Submission to the National Health and Hospitals
Reform Commission
The Council of Remote Area Nurses of Australia (CRANA) is the only
national organisation with the sole purpose of representing remote nurses and
as such we welcome the opportunity to put forward a submission to the Health
Reform Commission. Remote health status is poor in Australia with
unacceptable health outcomes and life expectancy gaps. Remote health
services and remote health practitioners – both having struggled in a resource
poor and neglected environment – have been amongst some of the most
innovative and have demonstrated the most health gain over the past ten years.
CRANA urges the Commission to consider the lessons learnt from this that
may be applied across the national health system. There is still a long way to
go.
We have read the first report and examined the health challenges and
principles. These align with principles identified by CRANA and the
challenging health issues faced by remote area nurses and remote health
services. At this stage we have nothing to add to their descriptions. We are
particularly pleased you have articulated equity, respectful and ethical care and
a person and family centred approach.
CRANA is a member organisation, established twenty five years ago (1983) by
remote area nurses from across Australia in recognition that the health status of
people in remote areas was poor and was significantly dependent on a well
trained, supported and sufficient workforce, and the need to redress the social
justice issues and health inequalities.
Remote area nurses, through CRANA, have concentrated on a dual approach to
overcoming the challenges and inequalities in remote Australia: what could we
do for ourselves to improve the quality of health care, and what we could add
voice to and do with others: public health advocacy to bring about change in
the impacts of the determinants of health. Interdisciplinary collaboration and
focus on the aim of CRANA ‘safe and high quality health care to remote areas
of Australia and her Territories’ has seen a sustained advocacy program and
participation in research as well as successful innovation in remote
professional and management education, clinical upskilling, best practice,
health systems and health service development and professional support. It has
also seen the development of a strong evidence base on which policy decisions
and clinical care can be made.
Remote Australia spans ninety percent of Australia’s land mass and between
six and twenty three percent of the population, depending on the classifications
used. It is characterised by small, dispersed and diverse populations, harsh
environments, climatic extremes, poor infrastructure and access to transport
and high health need. Climate variability and rural restructure has seen some
previously categorised rural areas become remote in terms of service provision.
Remote Australia is also home to the mining industrial base, of which are some
of the wealthiest.
The provision of health services in remote Australia is a confused mixture of Federal or State funded,
State, Territory Government or NGO administered, regional and individual Aboriginal community
controlled heath organisations and not for profit organisations such as Silver Chain, Uniting Church
Frontier Services, or Victorian Bush Nurses Association, delivered with a smattering of services
provided by tourism, industrial or mining companies, predominately for their staff. In fact, a feature of
remote Australia is that Government did not, until relatively recent times, see they had a role in the
provision of health services, regardless of the ethnic characteristics of the population. This is in
contrast to large rural towns and regional cities where, minimally, a hospital then a community health
service was developed. This situation means that there is considerable catch up to be achieved in
infrastructure, funding and service development as well as an attitudinal change to one where remote
areas matter and is faced as a challenge, instead of a frustrating basket case.
According to CRANA data, there are two hundred and forty eight clinics staffed by five hundred and
ninety five nurses and ninety hospitals with fourteen hundred and ninety one nurses in remote and
very remote areas. The term ‘hospital’ is defined as a facility where there is qualified staff on duty
over the 24 hour period and the capacity for inpatients. Several of these hospitals are remote regional
hospitals, with large staffing across the disciplines. After hours services in the clinics is provided by
on call arrangements by the remote area nurses and health workers, where present. This is significant
as there are 51 clinics with no resident remote area nurse, 72 that are single nurse posts and a further
61 in very remote areas staffed by only two remote area nurses, all providing 24 hour cover seven
days a week.
The on-the-ground remote health services are complemented by the ‘mantle of safety’ aero-medical
services provided largely by the Royal Flying Doctor Service and the State and Territory and
Aboriginal Community Controlled Health Service fly-in or drive-in medical and allied health support.
There are few resident doctors. In the Northern Territory there are 78 very remote clinics dispersed
across the state staffed by remote area nurses, very few have resident doctors, in fact only nine of
these towns and communities in the NT have resident doctors, the remainder receive intermittent visits
dependant on medical availability.
