MIC CAVAZZINI: Welcome to Pomegranate Health, a podcast about the culture of medicine. I’m Mic Cavazzini, for the Royal Australasian College of Physicians.
In the last couple of episodes we looked at the challenges and rewards of physician training in regional settings in Australia. We visited from the country town of Dubbo, and the remote regional service in Western Australia’s Kimberley.
Today we’ll hear three perspectives on rural medicine in New-Zealand Aotearoa, recorded at the RACP Congress in May 2019. New Zealand doesn’t have the same extremes of remoteness of Australia, but it does have a rugged landscape that results small and scattered communities. And there is a strong rural identity, though the proportion of the population classified as rural is now around 16 percent.
As you’ll hear today, the populations which are disproportionately underserviced and in worse health, are not necessarily the most remote. The demarcations fall much more starkly along lines of socioeconomic status and race and areas of need are as often in minor urban settings as they are in the country. But there are solutions, and great experiences to be had serving these communities.
The first speaker is Dr Ross Lawrenson, Professor of Population Health at the University of Waikato and Population Health Advisor for the Waikato District Health Board.
ROSS LAWRENSON: You know, the premise that we’re really talking about today is the rural communities have poorer access to healthcare and because of that they get poorer health outcomes and that we can fix this by having the appropriate quality and capability in the rural health workforce.
The rural populations in New Zealand back in the 1880s, you know, 60 per cent of our population was rural, we were, and we still are a very agricultural-based society, but today it’s around 14 or 15 per cent of our population in New Zealand. And that means that the rural population is small in proportion and therefore has no political voice, and I think one of the things that we’re very jealous of with the Australian situation is that your rural populations have a very strong political voice and are taken note of within your elections that you’re going through at the moment, our rural populations are pretty much ignored as far as the political scenario is concerned.
One of our problems is what is the definition of rural. So what classifications have we used? Well, one of our problems when we’re doing research in New Zealand is we do not have a standard classification of rural. We’ve used catchment areas of rural hospitals, we’ve used territorial local authorities or we use our NZ stats classifications, so the question is does that matter?
Well, this is two reports, one done by the Ministry of Health in 2007, which came out and said that urban dwellers were more likely to have been diagnosed with heart disease than rural dwellers. The National Health Committee in 2010 said rural people are more likely to have ischemic heart disease than urban dwellers. They were using exactly the same data, but if you classified minor urban centres as urban, then urban people have more heart disease, if you classify only these as rural then they have less heart disease.
We have changed that classification to include not only population density but also, like me, where do people work as well as live, and the urban influence on rural populations? So I live on a rural block 30 kms outside of Hamilton but the issue is I work in Hamilton, and a lot of the people around me do. So we have four rural classifications from rural areas with a high urban influence through to those that are highly remote, which in a New Zealand context is around two to three hours away from a major centre.
But, in fact, we have two sorts of rural communities. We have the high needs rural communities that are decreasing in population, that the population there is aging, but then we have the tourist centres, the Wanakas and the Queenstowns and the nice rural seaside communities, which are actually increasing in population and are very wealthy, and so the health needs of these two populations we average out and then say oh, there’s not a lot of difference between rural and urban populations, but within that grouping there’s huge disparities. So in South Waikato, 65 per cent or 64 per cent of the population there are in social deprivation 9 and 10; in Waipa, where I live, 0.9 per cent of the population are in social deprivation 9 and 10. So when we’re planning services they need to be locality based because there’s a huge variation in the health needs in those populations.
There are some interesting things about rural populations, the more rural you get the more male you get, so all of the rural communities have more men than women, all of our urban communities have more females than males. But the other big thing that we need to think about around our rural populations is their age structure, and so this is just in the Waikato, in our rural areas, but this is what we’re predicting over the next 20 years, it's the elderly population where we’re going to see massive growth.
So if you’re a rural doctor or a rural community what you’re going to be seeing is a huge increase in your geriatric population and you’re going to become looking after the elderly. But if you look at the child population, as I said, it is staying static or decreasing, but, actually, for the Māori population we’ve got 154 per cent increase in the Māori child population and a decrease in the Pākehā population.
So what does that really mean? Well, in the Waikato, for instance, we have 40 percet of our births are Māori and of 162 midwives we have two that are Māori. 25 per cent of our population is Māori, so how we are dealing with these two populations is a really key issue.
