National Rural Health Conference 2015 – Closer to Home.
rural
New Zealand “Alliance Contracting” Workshop – Sept 4th 2014
Alliancing is one approach that the New Zealand health system can use to efficiently allocate scarce resources through building communities of interest across more than one practitioner or organisation. There are core elements to alliancing that contribute to improving success.
An Alliance reflects a group of organisations agreeing to work together to achieve shared outcomes and using a shared decision-making forum, the Alliance Leadership Team (ALT). The approach provides a more ‘fit for purpose’ arrangement that promotes and facilitates integration, regional service planning, and alliance funding and planning. It provides a mechanism for clinical leaders to be involved in the development of health services.
Service Level Alliances are established by the ALT, as required, to implement significant service change and or specific service redesign. ALTs are decision-making forums for organising groups of related health services, including decisions on contractual mechanisms and budgets.
Who will be involved in a Rural Service Level Alliance?
DHBs, primary health organisations (PHOs) and providers will work together in a Rural Service Level Alliance. They will involve GPs and possibly other health professionals and organisations who deliver a given service. They are likely to engage with patient groups and communities. The range of participants depends on the agreed scope of the discussions.
Workshop Summary:
More than 80 representatives from rural general practices New Zealand-wide, DHBs, PHOs and other allied rural sector organisations attended a workshop in Wellington on September 4 to hear about and discuss the new Alliancing era and its impact on rural communities.
In October 2013, Associate Health Minister Jo Goodhew announced the Government’s support for a new way of allocating rural funding through Service Level Alliances and that additional rural funding would be provided in the form of transitional funding and rural practice sustainability funding.
Alliancing will see DHBs, PHOs and other health providers’ work together in Rural Service Level Alliance Teams. These teams will involve GPs and other health professionals, and organisations and could also involve community representation. Discussions and negotiations will ultimately determine funding levels allocated to rural practices for services provided.
Organised jointly by the New Zealand Rural General Practice Network and the Ministry of Health, workshop delegates gathered at the Rydges Hotel to hear speakers including the Deputy Director-General of the Sector Capability and Implementation Business Unit Cathy O’Malley, Network chairperson Dr Jo Scott-Jones, Network Board members and representatives from Midland Health Network and the Canterbury Clinical Network speak about the Alliancing concept and their experiences of instituting it. During the day delegates participated in workshops, listened to panel discussions and discussed and questioned the Alliancing concept.
New Zealand Rural General Practice Network chairperson Dr Jo Scott-Jones was delighted with the turn-out and with the positive attitude from delegates to embracing the new funding era. He urged them to “get involved” in the process and engage with their peers, communities, allied health services, DHBs and PHOs to ensure the future viability of their practices and services to communities and patients.
Dr Scott-Jones said Alliancing offered a formal infrastructure which would allow rural general practice to look closely at the way it operates alongside PHOs and DHBs.
“We need to be open to how we can “do things better”, so that services in rural communities continue into the future.
“At the same time we need to ensure the current somewhat fragile services are supported and retain their financially viability.”
Key outcomes of the workshop were:
• A MoH assurance that “there is no intent for rural funding to go anywhere other than rural general practice” There has been a lot of anxiety about this amongst providers. The process was much more about the sustainability of services in communities than about the funding.
• If an ALT wants to just talk about changing the “rural premium” funding streams it has missed the point – this is about big picture planning and innovation and is a real opportunity to develop sustainable rural health services
• Examples of Alliancing work already underway around the country provided an opportunity for delegates to hear what had worked well
• Acknowledgement that many rural practitioners, PHOs and DHBs will want to take their time over this process and develop these new relationships with trust and integrity
• The Network will continue to facilitate/share progress related to rural Alliancing
• Key messages and interviews with presenters will be available via the Network’s website: www.rgpn.org.nz
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The Importance of Training in Rural Areas
The recent Rural Health Conference in Gramado gave us time to reflect on a number of important issues facing rural communities across the world – along with the pressures of climate change, population growth and increasing burdens of chronic disease the “perfect storm” is compounded by the continued problem of access to the quality medical services.
New Zealand began life as a rural nation, and our national identity takes pride in our ‘can-do’ approach to life. It is a fundamental human right that people living in all regions have access to high quality health services, perhaps especially in regions at distance from main population centres, regions that are often the backbone of a country’s economic wealth, and centre of leisure activities (1).
Having a healthy, engaged and well educated health workforce is important to the wellbeing of all communities. Attracting health professionals to live and work in rural areas is an international problem familiar to all WONCA members (2).
It may be a little confusing why this is a problem for those of us that have made this lifestyle choice, but it may be more prevalent in areas where there is a high demand, especially on after hours care, low reward and professional isolation and where family and social issues put pressure on rural providers (3).
In New Zealand year after year GP workforce surveys have detailed the on-going problems of recruitment and retention into rural practice (4-6), and the shortage of providers in rural areas continues, with over 25% of practices currently seeking full time GPs and Nurses (Rural General Practice Network unpublished data 2014.)
The medical workforce is the best studied example of a need that is widely reported to affect rural nurses, pharmacists, midwives, dentists and physiotherapists (7).