As described, some remote towns and communities have the services of resident remote area nurses
alone, some have additional Indigenous Health Workers many of whom have been community
employees receiving Community Development Employment Program (CDEP, work for the dole)
payments for their work, and some have a hospital or multipurpose service or aged care service.
Despite increases from a very poor funding base – most remote services are engaged solely in rescue
health care – that is focusing on the acute and more recently on chronic disease, with inadequate focus
on prevention and health promotion. This is a big concern to remote area nurses. Staff who are
fatigued from extended on call find it difficult to refocus on these important areas and are the first to
be sacrificed when staffing is tight, a frequent occurrence.
Many of the health professionals who work in remote areas are not trained for the role – that of
generalist specialist in the remote context. Much of it is learned on the job which is clearly an
unsatisfactory situation. It is inadequate, unsafe and contributes to discontinuity of care, missed
opportunities for timely health care and is destructive to the health professional and patient’s sense of
trust and confidence.
On the up side, a result of this historical staffing of remote services has been innovation in
collaborative practice, tele-health, best practice, professional support, and up skilling and generalist
education models. CRANA would not recommend starving services of resources as a strategy to
create innovation, however the models of collaboration and innovation that have resulted from the
resource poor areas could well be applied elsewhere.
Collaborative practice and teamwork is a strong feature of remote practice. All professions are
required to work beyond traditional boundaries; there is much less patch protection and more genuine
professional respect and support that have resulted in a strong collegiality. These relationships have
been tested with the iniquitous distribution of incentives and support mechanisms provided by the
Federal and, to a lesser extent, State governments. The relentless focus on GPs and disregard for
remote area nurses, Indigenous health workers and allied health workers has been destructive to
professional relationships. GPs are important to remote health, but not at the expense of the rest of the
team, and frankly they do not have a dominant presence, despite the ten years of significant
investment.
CRANA believes all effort should be made to maximise the recruitment and retention of the medical
workforce together with the other members of the team. Indigenous health workers, remote area
nurses, general practitioners, community physicians and pediatricians, allied health workers,
community welfare workers, pharmacists and oral health practitioners are poorly distributed and to a
large extent have significant boundary blurring. This is a good thing in that there is support, however,
if one group is preferenced over the other, the signal that they don’t matter becomes clear and
demoralises the workforce. This has been very evident during the recent ‘NT Emergency Response’.
The new health system must value its workforce and maximise the potential of all professions. A
remote support incentive program should be introduced to recruit, educate, support, retain and refresh
the workforce.
Tele health was born in remote areas with the pedal radio and the sector continues to be an
enthusiastic experimenter and adapter to the evolving technology – the telephone has been the most
successful despite the promises of videoconferencing. Ellis demonstrated that the use of digital
photography, standard descriptions and expert advice significantly improved the outcomes of chronic
wound care including lower limb retention, and in fact, life. Remote Australia needs to benefit first not
last from developing technologies. Point of care testing, tele-radiology, dermatology and wound care
all should be institutionalised, not bit trials. CRANA recommends the Commission factor the funding
of these into the financing model.
The high health need, morbidity and mortality in remote Australia saw the development and very fast
adoption of best practice clinical guidelines. This is a ‘by the user for the user’ process and lessons
from this can be applied across clinical practice. The CARPA Standard Treatment Manual guides
clinical practice for all health professionals in the Northern Territory and the adjoining three states of
Central Australia. They are not standing orders for nurses, but best practice for clinicians and have
been in use since 1991. This has resulted in the best possible clinical care for the common and
complex conditions, rational use of medicines and the development of the systems that support that
care such as recall systems and now audit processes to further develop quality in clinical practice such
as the ABCD program. While this occurs in some clinics, it is not institutionalised across remote
Australia, and should be. There should be no difference in the principles of quality care in Torres
Strait, western QLD, and the high country of Victoria, the Kimberly or the Western Desert. Best
practice is best practice, all care needs to be adapted to the individual.
The current situation where jurisdictions refuse to endorse best practice guidelines on parochial
grounds must end. It is not value for money to reinvent the same best practice guidelines around the
country. Collaboration could be encouraged through incentives and having a culture of safety and
quality rewarded. Programs such as ABCD should be utilised to improve health care and grow clinical
practice. To maximise the success of this, remote area nurses should be able to institute a home
medicines review for patients on chronic medications. Health services should account for the
standards they apply and report against. Currently, remote practice is invisible in the national data set
– the data is not collected, so tracking of progress or analysis of trends in primary care is not at all
possible. This should be rectified. Remote clinics should keep nationally consistent data for planning
and review. Quality clinical care will prevent many expensive emergency air evacuations and
potentially avoidable hospital admissions.