So overall there was no significant differences in the prevalence or health outcomes of things like diabetes for urban versus rural, for females prevalence of diagnosed arthritis—These are minor differences in needs and health outcomes. And we found that, similarly we did a study on breast cancer and were interested in looking at is there a difference in outcomes from breast cancer between urban and rural communities, and the answer is no, there is no difference in breast cancer, specific mortality for rural versus urban, or cause mortality.
But if you split it by Māori and non-Māori, rural Māori have higher mortality than urban Māori. You could see there was almost a 50% or a 40 to 50% increase in mortality for rural Māori women compared with urban Māori women, whereas for rural Pākehā, if anything, there’s slightly less mortality. So very different outcomes in different influences of access to healthcare for Maori compared with non-Māori.
And we, again, have done another study looking at the, or the number of GPs per 10,000 population in our rural communities in the Waikato and Midland region compared with urban. Thirteen GPs per 10,000 in our urban centres and seven in our rural areas. So there’s an access issue for rural patients, and these are just some of the headlines when you go onto Google and put in rural workforce you get comments like crisis, crisis keeps coming up, swift action needed on GP shortages. And that does make a difference.
This is just another study that we did looking at prescribing, and we’ve found that for mental health you had half the prescribing rate of antipsychotics in our deprived rural communities compared with our urban and advantaged communities. So access to general practice makes a difference.
So in summary, rural communities have poor access to health services. We need to be aware of the demographics of our population, so our rural communities are aging rapidly and we’re going to have increasing health needs because of that. But we mustn't forget that our younger Māori population is also proportionally going to be increasing, the way that we deal with those health needs is not the traditional way that we’ve done in the past.
Our small rural towns is where the greatest health need is and where we are suffering from a shortage of workforce. So I would plea that we do need to do something about the workforce but when we’re addressing our workforce issues we should take into account the population health needs that our rural populations have. Thank you very much.
MIC CAVAZZINI: Dr Martin London is a Fellow of the Royal New Zealand College of General Practitioners and opened the Christchurch Centre for Rural Health in 1994. He has been Chair of the Rural Health Alliance and continues to practice as a Rural GP Locum, when not developing his orchard in Little River. He talks about the how his hope of seeing a rural-based medical school in New Zealand, and how a much more effective a rural-based workforce can be.
MARTIN LONDON: You ask communities what do they want for their health, their top word is security. We know patients want continuity, seeing the same practitioners and building relationships with those practitioners They want to know that when one set of health workers leaves there will be others to follow. We know that on an individual basis they want time with their practitioners.
And as an aside I had a very interesting comment from one of the physicians at Greymouth Hospital about the huge cost of endlessly recruiting locums and replacements to their services, and the huge cost was not actually in agency fees or the extraordinarily high fees that we locums like to charge you all, but it’s the cost of labs and pharms. New people come along and they do more and more investigations or simply fail to reduce treatment. So that’s one of the big problems about continuity, continuity is about building relationships which avoid of those things happening.
If we talk about clinician-patient relationships, there was a wonderful talk given to the College of GPs in New Zealand, oh, it must be 20 years, 1990-something, I can’t remember, by Howard Brody from Michigan and he was saying you keep out of kind of court, by building relationships with your patients. Coming from an American, this was important but the really important thing about it is that if you’ve got a good ongoing continuous relationship with that patient, certainly it’s humane, secondly it’s highly scientific because above all, history, history, history is what guides our diagnosis. And it’s very cost-effective because if you spend that little bit of extra time paying attention, being present, you realise why we don’t need to do a CRP or a CT or whatever it is because you understand what’s going on. That’s a little soapbox of mine which I continue.
My other soapbox is retention before recruitment, okay? Recruitment is an exercise in advertising, retention is paying attention to your workforce so that they want to stay, so that others look and say, well, it’s alright for them, I’d like to go and join them. I’m dreaming, and we’re getting a bit closer at times, of reaching the point where people ask themselves, “where is my rural practice?” because it’s the place to be. Why? Because the people out there are having such a good time.
What gives me a good time in rural practice that makes me want to stay now for over 30 years, adequate income - okay, we’re not talking riches untold, but the dollars have got to add up, we all have to retire at some time. Sufficient time off is vital, of course, to retention vitality. And what I’m going to throw to you is what do we mean by a supportive, professional environment? A stable team is important, continuing professional development, access to that is important, but above all its relationships within the team. That’s the team that you’ve retained, it’s self-perpetuating. If you’ve got a team that wants to stay together they will stay together and it strengthens that group. Between disciplines, between the doctors and the nurses and the mental health workers and so on.
