3.1.1 National Rural health Strategy
3.1.2 Healthy Horizons
3.1.3 Regional Health Strategy and the Rural Health Strategy
3.1.4 National Health Workforce Strategic Framework
3.1.5 Productivity Commission's report on health workforce
3.1.6 National Health and Hospital Reform Commission
3.1.7 Key recent initiatives
3.1.8 Summary of recent rural health policy developments
3.1.1 National Rural Health StrategyThe current trajectory of rural health reform at a national level can be traced back to 1991, and the first National Rural Health Conference, which laid the ground work for a national approach to rural health issues (Commonwealth of Australia 1992). In 1994, the Australian Health Ministers’ Conference endorsed the first National Rural Health Strategy, seeking to provide a framework for coordination of Commonwealth, State and Territory rural health initiatives (Australian Health Ministers’ Conference 1994). The strategy was subsequently updated in 1996 (Australian Health Ministers' Conference 1996).
The broad goals of the National Rural Health Strategy were to guide provision of equitably accessible rural health services that were tailored to the needs of rural communities. The Strategy also sought to provide a mechanism for identifying and addressing agreed health priorities, and measuring progress towards rural health goals.
3.1.2 Healthy HorizonsHealthy Horizons, a framework to guide the development of health programs and services in rural, regional and remote Australia (National Rural Health Alliance 1999) and its successor Healthy Horizons: Outlook 2003-2007 (National Rural Health Alliance 2003) built on the original National Rural Health Strategy, revising and refining the framework for development and implementation of rural health initiatives. Top of page
Healthy Horizons acknowledged that demands on the health system as a whole had shifted. In response, the system itself was moving towards strengthening the capacity of community-based primary care services as the foundation of the health system. There was a recognition that rural health also needed to adapt to this new approach. Healthy Horizons originally set out seven interdependent policy objectives, which were reaffirmed in the 2003-2007 document:
- improve highest health priorities first;
- improve the health of Aboriginal and Torres Strait Islander peoples living in rural, regional and remote Australia;
- undertake research and provide better information to rural, regional and remote Australians;
- develop flexible and coordinated services;
- maintain a skilled and responsive health workforce;
- develop needs-based flexible funding arrangements for rural, regional and remote Australia; and
- achieve recognition of rural, regional and remote health as an important component of the Australian health system.
3.1.3 Regional Health Strategy and the Rural Health StrategyIn 2000, the Commonwealth Government secured the support of the Australian Health Ministers for a Regional Health Strategy incorporating a range of interventions addressing three main themes:
- increasing and strengthening the rural health professionals workforce;
- enhancing rural education and training for health professionals; and
- increasing health services into regional Australia (Department of Health and Ageing 2000).
3.1.4 National Health Workforce Strategic FrameworkIn 2004, the Australian Health Ministers' Conference (AHMC) released the National Health Workforce Strategic Framework, which described key principles and strategies that should underpin a strategic approach to addressing issues relating to the national health workforce.
The Framework referenced a number of sector specific documents, including Healthy Horizons, and paid particular attention to issues affecting rural Australia, identifying three key recurrent themes in previous work; demographic change in Australia (with the health workforce and consumers), new technologies and health care, and empowered consumers (Australian Health Ministers’ Conference 2004).
AHMC outlined a vision for a sustainable, skilled and well-distributed health workforce with a population health focus, and described seven key principles that supported this vision. These can be paraphrased as self sufficiency of workforce supply; distribution achieving equitable access; supportive and attractive health workplaces; cohesion between health, education, vocational training and regulatory sectors to support lifelong learning; recognition of changing professional roles; population and consumer focussed health policy; and collaboration between all health policy stakeholders.Top of page
3.1.5 Productivity Commission's report on health workforceIn 2004, the Council of Australian Governments (COAG) directed the Productivity Commission to undertake a review of Australia’s health workforce, taking into account the work of the AHMC. The
Commission's brief was to identify improvements to institutional, regulatory and funding arrangements in the health care context (Productivity Commission 2005).
The Commission acknowledged in its research report of 2005, Australia's health workforce, that Australia faced significant supply and demand challenges relating to its health workforce, and suggesting four key policy responses:
- reducing underlying demand for services through public health strategies;
- increasing education and training places for some professions;
- improving workforce retention and re-entry; and
- improving productivity and effectiveness of the health workforce.