The design and funding of the local health service and the type of support available does not appear to
be the result of any State, Territory or Nationally planned strategy. Nor does it appear to be related to
any standards, benchmarks or need. Indeed there is a stark contrast between the resourcing of many
very remote Indigenous communities, and smaller, rural, predominately non-Indigenous communities
for example. In addition, the funding models used to provide the basic primary care and extended care
needed by remote towns and communities have been evolving and are far from complete. The current
equity model, Primary Health Care Access Program (PHCAP) used to cash out Medicare for primary
care services and loaded for morbidity and remoteness has made some difference in increasing the
number of remote health professionals and services. This same model, however, in some regions has
seen the development of parallel services, top heavy in administration and low on integration on the
ground. This surely has to be a stopgap measure until appropriate regional population and morbidity
based funding models are developed that appropriately meets the needs of each remote community.
Some form of capitation model could be used not only in remote areas but also in cities and towns.
This allows for population planning, localised services and the best use of the skills in the team. A
financial reimbursement for timed consults is not value for money in any area of primary care and
leads to poor care and missed opportunities. People need to be seen as people, not a single disease or
body part. CRANA urges the Commission to address this as a national priority and seeks that the
Commission work on the development of a single health system for Australia that equitably meets the
health care needs of remote and small rural towns and communities.
CRANA has promoted the role of the nurse practitioner throughout Australia and has provided
member input into each of the State and Territory initiatives to amend the legislation and develop the
role. CRANA firmly believes that appropriately trained and supported expert nurses are the right
practitioner for remote Australia, not as a replacement GP model, but as a primary care enhancement.
They add value in their own right, as has been demonstrated by the fact that remote clinics are already
staffed by nurses, who should be at least credentialed as remote area nurses. Some of these will
become authorised remote nurse practitioners and would provide the clinical leadership the teams so
much need. Nurses have a holistic view of health and wellbeing and despite nursing moving toward
the specialist models adopted by nursing medicine and allied health, remote area nursing remains
specialist generalist and still provides for the day to day health and care needs of individuals and
communities from a wellness model.
Remote area nurse practitioners are a recognised and legally authorised health professional in
Australia. Their role is widely acknowledged by the community at large and the health professions
and services. The major barrier to the uptake of nurse practitioners in remote areas is health financing.
The pharmacy, pathology and medical imaging investigations ordered by Remote area nurse
practitioners do not receive the same Government subsidy that the rest of the population receives
through MBS & PBS. The greater majority of the remote population is very poor, many are
indigenous and cannot afford out of pocket payments for these services. A sensible approach in the
Close the Gap strategy would be to utilise the expertise in place and improve the quality of care
provided by remote area nurse practitioners. It is not tenable that the detection, response to treatment
or progression of acute or chronic disease goes unmonitored. This is a social justice, safety and
quality and equity issue. Remote area nurse practitioners should be allocated a professional identifier
- PBS and Medicare provider numbers and appropriate Medicare type pricing models need to be
developed for the services that remote area nurse practitioners provide. Remote area nurses and
remote area nurse practitioners do not work in private practice – they are employed in services. This
strategy is one for public good and CRANA is keen to work with the government to develop these
models.
A critical time for families and health services is the prenatal and early years of life. Foetal
programming and the early years experience lay down the architecture for the child and adult life
experience and expectancy. Maternity services to rural and remote areas are in crisis. The lack of
Midwives, GP proceduralists, the deskilling of rural midwives and inadequate numbers of remote
midwives have meant that many local, community based maternity services have shut down,
withdrawn or are not available at all. Women have the choice of remaining in their communities for
the antenatal period where there may not be a midwife, GP or visiting GP to provide that service.
