training of rural practitioners is also vital. A variety of initiatives are being developed to increase the support available to rural practitioners. Examples of developments in clinical education, training and ongoing support are presented below. In early 1999 the HFA approved support for a Director of Rural Health based in the South Island. The director will work with South Island rural GPs to promote rural practice and liaise with training providers. Consideration is being given to supporting a similar post for the North Island. The General Practitioners’ Vocational Training Programme (GPVTP), purchased by the HFA through the Clinical Training Agency, is being re-oriented to be better at meeting rural health needs. From the year 2000, the programme will place more emphasis on the rural GP’s role as part of a multi-disciplinary team delivering care to individual patients, and in carrying out proactive health programmes to improve the health and wellbeing of the people of that practice. The GPVTP will also investigate ways to enhance the recruitment and retention of trainees in rural practices. The Dunedin School of Medicine is establishing a rural health network. The Dunedin School of Medicine will provide administrative support to the network as well as supplying visiting specialists to rural areas for teaching purposes. Part of the School’s new approach to rural training includes undergraduate fieldwork in rural areas. It is proposed that through their training, students will be attached to practices in rural areas for periods of up to seven weeks in the fifth year of the course and for four weeks in the sixth year. A new multi-disciplinary Diploma of Health Sciences (Primary Rural Health Care) is being offered by the University of Otago. The Diploma aims to enhance the skills of nurses and doctors in rural areas. The Clinical Training Agency aims to fund approximately 30 training places each year. The Goodfellow Unit (Department of General Practice, Auckland Medical School) is contracted to provide education and peer support to rural GPs and practice nurses in the midland region of the North Island. The Christchurch School of Medicine Department of Public Health and General Practice has a locum support service for practitioners in rural areas. A similar scheme is provided by Southlink Health Independent Practitioner Association network. Both of these schemes offer relief for rural practitioners to make it easier for them to get away for study and annual leave. It is anticipated that more programmes such as these will be developed. Wider GP networks can offer more opportunities for fostering professional development. For example, the Northern Rural General Practice Consortium Inc (which has a membership of 54 GPs and 53 practice nurses, comprising 95 percent of all rural general practices north of Wellsford) employs a professional development facilitator to provide continuing medical education programmes and other ongoing training and development for its GP members. It also employs a practice nurse facilitator to provide continuing education, peer review and support services to its practice nurse members. The Paediatric Specialist Services review is currently developing a network which will permit isolated paediatric specialists to have more regular contact with peers in order to reduce professional isolation and improve quality of care for rural children. A further proposal under development by the Dunedin School of Medicine is the provision of a nationally recognised qualification for medical practitioners who staff rural hospitals. Learning aims would include the management of medical emergencies, resuscitation and stabilisation, and the transfer of patients to base hospitals. Multidisciplinary Diploma of Health Sciences (Primary Rural Health Care) Jean Ross and Dr Martin London, directors of Christchurch’s Centre for Rural Health established in 1994, are adding another string to their bow of rural specialist services. With a good knowledge of rural practice issues and a broad rural health practitioner database, the rural health centre, urged on by the Clinical Training Agency, is introducing a Diploma of Health Sciences (Primary Rural Health Care) for GPs and nurses as part of its integrated rural health support package. ‘We were aware of the challenges experienced by rural health professionals and their families in Canterbury and Westland. Research showed they were isolated and the consequent impact this had on the delivery of health services to rural communities,’ says Jean. The centre was initially set up to improve the quality of patient care in rural practices, but it has moved forward to emphasise the team approach for effective health delivery. ‘The basis of the diploma is to advance the skills of the practitioners so they are clinically able to take on the diverse roles encountered in a rural environment and adapt their work practice to fit in with the community. On completing the diploma, GPs and nurses will either be in a better position to stay in the rural environment or have the ability to decide it is not for them.’ Three papers have been developed to date as part of the Diploma course. Advanced Rural Primary Care, initially run for rural nurses, has been broadened to include GPs. It covers clinical assessment and procedural skills to manage rural patient pre-hospital emergency care, develops advanced health assessment skills for nurses, and extends clinical skills relevant to rural practitioners. The Rural Communities and Team Function paper develops an understanding of rural communities and skills to optimise the experience of life in a small community. The emphasis is on effective team function and integration in rural communities. The third paper, Applied Clinical Rural Practice, begins in 2000 and is based on placement in rural practices with supervision and mentor input. Nurse prescribing Currently, the Medicines Act 1981 limits the prescribing of prescription medicines to medical practitioners, dentists and midwives. In May 1998 the Minister of Health announced that Cabinet had agreed to amend the Medicines Act to enable the formulation of regulations to: extend prescribing rights to nurses and other defined groups of health professionals designate health professionals who are able to select and administer specific prescription medicines, for particular classes of patients, when acting in accordance with standing orders.3 Nurse prescribing is being introduced with considerable caution to make sure it is safe and works well. Initially it will be limited to certain paediatric and geriatric applications. There is considerable concern being expressed by GPs at this development. The Ministry of Health is working with all parties involved to make sure the implementation goes well and that people benefit overall. If the initial implementation of