Spotlight on rural health sector in interim Health and Disability System Review

On September 3 the New Zealand Health and Disability System Review released its interim report on the New Zealand health and disability system.

The 300-page document is the first report from the System Review, and it indicates clear areas of focus, rather than making recommendations. Recommendations will follow in the next report which is due in March 2020.

The Report finds that:

• The health system is complex and fragmented

• There is an absence of collaboration within and across the health system

• Consumers frequently struggle to access services

• Inequity of access is a growing concern

• There are significant concerns expressed around leadership and culture within the health system

• The health system is not delivering for Maori

• The level of service delivery for rural communities is unacceptable

• There is need for clarity around the country’s hospital network and the need for a rural hospital strategy.

Rural focus

The report also notes the widespread support for rural community health hubs and asks the question as to how these should be most effectively funded. It clearly acknowledges the issues around the definition of ‘rural’ and how the lack of clarity here can skew outcomes, reporting and understanding.

Page two of the report makes the clearest statement about rural health from anywhere in the report: “And we have seen rural communities forced to make do with a level of service accessibility that is simply unacceptable.”

To read the full report click HERE (PDF 7.28 MB). Or continue reading below for summary points:

The following points are extracts directly from the report that are of particular relevance to the Network and its strategic programme of work:

• “… there are staff shortages and many hospital staff feel stressed or burnt out. In rural areas, in particular, hospitals feel under pressure to provide necessary staff and often rely on international workforces.”

• “Difficulties in attracting and retaining the rural health workforce have been highlighted repeatedly.”

• “Rural communities face particular challenges and need solutions designed specifically for them.”

• “Rural New Zealand is a diverse population, and access to health services varies significantly across New Zealand. Rural populations continue to be resilient and innovative in solutions to health care. However, while data is limited, indications are that people living in rural towns can have poorer health outcomes, including lower life expectancy, than people living in cities or surrounding rural areas, an effect that is accentuated for rural Maori and disabled people. As noted, mental health challenges and access to health and support services in rural areas remain a priority.”

• “Rural Tier 2 service delivery models will need to be supported by enhanced remote access to specialist services, enabling a wider variety of planned services to be accessed locally. The system also needs to be designed to reduce the need for patients to travel to outpatient clinic appointments and to better support generalist-led models of care for rural communities.”

• “Formal evaluation of rural hospitals is limited. A survey undertaken in 1999 is one of the few pieces of published research. The report of the survey notes: “The diversity of results suggests that New Zealand rural hospital[s] do not fit a homogenous concept… Clearly, the health system needs to have a better understanding of the form, structure, and function of diverse rural hospitals and their contribution to health service delivery and have a strategy for their development.”

• “Geographic distribution of the workforce is a major challenge, particularly for primary care and rural and provincial hospitals, which can struggle to recruit and retain the workforce they need, despite a number of initiatives to meet this challenge. In general, job applicants and trainees tend to favour large cities, particularly Auckland, although the Voluntary Bonding Scheme is helping.

• “At a recent sector workshop on priorities for health and disability workforce staffing, rural areas were generally viewed as a high priority.”

• “We have seen rural communities demonstrating a degree of flexibility and cohesiveness that could be a model for the rest of the system.”

• “[Over the next 20 years] rural areas are projected to grow slightly faster than other main urban areas at 14% (an increase of 100,000 people on current numbers).”

• “Suicide rates remain higher for males than females, for Maori than non-Maori, and for people in rural areas than in urban areas.”

• “One challenge when considering equity of health outcomes in rural populations is in the use of rural and urban categorisation, which does not accurately account for the populations that access rural or urban health services. As a result, significant numbers of the population designated as ‘rural’ live near to large urban centres and can access urban health services. Conversely, some small rural communities are grouped with larger centres and defined as ‘independent urban’, despite some communities having fewer than 1000 residents and accessing rural health services.”

• “A rural health report by the National Health Committee in 2010 concluded that life expectancy and other measures of health status were similar for rural and urban populations. Life expectancy for rural Maori was slightly lower than for urban Maori. Factors identified as contributing to poorer access to health services in rural communities were socioeconomic deprivation, geographical and distance barriers, transport, telecommunications, cost of access to service, and service acceptability.”

•“Research in 2016 identified disparity in disease rates, access to services, and outcomes when comparing rural and urban communities.”

•“A common theme in Phase One was the need to develop different models of service provision to better meet the needs of people who live in rural areas.”

•“Workforces are taking on roles previously undertaken by others, for example nurse-led models are being adopted, particularly in rural areas, and nurse prescribers and nurse practitioners are playing an important role in supporting the management of patients with chronic conditions.”

•“For Tier 1 services to be effective, they need to be designed to support the community they are serving. The Panel observed positive examples of rural communities using technology and more flexible working arrangements to provide more comprehensive service coverage. We believe many lessons can be learnt from these examples and applied to make urban services more effective and efficient.”

Maori and rural

There is a strong focus in the report on the failings of the health system in terms of delivery for Maori:

• “Maori were … less likely than non-Maori to report being offered a choice of appointment times, to be seen on time, or to be seen within their preferred timeframes in general practice. Maori adults and children are more than twice as likely not to have collected prescription medications because of cost than non-Maori adults and children. Approximately 22% of rangatahi Maori were unable to access the care they needed in the previous year and were significantly less likely than Pakeha youth to be able to access the care they needed.”

• “Evidence shows that engagement with the health system increases advantages for non-Maori and disadvantages for Maori across the life course. Where Maori are accessing health services, they do not always receive optimal quality of care, and this negatively affects outcomes for Maori. Lower quality of care includes suboptimal prescribing and over-prescribing to Maori, poor communication between professionals and Maori patients, delays in treatment and surgical interventions, and longer hospital bed stays after acute admissions.”

• “In particular, it was noted that the lack of a specific national Maori investment plan for health services meant that health funding is not invested where it’s most needed, particularly in relation to achieving health equity for Maori and the provision of rural health services.”

• “New Zealand’s Maori health workforce challenges centre on the capacity and capability of the Maori workforce, attracting and retaining Maori health professionals to work in rural areas.”

• “The needs of Maori in rural communities is another issue of major interest. Resolving health inequities between Maori and non-Maori in rural areas is a priority.



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