They are also forced to make very difficult decisions on the location for their birth. Faced with these
‘choices’, many women opt to receive no or little care, or present late for antenatal care for fear of
being sent to a distant location away from their other children and families for often extended periods
of time, usually many weeks. Other women accept the offer of distant care and face the high financial
burden of relocating themselves and their families or the emotional burden of family dislocation,
disruption or splitting. This is likely to contribute to domestic violence, impact on the bonding and
attachment of the baby and the family and cause increased stress. CRANA is keen to work with State,
Territory and Federal governments and other interested organisations and consumers to find a solution
to this crisis. Evidence from Internationally established programs such as home visiting, quality
prenatal, postnatal and child health care, nutrition and emotional support should be examined and
instituted across remote Australia. This is too important a time to prevaricate.
Poverty continues to be an important factor influencing health outcomes for remote Australians,
particularly Indigenous Australians. It is well documented that with increasing rurality, the Indigenous
proportion of the population increases, accounting for higher morbidity rates and reduced life
expectancy. Therefore it is true that remote Indigenous people have become an underclass in
Australia’s society. Good quality health care, prevention, health promotion and addressing the social
determinants of health are essential in closing the gap between remote and urban Australians. Remote
area nurses are in remote communities; they experience the daily problems with communities and are
part of the community. CRANA is an organisation that stands strongly for social justice and works
towards improving the health outcomes for those most in need in our society. We urge the
Commission to take a broad view of health when determining the future of the health system. It is the
health of the whole community that matters and by that we mean the whole Australian community
including those who live and work in rural and remote areas. Health includes education and
employment and links need to be made between the health, education and employment systems for a
successful health system for the future.
The provision of a suitably trained and qualified health workforce is an issue for Australia and a very
important issue for remote and Indigenous health. Australia should aim to provide its own workforce
into the future. It clearly will look different to what we currently have but maybe more like what
remote currently has – generalists at several levels. In order to meet the ever-changing health
environment and to deliver high quality health and social services throughout Australia as well as in
remote areas, investments need to be made at the undergraduate, postgraduate and continuing
professional education levels for all practitioners. It is not good enough to recruit ‘volunteers’ with no
remote experience or overseas trained professionals and not offer up skilling and ongoing support.
This is currently the situation. There needs to be a focus on improving the numbers of Indigenous
professionals and mechanisms for supporting training for all professionals for this important work from undergraduate recruitment, support, placements and cadetships, fast track training for remote
practice and training for remote specialists such as Remote area nurse practitioners, midwives, GPs,
allied health, dentists, pharmacists and managers. This should be an integrated program, building on
the structures of the University Departments of Rural Health such as the Centre for Remote Health,
clinical schools and the professional organisations engaged in training such as CRANA and ACRRM.
The greater majority of health care takes place out of hospital – the workforce needs to be trained, also
predominantly out of hospital, not excluding hospital, but balanced. The Productivity Commission has
reported on strategies to improve the capacity of the workforce. A way of improving the comfort of
meshed boundaries rather than sharper professional boundaries is required.
It is true that there is a national and international health workforce shortage that will in fact get worse
as the current generation of health professionals reaches retirement age and the demand for services
grows. Whatever design the future health system brings, we need to start work on producing a
workforce for it now, not with trials or projects, but with a well resourced program that has a strong
focus on all professionals being equipped for prevention and collaboration. To achieve this, a stronger
link between the health sector, the universities and colleges is required. A significant investment in
interdisciplinary curriculum design, the relinking of clinical training with the clinical settings and
specific support and clinical teaching investments in remote regional areas, inclusive of high quality
IT and accommodation is also needed.
The recent Federal Government intervention in the Northern Territory has put the issue of supporting
families and children on the national agenda. Youth need to be added to this mix. The issues that have
been brought to the nation’s attention include:
•
the lack of appropriate child rearing in transition cultures;
•
the lack of law and order; the lack of employment opportunities for young people;
•
the impact of the premature death and consequent disintegration of culture and family
influences and
•
the cost of living in remote communities.
Despite these issues, people still want to live in remote areas. Why you may well ask? The
environment is often beautiful, sometimes harsh but always inspiring; the people are genuine; there is
a sense of both urgency and timelessness and a strong connection with the country that Indigenous,
and some rural people express and feel acutely and non-Indigenous people learn to appreciate. They
have much to offer Australia and are an integral part of the nation, central to its wellbeing. The link
between environment, health and land management may offer a part of the way forward, not only in
food production, but in environmental management and cultural value for the nation. Caring for
country is an important environmental issue and coast watch is a good example of Indigenous people
engaging in real economic activity that may have been otherwise outsourced by tender. Economic
development opportunity is often present if looked for.
