Author: opotikigp

More on the 12th Wonca World Rural Health Conference

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Attending in international conference is always a valuable experience for me personally and for the two sponsoring organizations who helped towards my costs (The RNZCGP and the NZRGPN) important in maintaining an international profile and being able to influence decision making at this level in WONCA.

The conference was attended by Michael Kidd and Amanda Howe (WONCA president and president elect) and both of these people acknowledged the Wonca Working Party on Rural Practice (WWPRP) as the most productive working party within WONCA and that the qualIty and breadth of work produced in the past has had international influence, in particular in WONCA’s work with the WHO and UN.

Attendance at the WWPRP meeting on April 2nd was as usual very open and inclusive, this has been the philosophy of the working party, which has run on the basis of a core of dedicated and recurrently attending members who support a small executive. The whole working party meets face to face once a year at each rural or world WONCA conference, and these meetings take the form of a “council” made up by the people who attend.

I am an executive member (I was appointed as “public relations officer” in 2013 )

Present at this meeting were people from Alaska, Usa, Canada, Columbia, South Africa, Croatia, Serbia, Brazil, Australia, New Zealand, Nigeria, Germany, Norway and the UK.

Membership of the organisation was discussed and it was generally agreed that the WWPRP would remain open to all who come to the meetings, with an executive, a core of active members and a network of other interested people.
It was hoped that the working party will achieve a balance of gender, and more younger people, over the next 3 years.

Questions were raised about how to engage with “3rd world” countries especially when income is limited, and language a barrier. The executive will work on this but has in the past year established an active “google list server” creating email linkage between interested members (this has over 300 rural doctors linked currently and is still rising,) we have had a monthly “rural round up” in WONCA news, and have an active “twitter” presence @ruralwonca.

The group asked the executive to look at a regional structure for membership of the WWPRP whilst retaining the current open membership. Whilst applying some structure to membership of the WWPRP associated with WONCA regions the group suggested the executive use other working party policies to identify gaps, for example in the Working party for women, each region has an older and a younger member.

Social media links are an opportunity we need to build on – the group suggested the executive build and administer a “facebook” or “google hangouts” social presence as members of the list server seem to need a social outlet as well as discussion forum.

Funding was discussed as a perennial problem and some ideas as to how to raise money discussed.

The WWPRP has developed over time a number of influential policies, statements and declarations, these are being reviewed and people were allocated a responsibility. I will be looking at the policy on Information Technology and its use to improve rural health outcomes.

The main work undertaken by the Working Party over the past 7 years apart from the regular conferences has been the development of the Rural Medical Education Guidebook launched at this conference and the Melbourne Manifesto statement around ethical international recruitment.

Other issues to be discussed in workshops in this conference include the future role of rural hospitals, and rural proofing of policy. The WWPRP spent some time discussing these workshops and organizing the role of WWPRP members over the next few days.

The Dubrovnic conference in 2015 was discussed, and the organizing team, have decided to build in a nursing stream to be added to the conference, previous conferences I have attended have had a strong inter-professional education flavour to them, reflecting this.

The conference itself started the following day and although it is usual to find the main benefit from attending a conference like this is in the out of session networking and connections, all the keynote and individual workshop sessions were both useful and engaging.

Highlights of the conference programme included Michael Kidd’s presentation, inspired by the WWPRP guidebook and previous work, in which amongst other things, he quoted from the chapter of the Guidebook written by NZ’s Campbell Murdoch where he paraphrases Tudor Hart’s Inverse care law, claiming that quality of care is thought by some specialists to be inversely proportional to the distance from a teaching hospital.

Amanda Howe talked mainly about the role WONCA has in the international sector and how important it is for member organizations, through bodies like the WWPRP and the Working party of indigenous people, headed by Tane Taylor from New Zealand to be engaged in its work.

Roger Strasser gave the second John MacLeod address, succinctly detailing a lifetime’s worth of research and practice around rural medical education into a fascinating forty minutes. Along with John Wynn Jones’s keynote on Rural Proofing, these two orations emphasized the importance of rural communities to their countries, and of rural health workforce to those communities. They showed ways of addressing the issues raised by distance, lack of amenities, extended community expectations and workforce retention, recruitment and training.

I am very much looking forward to these speeches being available on line through the post conference website.

