OPINION: Out with the New, In with the Old


Rural and Remote Medical Services Ltd (or RARMS for short) was established by rural doctors in NSW as a charity in 2001 to help rural and remote communities that struggled to attract and retain medical and health workforce.


Over 20 years we have helped more than a dozen communities to build strong and sustainable primary health care services.


Today we support over 20,000 active patients in 8 disadvantaged rural and remote communities, and a further 250,000 people across the southern NSW and residential aged care facilities.


We are just one of a number of highly successful models of sustainable rural and remote health care identified by Wakerman and Humphries et al in their seminal research on this topic [1].


Wakerman and Humphries et al 2008 literature review on what makes a sustainable model of rural and remote health service delivery found that the RARMS ‘Walk-in, Walk-out’ model, and the ACCHO model, were among a number of exemplars for health care delivery for rural and remote towns [1].


Wakerman and Humphries et al have also identified several barriers and enablers to sustainable rural and remote health systems [2]:


Barriers

  • Many rural health initiatives result from a “liberation of ideas” within government in response to concerns from disaffected rural and remote electorates that can lead to isolated, fragmented and ad-hoc responses.

  • There is too much reliance on new and “innovative” pilot projects rather than sustainable and proven solutions.

  • Cost-shifting between federal and state/territory health authorities, a lack of change management capability, and turf issues can undermine the ability to develop funding models appropriate to ensure sustainability of rural and remote health care.


Enablers

  • Community involvement is essential for effective service implementation and sustainability.

  • Community based boards contribute significantly to service sustainability including leadership from local health professionals.

  • A strong Primary Health Care approach, encompassing community participation, multidisciplinary practice, a focus on disease prevention, and a shared leadership vision for the service, characterised successful models.

  • Adequate funding and appropriate funding mechanisms are required to provide more financially attractive package for GPs.

  • Effective working relationships between organisations and their leaders facilitate access to a broader range of services, professional development activities, peer support etc.

  • Adequate infrastructure is vital for implementation and sustainability.

  • Efficient IT systems and appropriate physical infrastructure were particularly critical to effective chronic disease management.

  • Workforce supply was not a dominant factor affecting implementation but investment in career planning and pathways for health professionals was an important part of career maintenance.


In 2020 RARMS commenced a program of community consultations around the future of rural and remote health as hospital services continued to decline and more and more GPs retired.


The idea of funding Rural and Remote Community Health Organisations, incorporating successful features of the RARMS model, has been widely embraced.


This work complements the policy research of the National Rural Health Alliance which is advocating for Rural Area Community Controlled Health Organisations modelled after the ACCHOs which has been so successful in delivering health services for Aboriginal and Torres Strait Islander communities.


But to progress towards a solution we need to move beyond the idea that the States and Commonwealth will ever resolve their differences around health funding. This has been holding back genuine reform of rural and remote health for decades.


The only answer to the problem is for the Commonwealth to take full responsibility for primary health care in rural and remote communities. This could be funded by redirecting existing resources to independent primary health care providers to operate in rural and remote towns using a range of flexible and proven models that reflect local community need.


Both the RARMS and ACCHO model are tried and tested, and research shows that they are effective in delivering sustainable health care and workforce to areas of need if the policy settings and funding model is right.


Strengthening primary health care in rural and remote towns also makes economic sense. It reduces preventable illness and avoidable hospitalisations, meaning that the Commonwealth will pay less than it otherwise would for hospitals and health care in the future.


To ensure the future delivery of accessible health care in rural and remote communities, we cannot spend the next ten years wasting millions of dollars evaluating new and innovative models of service delivery to determine if they might work. We need to invest in what we already know works and is delivering successful outcomes on the ground.


[1] Wakerman, J., Humphreys, J.S., Wells, R. et al. Primary health care delivery models in rural and remote Australia – a systematic review. BMC Health Serv Res8, 276 (2008). https://bmchealthservres.biomedcentral.com/articles/10.1186/1472-6963-8-276

[2] John Wakerman, John S Humphreys, Robert Wells, Pim Kuipers, Judith A Jones, Philip Entwistle and Leigh Kinsman. Features of effective primary health care models in rural and remote Australia: a case-study analysis. Med J Aust 2009; 191 (2): 88-91. https://www.mja.com.au/journal/2009/191/2/features-effective-primary-health-care-models-rural-and-remote-australia-case.