There are health professionals who want to work in remote areas, love the work they do and the
lifestyle they lead. This dispels the myth that professionals don’t want to work remote. It is the
professional and physical fatigue, resentment of inadequate management support, lack of opportunity
to contribute where appropriate and being undervalued that leads to frustration, burnout and a high
turnover. This is largely preventable. A focus on this as a benchmark would see services strive to
improve their effort. Staff friendly services such as the Magnet hospitals in the USA or the nurse
friendly facility programs in Texas may offer insights as to how we balance demand, supply and value
for all professionals and the patients and people who use the service.
The management of chronic disease is particularly challenging, expensive and very worthwhile. It is
critical for any society to maintain its early and middle age adults. Remote practitioners have been
able to demonstrate improvements in renal survival, emergency evacuations and reductions in
cardiovascular risk factor indicators, in particular blood pressure through the use of improved health
information, quality and best practice systems, clinical governance and guidelines and up skilling.
These are unfortunately not universal across remote Australia but rather are examples where trials or
enthusiastic leaders influenced care. There is evidence that they are slowly being institutionalised as
recognition of the impact of best practice and associated systems of care. Australia’s future health
system should learn from this and build these safety and quality pillars into the health system structure
along with a universal health record for the region. Issues of privacy and data protection need to be
sorted.
Remote area nurses have always led the way in bridging timely clinical care, demonstrating the use of
telecommunications technology to increase the reach of allied health and specialists’ services into the
most remote areas of Australia. We agree that more nurses, GPs and other health professionals are
needed in remote Australia. We also recognise that remote area nurses are the primary care providers
in the majority of remote areas, the care coordinators in chronic disease and are also the primary care
gatekeeper and advocate for access to the specialist resources of the health system and so require
reliable IT systems and Ehealth to do this.
We urge the commission to factor in the use of innovative technologies that will allow us to augment
better access to a wider range of specialist services, including remote area nurse and remote area nurse
practitioner referral, GP, midwife, specialist or home medicine review and case planning. In addition,
we ask the Commission to recommend development of structured referral pathways and organised
telehealth clinics and services that make access to tertiary and specialist services easier and not based
on individual clinicians’ relationships with specialists.
One critical issue is financial and social support for individuals and their families for travel and
accommodation to access dental and specialist services in town, another region, or city. Social and
emotional wellbeing is critical to healing and recovery and is sometimes a determinant or influence in
the uptake of a specialist service. For example, in women choosing radical surgery over treatment,
mastectomy over radio or chemo therapy because they cannot leave their families for an extended
time, may be frightened to do so alone or cannot afford the travel, accommodation or specialist fees.
CRANA in partnership with other organisations has already developed a number of innovative
programs designed to strengthen the remote health workforce.
•
The Bush Crisis Line and Support Services is a telephone debriefing and counseling service
for rural and remote health care providers and their families that provides invaluable personal
support.
•
The Remote Emergency Care (REC) course, which brings expert emergency physicians,
nurses and paramedics to rural and remote areas to train multidisciplinary groups in the
advanced management of medical emergencies and trauma in the remote context.
•
The Maternity Emergency (MEC) course, which trains non-midwives and GPs in the
management of maternal emergencies until they can get the woman and baby to definitive care
(often the next day).
•
The Primary Health Care course examines the principles of Primary Health Care compared to
those of the medical model, challenging participants to incorporate those principles into
everyday practice.
•
The Pharmacotherapeutics for Remote Area Nurses course provides education in the area of
prescribing, dispensing, monitoring and adjusting therapies, stock control, patient education
and legislative issues. This is an important course for the nurses who have to undertake this
role as part of their every day practice.
•
The orientation, cultural awareness and debriefing program developed to support the child
health teams deployed for the Federal Government intervention in the NT, that now orientates
new people to the discipline and context.
•
The Telephone Education Nurses Network, an innovative approach to CPD.
•
Chronic disease in remote Practice.
•
Child, woman and family health
•
Sexually Transmitted Infections: a population health approach.
•
Child and adult sexual assault and forensic care.
These programs are all coordinated and managed by the CRANA Corporate Services Centre based in
Alice Springs or in collaboration with the Centre for Remote Health.