The national registration and accreditation scheme aims to facilitate workforce mobility, reduce "red tape", facilitate quality training and assessment of overseas trained professionals, promote access to health services and have regard to continuous development of a flexible, responsive and sustainable workforce, and to allow innovation in both education and service delivery (Council of Australian Governments 2008a).
The Commission also acknowledged the specific challenges facing health workers in rural and remote Australia, in particular: limited access to professional support, fewer professional development opportunities; lower housing standards; fewer education and employment opportunities for other family members; and social isolation. Many rural health service employers also face significant difficulties recruiting and retaining staff, with a subsequent impact on both access to and continuity of care for health care consumers (Productivity Commission 2005).
In response to these issues, the Commission identified two promising strategies for rural health workforce development - education and training in rural and remote areas, and 'block funding' models to support provision of comprehensive health services (Productivity Commission 2005).
Since publication, the Productivity Commission's report has been influential in shaping the health care debate, with COAG having accepted most of the key recommendations contained in that report. Discussions are continuing with regard to the most effective implementation of the recommendations.
In 2007, Hepburn and Healy surveyed 41 Australian health policy experts and stakeholders, seeking views on the Productivity Commission’s recommendations, and the 2006 COAG health workforce reform. Health status improvements were identified as an important outcome measure to health workforce reform; however the authors made the observation that:
[i]t cannot be assumed that improved health will naturally result from 'more' health workers or 'more' health care. Training and performance of the workforce, combined with its quality, distribution and support within the broader health system, is likely to do more to influence health status than the number of health professionals alone (Hepburn and Healy 2007).Top of page
3.1.6 National Health and Hospital Reform CommissionThe establishment of the National Health and Hospital Reform Commission is potentially one of the most significant reform initiatives in recent times. The NHHRC was established in February 2008 to develop a long-term health reform plan. The Commission will provide advice to Government on performance benchmarks and practical reforms to the Australian health system to meet a range of longterm challenges, including access to services, the growing burden of chronic disease, population ageing, costs and inefficiencies generated by blame and cost shifting, and the escalating costs of new health technologies (National Health and Hospital Reform Commission 2007).
In April 2008, the NHHRC produced its first report, Beyond the blame game: accountability and performance benchmarks for the next Australian Health Care Agreements, in which it provided a framework for the next round of Health Care Agreements between the Commonwealth and the States and Territories (National Health and Hospital Reform Commission 2008). The proposed framework describes service design principles (generally relating to what health consumers want from the system) and governance principles (generally how the system should work):
[R]ecommended service design principles are: people and family centred; equity; shared responsibility; strengthening prevention and wellness; value for money; providing for future generations; recognising broader environmental influences that shape our health; and comprehensive. [The NHHRC’s] governance principles are: taking the long term view; safety and quality; transparency and accountability; public voice; a respectful and ethical system; responsible spending on health, and a culture of reflective improvement and innovation (National Health and Hospital Reform Commission 2008).
The Beyond the blame game report also identified twelve 'critical challenges' for the health system, selected because they represent areas where the need for change is both well understood and widely documented (National Health and Hospital Reform Commission 2008).
'Critical challenges' of particular relevance for this report are: the need to improve distribution of, and equitable access to, services; ensuring adequate numbers of well-trained health professionals, and promoting research. In relation to the latter, the report makes particular mention of the difficulties in finding sufficient and appropriate clinical placements for health professionals in training, and of the lack of ‘protected time’ for those in teaching and research roles.
Building on the principles and critical challenges already identified, the Commission aims to provide a long-term plan for the health system, which addresses the need to:
- reduce inefficiencies generated by cost-shifting, blame-shifting and buck-passing;
- better integrate and coordinate care across all aspects of the health sector, particularly between primary care and hospital services around key measurable outputs for health;
- bring a greater focus on prevention to the health system;
- better integrate acute services and aged care services, and improve the transition between hospital and aged care;
- improve frontline care to better promote healthy lifestyles and prevent and intervene early in chronic illness;
- improve the provision of health services in rural areas;
- improve Indigenous health outcomes; and
- provide a well qualified and sustainable health workforce into the future (National Health and Hospital Reform Commission 2008).