New Zealand needs 50% of its medical graduates to choose General Practice as a career, currently only 29% have a “strong interest” in doing so at the end of the medical degree offered by Auckland University, (8) and it is unclear how many NZ graduates actually become GPs and even less is known about how many of them to choose rural practice.
We do know that currently only 9.2% of doctors working in rural areas are NZ trained, and only 16.4% of NZ trained GPs choose to work in rural areas (9). We do know that as a proportion of the workforce the number of GPs is falling compared to specialists (10).
Rural workforce statistics show that the average age of rural General Practitioners continues to age and these communities rely heavily on international medical graduates to provide services. This leads to a continuing need for recruitment as we are failing to “grow our own” health workforce (9).
If we are to “grow our own” workforce it is very clear from international studies that choosing students with rural interests and backgrounds, exposing undergraduates to positive training experiences in rural areas, and providing well supported career pathways in rural practice increases the intention of medical students to work in rural communities once they graduate (2, 11).
We know that the career decisions of students and young professionals in the future will be affected by the way health career choices are viewed by society, available financial incentives, appropriate professional development and career opportunities, the availability of locums, a good quality of life ability to achieve balance, and the lifestyle choices of their spouses and family needs (2).
Many of us involved in education will be aware of the idea of “constructive alignment” of intended learning outcomes – what we hope to achieve – and the assessment and learning activities that are planned. The same theory applies to issues that face us in our rural communities.
We want to see an improvement in the health outcomes for rural communities, “Health for All Rural People”, we need our governments, colleges and colleagues to be measuring these outcomes – because of it is not measured it won’t be changed – and then we need our recruitment and retention and service delivery model thinking to be focused on achieving these outcomes.
This may seem bigger than Ben Hur but from what we do know it is clear that in order to meet the needs of our current and future population, in order to achieve equity and fairness or health outcomes for rural communities, in order to support and further develop the economic health of our rural sector, government needs to further support and expand initiatives that that increase exposure of training health professionals to positive rural experiences.
Dr Jo Scott-Jones
REFERENCES:
1. Ministry for Primary Industries : Rural Communities 2014 [09/05/2014]. Available from:http://www.mpi.govt.nz/agriculture/rural-communities.
2. WHO. Increasing access to health workers in remote and rural areas through improved retention:global policy recommendations. Geneva: World Health Organisation, 2010.
3. Burton J. Rural Health Care In New Zealand. Wellington: Royal New Zealand College of General Practitioners, 1999.
4. London M. New Zealand Annual Rural Workforce Survey 2000. Christchurch: Centre For Rural Health; 2001.
5. Mel Pande M, Fretter J, Stenson A, Webber C, Turner J. Royal New Zealand College Of General Practitioners Workforce Survey 2005 part 3: General Practitioners In Urban and Rural New Zealand. 2006.
6. The New Zealand Medical Workforce 2007. New Zealand Medical Council; 2008.
7. Health Workforce Development: An Overview. In: Health Mo, editor. Wellington, New Zealand2006.
8. Poole P, Bourke D, Shulruf B. Increasing medical student interest in general practice in New Zealand: where to from here? The New Zealand medical journal. 2010;123(1315):12.
9. Garces-Ozanne A, Yow A, Audas R. Rural practice and retention in New Zealand: an examination of New Zealand-trained and foreign-trained doctors. The New Zealand Medical Journal (Online). 2011;124(1330):14-23.
10. Medical Council of New Zealand: The New Zealand Medical Workforce in 2012 Wellington, New Zealand2013.
11. Walker JH, DeWitt DE, Pallant JF, CE. C. Rural origin plus a rural clinical school placement is a significant predictor of medical students’ intentions to practice rurally: a multi-university study. Rural and Remote Health. 2012;12(1908):Online.
12. Farry P, Hill D, Isobel Martin I. What would attract general practice trainees into rural practice in New Zealand? NZMJ. 2002;115(1161).
13. Worley P, Strasser R, D. P. Can medical students learn specialist disciplines based in rural practice: lessons from students’ self reported experience and competence. Rural and Remote Health. 2004;4(338):Online.
14. Ministry of Health: Voluntary Bonding Scheme Wellington, New Zealand2014 [09/05/2014]. Available from: http://www.health.govt.nz/our-work/health-workforce/voluntary-bonding-scheme.
15. Rural Health Interprofessional Immersion Programme Wellington, New Zealand2014 [09/05/2014]. Available from: http://www.rhiip.ac.nz/.
16. University of Otago: Rural Medical Immersion Programme Otago University, New Zealand2014 [09/05/2014]. Available from: http://rmip.otago.ac.nz/.
17. P Poole, W Bagg, B O’Connor, A Dare, J McKimm, K Meredith, et al. The Northland Regional-Rural program (Pukawakawa): broadening medical undergraduate learning in New Zealand. Rural and Remote Health. 2010;10(1254):Online
(published in Wonca News June 2014)
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Wonca World Rural Health Conference Gramado April 2014
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.
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First Post -Truth develops over Time
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….
Don't Shoot.. 