In addition to these programs, CRANA works with universities to develop and deliver high quality
courses for remote health practitioners. The partnership between CRANA and Flinders University has
led to the Remote Health Practice program run out of the Centre for Remote Health in Alice Springs.
This award-winning suite of courses has provided remote area nurses, allied health professionals,
doctors, managers, oral health practitioners, and other members of the multidisciplinary remote health
team from across Australia relevant and flexible higher education offerings up to Masters level. It is
an advanced practice, vocational registration, and public health program – recognising the uniqueness
of remote practice and the importance of a broad skill and knowledge base, particularly in Indigenous
health in the workforce. This program is by all comparisons under funded. It has one 0.75 FTE funded
academic position – the remainder of the academic contribution comes from the full fees paid by
students and impedes the potential of the program. It is well recognised that clinical education, done
well, requires significant investment. Compared to the Clinical Schools, this is a very poor cousin.
CRANA recommends the proper funding of postgraduate education.
Remote practitioners, through CRANA, take an active role in the development and distribution of key
evidence-based practice resources used by remote practitioners in their daily practice such as the
CARPA Standard Treatment Manual and the CRANA Clinical Procedures Manual. The uptake and
impact of evidence-based primary care in remote Australia is one of the great success stories. One of
the factors in this success is that the guidelines are for all professionals, not just standing orders for
nurses. They are developed by the users for the users, have high standing internationally, are
accessible and recognise the real world in which people live and work. Another is that all, or the
greater majority, of the health professionals are employed by the range of remote health services and
hospitals, hence there is a greater alliance or connection to the practice setting and a collective desire
to make a difference.
This varies a little from state to state, where the only states that have private GPs in some of their
small rural and remote towns are Qld, WA and to a lesser extent NSW. These have traditionally had
GPs, with right to private practice, cover the hospital which now usually functions as a clinic. The
other feature of much of WA, Qld, NT and SA is that the remote and small rural services have
structured medical advice services for telephone consultations and advise as to which specialist to get
further advice from, often brokering this for the remote or isolated practitioner. The telephone medical
officer is dedicated to the task of providing telephone consults and rostered onto a day or night shift to
do so. They know the region, the demographics, public health profile and geography and can offer
practical advice to support the critical ongoing management of remote based care or stabilisation
while awaiting transfer, often for extended periods. They also use the evidence-based guidelines, so
all are working from the ‘same page’. This innovation, long accepted as part of remote practice, has
much to offer but shouldn’t be limited to remote, as it could work well in urban health care,
particularly for community health and disadvantaged groups.
The CRANA website is a key repository for a range of evidence-based guidelines, able to be accessed
by both members and non-members. The annual CRANA conference is an opportunity for students,
practitioners and academics to get together and debate a range of relevant ideas, present the findings
of research relevant to remote health and to find collegial support and inspiration for the coming year.
We ask that the Commission recognise the role and value of professional organisation support in the
architecture of Australia’s future of the health system. They play a critical role in the support,
advocacy and leadership, particularly clinical leadership for health professionals - in CRANA’s
instance, remote area nurses and other remote health professionals and, uniquely, their families.
CRANA members were canvassed for ideas to put to the Commission and the 2020 Summit. The
following is a summary of the ‘front of mind’ issues and submissions received from members:
Nursing issues
•
Demand exceeds supply – high health need, low number of professionals and under qualified
professional, inadequate skill mix in the team
•
Collaborative partnerships. Nurses want to work in partnership with Aboriginal people in all
areas of remote communities
•
They want more consumer involvement in health
•
There is a strong need for maternity services for all women in Australia - where they live,
provided by a ‘skilled provider’
•
Demoralised or undervalued workforce
•
Fatigued workforce and concern about quality care
Solution ideas
•
Qualified remote area nurses and remote nurse practitioners quickly rolled out in rural and
remote areas
•
Medicare provider numbers for nurse practitioners and midwives
•
Strengthen the focus on developing a robust Indigenous workforce
•
Support the current workforce to update their skills and refresh themselves
•
Abolish single nurse posts
•
Local training for Aboriginal health workers
•
Funded positions in health and education services for Aboriginal people in a range of roles not
just AHW or AEW- Administration, liaison, translation etc.
•
Reopen and reinvigorate rural and remote maternity services
•
Institute a no-fault, lifetime care plan for birth injury and accident victims and remove the
litigious influences to quality improvement programs and defensive health care. New Zealand
have gone down this path and it would be useful to examine their systems and processes.