With employers. How many of you have seen Death Star Canteen? Has anyone seen that, it’s a YouTube thing, Eddie Izzard, where Darth Vader comes down to the Death Star Canteen and starts abusing the little man who works behind the counter, and Darth Vader says do you know who I am? And the little man says do you know who I am? How many of us who are in positions of seniority, shall I say, really know who the people are we work with?
And the other important aspect of a supportive professional environment, and I’m going to throw this to you lot as physicians, is good relationships between primary and secondary services. If I know the person and have the respect of the person I’m referring to we can have a good conversation rather than as we in rural practice have often experienced, “Ah, it’s just a rural GP, you'd better send him.” Rather than a conversation of, “No, no, how do I manage this patient here?” The quality of that conversation is incredibly important.
So I’m going to go off sideways again, as I always do—I’m renowned for red herrings—and talk about RUFUS. Have we got a RUFUS in the room, a rural focussed urban specialist? These are are specialists who are employed to cover rural areas with the essence of actually going out to rural areas, spending time there, understanding context, understanding the teams that provide the care, doing some education while they’re out there, and being available for consultation in out-of-hours. So if I have a problem in paediatrics, my paediatric RUFUS, John Garrett, I can phone him up at any time, and I will phone him, I won’t phone the paediatrician on call because I have that relationship. RUFUS-type physicians who have a focussed interest in rural practice, all do a huge thing for creating a supportive professional environment.
Which brings me onto why a rural-based clinical school? Firstly, what do we mean by this? It would be dispersed, the teaching would happen out in rural areas, the administration would be out in rural areas, it is inter-disciplinary, so you’re already from the word go beginning to build the teams that are going to be retained out there because they’ve got to know each other. Community participation will be a crucial part of it and it will create the rural workforce pipeline.
We’re talking about teaching them core curriculum, we’re not teaching them rural health, it’s core curriculum. Amongst the people we teach out there will be people who want to be interventional cardiologists, but we know that the education they get in rural areas is at least as good, than what you get if you have an urban-based education.
It’s good for students, we’ve shown it, it’s good for practitioners, they have academic contact and there’s nothing more educational than sitting with a patient and having a student in your room asking you questions of why you’re doing this and why you’re doing that and teaching me what I’ve missed. It’s good for the patients, they get higher quality consultation, it’s good for rural communities. It is on the table with the Ministry of Health, they’re just putting their toe in the water. It is time to grasp the ongaonga. Does everyone know what ongaonga is? It’s the New Zealand nettle, urtica ferox, as opposed to urtica urtica, which you all probably know, but ferox, it is particularly ferocious. If you see this plant don’t pick it. Thank you.
MIC CAVAZZINI: Dr Douglas Lush is sole practitioner in an isolated town on the east coast of the North Island. The town of Uawa has a 900-strong community mostly from Ngati Porou iwi. Here he tells how rewarding his relationship with this community has been, but how it required a recalibration of some his loftier dreams as a public health physician.
DOUG LUSH: No Tāmaki Makaurau ahau. Ko Ngāti Pākehā te iwi. Kei Tūranga nui a Kiwi e noho ana ahau. Kei Ngāti Porou Hauora e mahi ana ahau. Ko Doug Lush taku ingoa. So I’m public health trained and I’ve left the comfort of the public service to move to a rural area where I’m now working. I’m giving very much a personal perspective of how it’s been for me and I’m hoping this might be of interest for public health physicians or other people who are looking for moving to a rural area or those people who have wondered why population policies fail to get traction in rural areas. So I did training in Darwin, I did the Masters of Applied Epidemiology and Canberra and qualified with the Faculty of Public Health in 1996.
I then moved to the comfort of the Ministry of Health bunker where I drank great coffee and wore very smart suits and also advised in population health, including advice to the emerging primary healthcare strategy, and I believed at that time that the Ministry had the necessary levers and incentives to ensure that primary care was population-focussed and that that would reduce inequalities. Since then I’ve become slightly more enlightened.
