A healthy rural New Zealand is important for our country
Dear new Government, DHBs, PHOs, and honourable colleagues in New Zealand,
We are now in the “Age of Alliancing” when local problems have an infrastructure to provide local solutions, but let me remind you of some national problems that need national solutions, and tell you why you should all worry about the state of rural health services in New Zealand.
I also want to point out some simple things that you can do to help.
Our culture is rural
New Zealand is a rural country, by history, by culture and by self-identity. We see ourselves as “number 8 wire” “can do Kiwis” who come from a county that is “100% pure[[1]]”.
Rural people make up almost 14% of the total population and 440,000 people live in rural New Zealand, over half of them outside small rural town centres[[2]].
Although the proportion of people living rurally is falling 1% a year as more people migrate to cities, and this has implications for their “political voice”- the actual number of people living rurally continues to grow.
Rural people need services
Rural communities serve the poorest and most deprived populations of New Zealand, and there is a higher proportion of Maori in rural communities compared to urban centres[1].
This means rural communities have high levels of need for health services; if we are to achieve “equitable” health outcomes for the most deprived of our populations we need to provide services where they are - in their community.
The modern concept of “access” is complex, but if we do not provide accessible services near to people, the use of the service suffers from “distance decay” – the further away a service is the less likely it is to be used[2]. We could be justifiably accused of doing nothing to combat Tudor-Harts inverse care law which states that the least resources go into the care of the neediest populations[3].
Health outcome measures are surprisingly good on a superficial look at rural community outcomes in New Zealand, however the official statistics are confounded by an unfortunate decision to lump together places like Taupo, Masterton, and Blenhiem with Opotiki, Te Anau, and Raetihi as “independent urban areas”.
But even accepting these anomalies it is still the case that rural Maori have the shortest life expectancy of all Maori communities, that more rural people with disabilities live at home than people in urban areas[4], that rural Maori are more likely to smoke, be overweight, have risky drinking habits, have diabetes, and anxiety disorders and less likely to have a GP, a dentist or an optician, than urban Maori or Pakeha[5].
The New Zealand Institute for Rural Health[6] shows that people who live in Independent Urban Areas as well as rural areas with low urban influence and in some satellite urban areashave the highest incidence of cardiovascular disease, malignancy, renal and respiratory disease alongside the highest levels of potentially avoidable mortalities and they make up a large percentage of secondary care activity.
Depression and anxiety disorders affect all areas of society, but the pressure seems to be more intense in rural areas where suicide has been a more prevalent behaviour. MoH statistics showin 2010 a suicide rate of 15.9 per 100,000 people for rural people[7]; this has dropped to 12.5/100,000 in 2011 but is still higher than for urban populations at 10.6/100,000.
We know that in the UK, farmers are amongst the highest risk occupational groups for suicide [8]and although the data is not collected in New Zealand in the same way based on coroner data, Federated Farmers have identified this as a high risk especially in years of financial hardship[9].
Having a healthy rural New Zealand is important for our country
The Ministry for Primary Industries says “agriculture is how New Zealand earns a living” it generates 70% of our merchandise export earnings and 12% of our GDP, this rural industry is “a major determinant of employment and social wellbeing” of our country [10]. The CIA’s “World Factbook[11]” has it that agriculture employs 7% of our population.
Tourism accounts for 10% of our employment and brings in $65m/day – around 16% of our foreign exchange earnings or 9% of our gross domestic product [12] much of this comes from rural New Zealand. The Flight of the Conchords parody posters “New Zealand – rocks” and “New Zealand – Just like Lord of the Rings” would not be possible without our rural backbone.
If you are not yet convinced that supporting the things that ensure the people living in rural communities remain healthy and happy and safe is important, the next time you are driving down a rural road on your way to visit a friend, go on holiday or be lost due to an Apple Maps error, just think how easy it would be to find your car upside down in a ditch.
“Who ya gonna call?”
I hope I have convinced you that having a good rural health infrastructureand healthy rural communities is essential for the health of all New Zealand.Unfortunately, we don’t have a healthy system.
Twenty-three organisations, including the Network, community, industry and professional groups have formed an organisation the “Rural Health Alliance Aotearoa New Zealand” [13] and everyone of these organisations is calling for the same thing - we need to put some concerted effort into improving the health and wellbeing of rural New Zealand.
Let’s look at one aspect of health infrastructure with some detail – the GP workforce.
The problems of the rural GP workforce are worse than those for the GP workforce as a whole.
In contrast to the stated intention of successive governments since the launch of the Primary Healthcare Strategy in 2001 Medical Council workforce data shows that since 1999 the ration of GPs to population nationally has decreased from 84/100,000 to 74/100,000.
There have been an extra 170 medical school places funded by the government since 2009, and some new initiatives like the Inter-professional Rural Immersion Programme introduced in 2012 in Whakatane and Gisborne.
There has been some improvement in the Voluntary Bonding Scheme focus on rural general practice and expansion into primary care nursing in 2013, but there remains much room for improvement in this scheme.
There are currently 651 active GP registrars in the GPEP training programme and 228 gained Fellowship in the 2013 calendar year, and with a recent boost to GP training funding up to 170 junior doctors will be in a GP training place in 2014-2015.
However, given that over 80% of GPs are aged 45 years and over, and around 40% of GPs intend to retire in the next 5-10 years, and RNZCGP president Tim Malloy states that currently New Zealand is 1000 GPs short of its ideal workforce[14] it is clear the GP workforce is under considerable pressure.
In rural general practice alone there are 40 permanent GP vacancies affecting 20% of rural practices around the country.
The data we have is limited but it can reasonably be assumed that the same situation applies to the rural primary care nurse workforce, as well as allied health, dental and pharmacy providers.
In order to properly assess the areas of need and what should be done we need regular and extensive workforce surveys that will help us to target our efforts to address the pressures effectively.
We understand something of the outcome issues in rural health, but getting accurate data would enable us to more specifically target areas for improvement and ensure what we put in place works.
There are some simple solutions to these problems:
Ministers, DHBs and PHOs:
- Collect rural specific data about workforce and health outcomes – we need serial data collected over time to show the effects of policy.
- Increase the amount of rural specific training that is undertaken in New Zealand – we know that people who come from rural areas and trained in rural areas are more likely to work in rural areas.
- Increase the attractiveness of working in rural New Zealand for health professionals – if people want to stay people will want to come.
Colleagues:
- Teach – there is a growing call for undergraduate and postgraduate placements in rural practice – we need to step up to the task and learn to “grow our own” workforce.
- Be financially responsible – in our health system your practices need to be profitable in order to be able to provide new levels of service, and to be attractive enough to retain and recruit
- Report on outcomes – write, speak at local service clubs, engage with local, regional and national bodies that are involved in your community – be visible and vocal about the good things you do.
Rural health issues transcend party politics, and need long term strategic thinking and implementation plans, we need a national rural health workforce strategy.
The Network/Alliancelooks forward to continuing to support members at all levels to achieve equity of health outcomes for rural communities across New Zealand.
[[1]]
[[2]]
[1]
[2]
[3]THE INVERSE CARE LAWJulian Tudor Hart The Lancet - 27 February 1971 ( Vol. 297, Issue 7696, Pages 405-412 )
[4]
[5]
[6]
[7]
[8]
[9]
[10]
[11]
[12]
[13]
[14]