•
Fund and support regional health services to employ, support and innovate local health care
optimising the skills and enthusiasm of the health professionals who want to work their craft,
not operate a business. This is how it works in remote areas, and Aboriginal Medical Services
and other areas could benefit from the model.
Remote Health Issues
•
Fragmented and iniquitous funding of remote health services, remote professional education
and support
•
Remote communities face poverty, housing and infrastructure problems including sewerage
and waste disposal
•
Dental Health is poor and impacts on health outcomes such as malnutrition, rheumatic heart
disease and premature delivery.
•
Lack of local employment opportunities
•
Lack of an appropriate education system, where English is not the first language of the
community
•
Young people in remote communities who don’t understand modern social and legal mores,
particularly around underage and consensual sex and relationships
•
Young people’s access to food
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Marginalised Aboriginal youth
•
Chronic and complex disease
•
Child health
•
Overcrowding
•
Churn factor in remote teams
•
Significantly inadequate infrastructure and funding for health care
Solution ideas
•
Single funding program
•
Nurses and teachers have units in English as a second language, as preparation for remote
work, as well as language training
•
Nurses and AHWs be employed in prevention roles including remote schools to address
primary and secondary prevention and problems such as ear, dental and mental health
problems
•
Integration of oral health into the health system; affordable dental care in remote communities.
Dental therapy is a well established career that can provide good care and health promotion in
remote communities
•
Prevention agency that can research and fund prevention programs – tell us what works
•
Health promotion that engages young people and parents - looks like Jamie Oliver’s restaurant
program for nutrition and
•
Nutrition subsidies for the vulnerable, antenates and small children
•
Sex Education and resilience development for teenagers that explores and talks about what is
OK in Australian society, what is not acceptable, and coping strategies delivered by young
people.
•
A funded volunteer program for young people to remote Australia similar to Australian
Volunteers International.
•
Housing
•
Infrastructure and staff funding
•
Remote health professional training program
Whole of health solutions
•
Keep what works
•
One health system. Cross-border and fragmented funding across the state commonwealth
divide creates lots of problems in continuity of care and coordination of services, overtaxing
reporting requirements mean that funds are sometimes not applied for as the resources to
comply are not present. This is wasteful and unnecessarily obstructionist to the health service
on the ground
•
Use available evidence on which to base policy decisions and have a monitoring and reporting
body to drive this
•
Turn good projects that have demonstrated success into ongoing programs. Short term funding
sucks us dry of motivation and enthusiasm; we are sick of having to write business cases for
small buckets of money and competing with other services, when we should be doing what we
have already proven works
•
Medicare needs an overhaul. Population and epidemiology based funding - for communities
where there are people with high levels of morbidity who need increased funding for chronic
disease programs. This would also allow accountability for the cost of remoteness
•
We need a standards and consumer watchdog with real teeth for health
•
Workforce development strategy that includes recruitment to the profession, support and
mentorship through the training, funded cadetships to cover the long clinical placement times
for undergraduates and training positions for postgraduates and specialists. Bonded
scholarship places should be allocated in regional and remote institutions, and clinical schools
and UDRHs strengthened to support these.
•
Fee relief or redemption in return for service, retention rewarded with inspiring professional
development opportunities and personal refreshment have all been described as essential to
building and maintaining a remote workforces. Reward successful education institutions that
retain strong links to practice and link retention and training indicators into the performance
indicators of health and education services as a lever or driver of change.
In summary, given the diversity of health care needs and the range of delivery modes in Australia that
are required to meet that need responsibly and ethically, there is a need to ensure that remote health
agencies and remote area nurses are included when discussing and planning health service delivery
into the future and we thank you for this opportunity. While CRANA has a proven track record in
supporting remote area nurses, health service improvement and of innovation, much remains to be
done to effect system change and the desired outcome improvement. It is an organisation that is
member driven, health outcome focused and is keen to work in partnership with government, nongovernment and professional organisations to close the life expectancy gap for remote and Indigenous
people and help keep the bush a vibrant place where all Australians can have the expectation of safe
high quality health care.
We would value the opportunity to follow up this submission with a meeting, teleconference or
ongoing email communication between the Commission and CRANA if that would add value to your
work.
Carole Taylor,
CEO, CRANA
6 June, 2008