When the opportunity came to move I took that opportunity and did some retraining in general practice and then moved to Uawa, which is a wonderful slice of paradise about 40 minutes north of Gisborne. It’s rich in history, 250 years ago this October Captain Cook sailed into this harbour and he was very warmly welcomed by the locals, as have I been in this community.
It’s about 1,000 people, mainly Māori, from a single iwi, and they’re disproportionately affected by communicable and non-communicable diseases, and very highly exposed to tobacco, to degraded ecosystems, to poverty, to damp houses, to dangerous jobs and pastimes to dangerous roads and a dangerous and unrelenting ocean.
So I work for Ngati Porou Hauora, so Ngati Porou Hauora has six clinics up the east cape, I’m a part-time sole practitioner here at Uawa and when I moved there I thought this would be the perfect place to practice a population health focus. In that it’s a single iwi, they’ve been living there for many generations. However, I’ve found that the community and the practice are all focused on acute care, so everyone who books to seem me books the next possible appointment and we never seem to have the time, resources or space to actually get ahead of that acute demand that we have.
Clinical challenges, so I am, as I said, I’m part time GP, I have no clinical support, which is a very difficult and dangerous place, I guess, to be in. It’s difficult to keep up to date with the immense amount of information you need to have to be a practitioner. There’s this benign neglect, I’m very as well as that it’s often easy not to order investigations, not to refer patients, not to start medications, and that can actually perpetuate inequalities.
There’s great fragmentation of contracts, for instance we don’t have a contract for doing smoking cessation, and half of our hapu or pregnant mums are smokers throughout pregnancy, so an enormous problem. And then inefficiencies of small scale, we’re the smallest PHO in the country, and it means we don’t have back office staff for analysing data or for doing many of those back office functions or to carry on relationships with the DHB.
Recruitment issues. So recruitment of doctors from overseas is expensive, both in terms of getting into the country but also in terms of orientation, they don’t understand rural, and invariably these people don’t stay, so that six months is the maximum I’ve seen people stay within our organisation.
And then there’s variable motivations for moving to rural areas. So some people will be escaping the big city, some people will be escaping other experiences. Some come with grandiose delusions about what they can achieve, others come with a missionary zeal, and often what they want and do isn’t at all aligned with the community.
I’ve just got a few photos of some of the activities I get involved in. So the coffee’s awful, it’s instant, but the kaimoana fresh from the sea simply prepared is magnificent. And we have community, or lunches once a month with other health providers to look at who are the most needy within the population and try and target some of our efforts towards those most needy. One of the logs that washed down the river last year, down the Uawa River, I got off the beach and I converted this to bike parking, which we put in front position outside our clinic, and we’re encouraging people to use active transport, so I’m very keen on encouraging healthy eating and healthy action. I attend the local school one a term and talk to the school boys about their current health and the importance of their health for their future roles they’re going to have in the community.
So I hope that any of you who are public health physicians looking at moving to rural will see this as a possibility to have a different experience. So just some suggestions. I think more flexible jobs, part time jobs, maybe joint placements with the DHB, a bit more creativity about what a GP job might look like. This idea of the aging, or this concept, or the reality of the aging workforce may be turning that on its head, that possibly end of career single experience physicians are the very people who should be working in this communities and are best placed to work in these communities.
Looking at non-financial incentives. There’s plenty of other reasons for living in these communities, the extraordinary sense of community, of achievement, and also working with the unworried unwell is much better than what you can experience in an urban setting. Thank you, tena kotou, tena kotou, tena kotoua katoa.
MIC CAVAZZINI: Many thanks to Doug Lush, Ross Lawrenson and Martin London for permitting me to adapt their lectures for this podcast. The views expressed are their own and may not represent those of the Royal Australasian College of Physician.
You’ll find links to their presentations from Congress 2019 at our website, racp.edu.au/podcast. There’s also a list of other useful resources for clinicians practicing in rural areas and you can also nominate a colleague for the RACP Medal for Clinical Service in Rural and Remote Areas.
Don’t forget, Fellows of the RACP can claim CPD credits for listening to the podcast—there’s a link on the web page that will prefill your logbook for you. Please share this podcast with colleagues or even leave an iTunes review if you like. You can subscribe to Pomegranate Health via any podcasting app on your phone, of if you prefer an email reminder, there’s an alerts list at our website.
You’re always send any feedback and story ideas to email@example.com. I’m Mic Cavazzini. Bye for now.