One of the changes implemented in Brazil compared to recent other WWPRP conferences was a “rural skills” stream, I ran a workshop focussing on or hospital assessment of trauma and pre hospital analgesia which was attended by around 15 Brazilian delegates and through the excellent “real time” translation worked well.

I also contributed to the workshop on small rural hospitals, sharing data from the DivRHM training scheme and emphasizing the NZ philosophy of including the Division within the RNZCGP. I also highlighted the joint training (around PRIME and APLS / ATLS) for example and extended responsibility of nurses in rural New Zealand.

I presented at the workshop on Rural Proofing and will continue to contribute to the work that is to be undertaken over the next 12 months leading to a larger presentation from the WWPRP on this issue in Dubrovnic in 2015. Amanda Howe took on board the message about rural proofing and committed to ensuring WONCA the executive considered “rural proofing” WONCA policy.

I also attended talks and workshops around concerning “rural stories”, innovation in rural practice, community engagement in rural areas, disaster management and rural family medicine, small group training “clinical jazz.”

I was also able to have NZ students highlight in the conference photographic exhibition.

The conference was personally very interesting and I learnt a lot. I consolidated relationships with other members of the WWPRP and made new connections with researchers in the USA (David Schmitz and Randall Longenecker) and the UK (Philip Wilson). I shared several conversations with Amanda Howe who is coming to the RNZCGP conference in July, and through conversations with Tanja (Croatia) expect to be invited to join the Dubrovnic organizing committee, along with a NZ rural nurse.

CONCLUSION

Rural health issues remain very important in the NZ context. Attending this conference and being part of the WWPRP help us to influence our own communities through the international influence it exhorts. We are strengthened by association with others dealing with similar issues.

The fact of being there indicates to our own Universities, members and Government that we do not suffer from what the Brazilians call “Stray Dog Syndrome” – the self doubt that arises from isolation.

I used the social network “twitter” (@RNZCGP1, @ruralwonca and #nzrgpn) to disseminate information about the conference as it happened, and will now undertake to disseminate further some of the learning from the conference through press releases, through this wordpress blog “Don’t shoot..” and facebook.

Wonca World Rural Health Conference Gramado April 2014

opotikigp family medicine, general practice, Healthcare, rural , , , ,

The WONCA WORKING PARTY on RURAL PRACTICE is the rural working group of the world organisation of academic associations and national colleges.
Amongst other work it runs regular conferences and Gramado in Brazil was host to the 12 th WWPRP conference.

The picture above is of Carlos Grossman and his wife Doris, he was heralded during the conference as the father of family medicine in Brazil, I spoke to him about why as a cardiologist in the 1970s he had decided to set up a family medicine programme.

His response was both simple and profound : ” We need to be close to the people.”

Is there a better explanation ?

Rural people are disadvantaged from the outset because of distance, Carlos Grossman recognised it is essential to have health care that is provided close to the people, by a professional trained to engage closely with them in their work and family life, a professional who shares the closeness of the community. This shared experience, also identified by McWhinney as a essential part of family practice, brings with it opportunities for fantastic work in supporting people to live happier and healthier lives.

It is a phenomenal thing to come to a realisation that the culture you work in as a GP is substantially different from that of other GPs, and the question of what it means to be a “rural” GP is worth a later exploration, suffice to say being able to spend time with like minded but different people, with a richly diverse way of dealing with a common set of challenges was not only interesting but I suspect will prove useful in the New Zealand context.

My task now is to share some of the ideas that were shared with me during the event.

For those of you who “twitter” searching through my recent tweets using #nzrgpn you will be able to find slides and comments from the main speakers.

Consider following me @opotikigp and @ruralwonca for future links and conversations about rural health.

Rural Resilience

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“He taru kahika” – Walk on, it is only summer rain falling – (Maori Proverb about resilience.) 

Resilience and sustainability are going to be the “buzz words” of 2014 I suspect. 

Rural communities in the 21st Century need to build resilience and as rural health providers can be powerful contributors to that work. 

They need resilience because they are facing the challenge of climate change.

They need resilience because they are facing economic pressure. 

They need resilience because they are getting smaller.

They need resilience because they are politically marginalised. 

They need resilience because no-one else is going to be there when push comes to shove. 

 

The New Zealand primary system in rural areas particularly depends on small businesses owned and operated by GPs – this competitive model of providing care is prone to inefficiency and reduces resilience as what is right for a business is often not what is right for a community. Competition between providers may result in “lean” businesses, but people’s needs are often sacrificed and long term planning and development takes second place to profit and short term gain.