nurse prescribing is successful, nurses in rural practices could be one group for which granting limited prescribing rights may be a useful and cost-effective complement to the services provided by rural GPs. In many rural areas there are excellent working relationships between health professionals who support each other’s work in the community. Extending prescribing rights in such an environment can strengthen the team and increase people’s access to timely services. As to the implementation of nurse prescribing, the Ministry of Health has established working groups comprising nurses, medical practitioners and pharmacists. These groups will define the scopes of practice and the generic classes of medicines that it may be appropriate for nurses to prescribe in the areas of child health (in the context of the family) and care of the elderly. The information provided by the working groups and wider consultation will form a basis for evaluating the benefits of safely extending prescribing rights. Maori provider development The increased number and diversity of Maori providers has been a feature of health changes since 1993. Maori providers have an important role to play in rural service delivery. One example of how the Government is encouraging workforce development of Maori health professionals to meet the needs of Maori is through the Maori Provider Development Scheme. The Government has committed funding over three years for Maori provider development to support the sustained growth of quality Maori providers of health services and to enhance the ability of Maori providers to deliver effective health services. A key element of the Maori Provider Development Scheme is to improve integration and co-ordination of health and disability support services for Maori, so that services are easier for Maori to use and are provided in ways that minimise the financial barriers to health care access. The establishment of mobile service delivery units – particularly for dental, primary care, child and youth health, and mental health services – which move within rural communities at specified intervals, aims to decrease the access and cost barriers that many rural communities face. For example, a caravan is being used to improve young people’s access to dental care in Northland. Te Puke Karanga Hauora Trust As part of Pipiriki Marae, Te Puke Karanga Hauora Trust provides nursing services and health education services to isolated communities on the Whanganui River. These communities have populations which are predominantly Maori. Te Puke Karanga Hauora Trust also co-ordinates services provided by other health professionals. The centre considers kaumatua wisdom and support to be a big bonus. Management has a monthly meeting with the community to discuss proposals and receive input. Manager Pet McDonnell says the service is a major asset for the community, taking in Tieke to the north and Jerusalem (Hiruharama) in the south, and all surrounding areas. ‘We’ve been going for two years and I think we can now say the local community views the service as its own service; as a community-owned service.’ The centre services about 200 people, ‘depending on who’s home,’ and a number of tourists in the summer. Flexibility is the name of the game, she says; whänau may come home for a weekend and stay for a month. ‘The old people now have access to a nurse at their doorstep, day or night. Someone is always on hand 24 hours a day. We have a vehicle for when people need to get to Wanganui Hospital’s accident and emergency service quickly or to take them to the doctor at Raetihi. We also have a helicopter arrangement with the local Department of Conservation office and through them we have radio access to Tieke Marae, which we also service. ‘We are currently devising an emergency plan for Tieke with Department of Conservation staff, and local people with boats who know the Whanganui River like the backs of their hands. The area is very isolated – you couldn’t expect an outsider in a helicopter to necessarily find Tieke quickly in an emergency.’ Pet believes the service has given local people more of a sense of security than they had before. ‘In the past, if you had a heart attack you’d get to hospital, but if you had an asthma attack, you’d probably just cope as best you could. Now, we can get people to hospital quickly and safely.’
Networking, partnership and technology
	New technologies are supporting big advances in many areas – health is no exception. Likewise, different agencies working together can make the sum significantly greater than the parts. There are many ways we can use our health resources more effectively through networking and partnership between providers and between welfare agencies. Modern technology is an especially useful tool for people to work together. It means that networking can now occur at a distance, greatly reducing isolation for all who use it. The Strengthening Families programme The Government supports intersectoral initiatives that recognise the range of causes behind poor health and disability. This is goal 10 of the Government’s Medium-Term Strategy for Health and Disability Support Services. The Strengthening Families strategy arose from Government’s concern about the ongoing inter-generational cycles of disadvantage and their impact on children and families. There was also recognition by the health, education and welfare sectors that there were many common areas of concern – for example, the same clients in the same localities of New Zealand. Service co-ordination at the local level At the local level, service co-ordination has been developed to help people at the front line work more closely together. This is achieved through inter-agency case management, identifying gaps and overlaps in services, and joint initiatives to use resources more effectively. The initiative first involved health, education and welfare agencies and has now expanded to include other government agencies and community groups. Local level co-ordination began with a pilot in 1996 and there are currently 54 local co-ordination groups covering the whole country, including rural areas such as the Bay of Islands, Central Hawke’s Bay and Buller/Westland. Client feedback confirms that the collaborative approach is beneficial. In addition, the sectors have developed greater understanding of each other’s services, and this provides opportunities to develop other intersectoral initiatives. As part of the Strengthening Families strategy, a more preventative approach is being explored in three priority areas (Northland, East Cape and Porirua / Hutt Valley). The number of priority areas is likely to increase. Family Start programme Family Start is an intensive home-visiting programme for at-risk families which starts at birth. The Family Start service aims to build the strength and capacity of families and