3.1.7 Key recent initiativesThe 2007-2008 Commonwealth budget announced a range of measures under the banner 'Supporting rural and regional Australians’ , which included funding for the University of Wollongong Rural Clinical School, the establishment of the Dental School at Charles Sturt University, and other measures aimed at retaining and enhancing the rural health workforce.
The Rudd Government’s first budget in 2008-2009 included key initiatives in health care reform, most notably the National Health and Hospitals Reform Commission and a $10 billion Health and Hospitals Infrastructure Fund, both signalling a reform agenda. It also delivered on Labor’s election commitment to fund "GP Super Clinics" (which will include teaching and training facilities) and increased support to medical and allied health professionals undertaking placements in rural areas, doubling the number of placements available to medical students through the John Flynn Placement Program and increasing scholarship support available for allied health workers, mental health nurses and psychologists (Department of Health and Ageing 2008b). This additional funding is a recognition of the difficulties faced by students in undertaking rural placements, as well as an acknowledgement of the importance of rural exposure in influencing students’ career decisions
An Office of Rural Health has also been established within the Department of Health and Ageing (Primary Care and Ambulatory Division), partly in response to the Audit of health workforce in rural and regional Australia (Department of Health and Ageing 2008a), with a mandate to drive rural health reform. The Office of Rural Health has been charged with the review of 60 rurally-targeted health programs, as well as the remoteness classification scheme commonly used to determine eligibility for many programs (Roxon 2008a).
Most recently, at its July 2008 meeting, COAG agreed to roll out the first 4,500 of a planned 50,000 vocational education and training places in priority health professions (Council of Australian Governments 2008b).
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3.1.8 Summary of recent rural health policy developmentsProviding rural health is a challenge; rural and remote locations have intrinsic characteristics which make traditional (usually urban) models of funding and providing health care inappropriate or less effective (Wakerman et all 2006). It is known that, in general, health status declines with increasing rurality, as do access to and utilisation of health services (Australian Institute of Health and Welfare 2008). Although a causal relationship has not been established, these factors underpin the rationale for much rural health policy. However, as many have acknowledged (Department of Health and Ageing 2004, Murray and Wronski 2006), it is not a simple matter of providing more health services in the bush. Rurally-focussed health models, including training models, need to be developed which address the specific and varied needs of rural and regional Australia (and especially the needs of Indigenous Australians).
Many rural health care policy initiatives seek to address either workforce supply or workforce demand factors (although some initiatives address both sides of this equation). Policy that aims to address demand-side factors seeks to decrease demand on the health system, generally through a population health approach aimed at promoting health and wellbeing, preventing disease, and detecting and intervening early where disease occurs to reduce overall mortality. Other demand-reduction strategies include programs to develop better self-management skills in people with chronic illness. The trend toward preventive health care and the population health approach is evident in health policy over the last 15 years.
Workforce-supply strategies include those aimed at increasing the number of professionals in the workforce, improving the distribution of that workforce,1 and rationalising the distribution of skills and responsibilities through innovative models of care. Other workforce supply strategies include the use of new technologies to increase the efficiency or the reach of services.
Workforce policy itself is shifting from a predominant focus on the medical sector, adopting a broader perspective on the health workforce as a whole which recognises that professional roles and role boundaries continue to change, and that healthcare is a collective responsibility. A key contributor to this change is the increase in team-based, interdisciplinary or multidisciplinary care provision which involves different health professionals working together, ideally in a coordinated way. The trend to a greater recognition of multidisciplinary care itself reflects in part the increasing expectations by health consumers.
At their core, these policies and strategies share a goal of contributing to a health workforce that is able to meet rural health consumers’ needs by providing the right mix of skills, in the right place, at the right time.
1 See McDonald et al 2008 for a recent review of different financing models to address access issues for patients with complex needs; they found that while individual financial incentives are widely used in Australia, they were not always effective in rural areas. "Alternative funding arrangements, such as capitation and contracting could be more widely adopted in Australia to enhance access to care for vulnerable population groups without fundamentally changing the overall fee-for-service financing arrangements."