PHOs and DHBs mainly show little or no regard for the long term future of primary care services, and time and time again we hear of practices closing, amalgamating, or struggling from locum to locum with little or no help or support from the system that is supposed to be responsible for the care of the community. 

As a profession we take responsibility for the whole person, we walk the talk when we adopt the bio-psychosocial model of care – we approach the individual and their family in a holistic way and address their physical, emotional, and spiritual needs to enhance their sense of wellness. Increasingly we need to do this for communities as well – people need communities to live and work in, and an unhealthy community makes life worse for everyone. 

It may seem too hard to begin to embrace the task of developing sustainable, well connected communities in which our patients can live – the good news is that it starts with ourselves as a community of rural providers. 

Small towns and communities may have rosy reputations as “rural idylls” but those of us that live in them know the truth that many small communities are exclusive, self absorbed, toxic to change and intolerant of difference. Financial sustainability of small business in small communities is marginal and a competitive business model adds stress into an already stressed work environment. Rivalries are not diluted by the sense of anonymity and distance that can be achieved in larger places, individual and generational grudges can develop and tend to be sustained. 

Health workers are not immune to these failings, we can develop professional jealousies and anxieties that make us inaccessible to others, and cut us off from our fellow health team members. 

However there are great examples of how we can do better.

In preparation for the upcoming conference in Gramado (http://www.woncarural2014.com.br/ingles/index.php) the Wonca Working Party for Rural Practice has been discussing the role of rural hospitals in communities and disaster preparedness. It is heartening to see initiatives like Arran Resilience (http://www.arranresilience.org.uk) showing how it can be done – if you have “the spark!” (http://www.globalfamilydoctor.com/News/RuralRoundupItsallaboutthepeople.aspx) 

It is also important that rural providers, despite being intensely busy day to day, become involved in national networks.  We bring a unique perspective to these tables and without our involvement our communities will be less visible, by being involved we can help make the people who have power focus on the resilience of our communities. This is what the New Zealand Rural General Practice Network (http://www.rgpn.org.nz/) is all about, linking together rural providers nationally and in combination with the Rural Health Alliance Aotearoa (http://www.youtube.com/watch?v=qHBcZV6Lzdg) bringing communities of interest together to keep rural health and wellness on the agenda. 

It doesn’t have to be so hard. Ask yourself – how often do you sit down with the other health providers that work in your area and share a cup of tea? There is a wealth of expertise in your neighbours that can be learnt from and built on, and you have a shared experience of care and can support each other in your work. Make 2014 the year to take advantage of your networks, put aside past grievances, pull up your big boy / girl  pants and get together for a chat.  

First Post -Truth develops over Time

opotikigp family medicine, general practice, Healthcare, rural , ,

Don’t shoot the messenger.

The purpose of taking this step into bloggersphere is to provide another outlet for my own opinions about the state of healthcare, in particular how rural communities, and in particular rural communities in New Zealand, fare.

I suspect that when Don Berwick and his colleagues delivered their Don Berwick’s report for the UK NHS they felt a bit like Phiddepides the apocryphal first marathon runner.

Phiddepides bore bad news of invasion, and of the failure of the government of the day to respond.

Berwick et al told the bad news to the UK government of the need for systematic and widespread change to address the failures of the health system, to develop a culture of learning and patient safety, and the letters he wrote, to management, staff and the public exhort a response. They not only challenge the system in England, but internationally. Have we responded?

Famously Phideppides died at the end of his courier run, conveniently I suspect, since the bearers of bad news often did not fare too well in ancient times.

Many bearers of bad news are still “shot down” at least metaphorically, and perhaps in an effort to avoid this people who challenge the status quo will couch their approaches as “solutions” spinning the bad news to assuage the anxieties of leading political parties.

The problem is it is almost impossible to keep everyone happy all the time whilst maintaining the feeling of freedom of expression.

I have been told that you need to play the game if you are to have influence, to treat the powerful like they are children in a sandpit, fighting for the bucket that makes the sandpies.

It seems to me that a regular personal viewpoint, expressed clearly and with the acknowledgement that it is often through expressing ideas and debate that opinions form, could help to get the message through to the children in the sandpit.

Here’s hoping they don’t shoot….