to ensure their children have the best possible start in life. Family Start is currently being run and evaluated in Whangarei, West Auckland and Rotorua. Additional funding for Family Start announced in the 1999 Budget will expand the programme to another 13 localities, including Kaitaia, Kawerau and Horowhenua. Telemedicine Telemedicine is being trialled and increasingly used to allow specialist expertise to be more widely accessible. An early example was the Waikato teledermatology service, which involved communication between Health Waikato and one of its satellite hospitals, Taumarunui. This has now been extended to involve GPs and is part of an international trial. As well as diagnosis, telemedicine can include distance prescribing, and nurse field workers supported by telecommunication links with doctors. The Starship Hospital has developed a telemedicine proposal to link paediatric specialists around New Zealand. This is being supported by HFA funding and the first task will be the formation of a national paediatric tumour board, to improve services to children with cancer. It is anticipated that telemedicine will increase rural practitioners’ access to specialist paediatric advice. Teleradiology The use of telephone and computer technology to gain access to radiology services provides significant opportunities to rural hospitals and health centres. Reading x-rays and CT scans remotely can be of particular value in determining whether or not a patient must be transported to another centre or not. It can also be of assistance where it is not feasible to have an onsite radiologist. Difficulty in recruiting a radiologist led Coast Health Care to contract with a Christchurch-based radiology service allowing urgent x-rays to be scanned through to Christchurch and a consultation provided within 20 minutes. A radiologist and a sonographer visit Greymouth Hospital weekly. This initiative has increased the quality of radiology services and reduced the need to refer West Coast people to Christchurch. Roadside to Bedside, the acute management system described earlier, will rely heavily on effective communication links and provider networks. Visiting specialists and service networks The different levels of health and disability support services need to be connected and to support each other through service networks. A good example of this in operation is the increasing use of visiting specialists in rural areas. This means that services are received by patients in their communities, and that the service is provided by a health professional who is experienced and has access to wider support networks. The visiting specialist services are particularly well received by disability support services consumers, who need to use these services often. Hospital in the home Provision of hospital-level care in the home may be an option for rural people in the future. A pilot project in Taranaki has commenced, which provides highly skilled nursing services to patients in their homes. Home-based care is being provided to patients who would normally be admitted to a hospital. This initiative is being trialled with patients relatively close to a base hospital. If it is successful, consideration could be given to whether this type of service could be used by rural people as long as skilled nursing, medical oversight and allied services are available. Information sharing Rural Health Network Local solutions to local problems ‘If you have seen one rural community, you have seen one rural community.’ Dannevirke Community Hospital manager Sharon Wards says local solutions to local problems are the way to go as no rural community is the same as another. But that doesn’t mean communities shouldn’t learn from each other, and with that in mind Sharon set about establishing the Rural Health Network. ‘The future is for rural health initiatives to solve their own health problems for their own communities, but those communities need support. We bit the bullet and did it ourselves – no one else was going to do it for us.’ The network’s inaugural conference was held at Dannevirke in August 1998. Delegates included managers, nurses, GPs and allied health professionals from both public and private sectors of rural health facilities. The conference developed a forum for sharing information about rural health services and best practice in the changing health environment. Sharon says common issues were the centralisation of health services and the different models of service provision. ‘It was great, we learned heaps. And the biggest plus was that we now have a list of contacts, and in each area there is someone to talk to about the issues surrounding rural health initiatives.’ A newsletter, with a detailed list of contacts, is being published as a resource kit for all those involved. Innovations in Health and Disability Services in New Zealand The Ministry of Health has developed a Web site focusing on innovative ways of delivering health and disability support services. This is called Innovations in Health and Disability Services in New Zealand (know.govt.nz). The three areas on the Web site are Action and Innovation, Integrated Care and Best Practice. Initially only the Integrated Care site is expected to have an interactive component. Provider interest will be assessed before establishing this component. This Web site could have the potential to enhance communications between rural health initiatives. If there is sufficient interest among rural practitioners, a specific rural site could be included either through incorporating rural care with one of these sections, or establishing a separate area for rural services. This could have an interactive component to facilitate the active exchange of ideas and information.
Rural public health
	There are a number of public health issues of particular importance in rural areas: sewage disposal water supplies (sufficiency and quality) exposure to unsafe levels of agrichemical spraydrift injuries and injury-related fatalities (people in rural areas experience a high rate of motor vehicle injuries and fatalities, and farm injuries) the health consequences of serious rural housing need (particularly affecting Maori) emergency management (particularly floods) exposure to zoonotic diseases.4 There will always be challenges associated with maintaining public health services in rural areas. Nonetheless, every effort must be made to retain viability of these services. Government at the local, regional and national levels is working to protect and enhance public health by improving water quality monitoring and providing information, for example, on food safety. FOOTNOTES: 3 Standing orders are instructions for the initiation of treatment by specified health professionals, for particular classes of patients, in specific situations. 4 Infections transmitted to humans from animals.