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CEO Address to the Australian Medical Council

Mr Jeff House, CEO, Services for Australian Rural and Remote Allied Health - SARRAH

We are meeting today on the land of the Ngunnawal people. I acknowledge them and their connection to this country and I pay my respects to their Elders: past, present and emerging.

Thank you for inviting me to speak to you today about rural health. SARRAH was established 23 years ago by a group of passionate allied health professionals working in remote communities in the Northern Territory – under the stars at a BBQ.

You can’t get more quintessentially rural if you try. And today, they are still just as passionate about allied health and its contribution to health and wellbeing in rural and remote communities.

They could see first-hand the impact they had on individuals and the communities in which they lived. They also understood all too well, what those communities looked like when access to health services didn’t exist.

The genesis and history of this organisation is never far from my thoughts and I’m very thankful to have the opportunity, in a small way, to add to SARRAH’s history and legacy.

SARRAH represents 27 different allied health professions. Allied Health Professionals are qualified to apply their skills to retain, restore or gain optimal physical, sensory, psychological, cognitive, social and cultural function of clients, groups and populations. They hold nationally accredited tertiary qualifications enabling eligibility for membership of their national self-regulating professional association or registration with their national Board.

Allied health professionals provide client focused, inter-professional and collaborative health care. This aligns them to their clients, the community, each other and their health professional colleagues. Without them, multi-disciplinary care isn’t possible.

Allied health professionals mainly work in either public practice, funded by State and Territory governments, or in private practice. As the bulk of their work does not attract an MBS rebate, the contribution that allied health makes to improve health and wellbeing often flies under the radar – and trying to find quality, accurate and recent data on the impact of allied health delivered privately on health and wellbeing is nigh on impossible.

In rural and remote Australia, the major health and wellbeing issue facing residents and the health professions is the growing wave of chronic disease.

The 2016 Survey of Healthcare found that people living in remote and very remote areas experience poorer access to a range of health services than people in major cities, and that people living outside major cities experience less sharing of information between health care providers than their city counterparts. The Survey also noted that three in five people in remote and very remote areas said not having a specialist nearby stopped them from seeing one. These are significant barriers that we need to overcome.

In the AIHW publication Australia’s Health 2016, it was noted:

Australians living in rural and remote areas tend to have lower life expectancy, higher rates of disease and injury, and poorer access to and use of health services than people living in Major cities.

In 2009–2011, people living in remote and very remote areas had mortality rates 1.4 times as high as people living in major cities. For nearly all causes of death, rates were higher for people living outside major cities, with people in remote and very remote areas faring the worst.

This is simply the result of not overcoming those barriers.

The Department of Health acknowledges that the optimal model for the management of chronic diseases is using a coordinated care multi-disciplinary team approach. To make this work in rural and remote settings will require innovation and determination to overcome the barriers I have outlined above. And it will need the Health Department to realise that the health workforce is more than doctors and nurses. Allied health has to be a central part of the solution – not just a quick sentence added in at the end.

Allied health, amongst other things, plays a vital role in the treatment and management of chronic diseases. If you are newly diagnosed with type 2 diabetes, for example, you may need to see a wide range of allied health professionals to help you understand your diagnosis and how to manage your health.

At different times you may need to access a dietitian, an exercise physiologist, a podiatrist, a physiotherapist or a psychologist. And if you live in a major city, you will be able to access this level of support. But this is not the case if you live in rural and remote communities.

Because many allied health providers work in private practice, we do not have data on the full 27 professions. The Australian Health Practitioner Registration Agency registers 15 health professions including 12 allied health professions, together with dental, medical and nursing professions.

This provides limited data for analysis, but with even the most cursory of examinations the significant maldistribution of allied health professions is easily apparent. (First slide)

(Second slide) By contrast, general practitioners are more evenly distributed with specialists in scarce supply with increasing remoteness.

But as the AIHW points out:

In 2014, based on total weekly hours worked the full-time equivalent rate of employed GPs per 100,000 population seemed higher in remote and very remote areas than in major cities; but:

• the overall rate of employed medical practitioners (including specialists) was significantly lower and

• the number of GP services provided per person in very remote areas during 2010–11 was about half that of major cities,

SARRAH recently worked with Novartis to develop a report on the economic impact of allied health professionals – particularly in rural and remote Australia. Jane Adams’ report found significant savings could be made – for example potential annual savings of $77.9 million were related to the prevention of kidney complications in patients with type II diabetes as a result of reducing HbA1c by 1%.

(Third slide) I want to look, very briefly, at this in more detail. Based on 2011-12 data, the prevalence of type 2 diabetes is higher in outer regional and remote/very remote communities than in major cities – but this is not a huge differential. Where the significant differentials occur is in the outcomes.

(Fourth slide) Looking at end stage kidney disease and deaths due to diabetes (as a primary or associated cause), if the outcomes we see in remote and very remote Australia were occurring in major cities, there would be a national outcry. (Fifth slide)

And there should be a national outcry – in a wealthy country, this is a diabolical result. As the data shows, the driver of this result is the level of diabetes and end stage kidney diseases in Aboriginal and Torres Strait Islander communities.

Our estimate, which I mentioned earlier, is that it should be possible to save around $80 million per annum if we reduce HbA1c by 1%. We should set this goal in remote and very remote health as an urgent priority – and put in place the data collection necessary to verify changes in outcomes.

There are 195,000 allied health professionals in Australia which represents around 25% of the health workforce. Those 195,000 professionals undertake 200 million health service provisions per year. However that 25% of the health workforce accounts for just over 6% of MBS expenditure.

That imbalance needs to be addressed if any progress is to be made in improving access to allied health particularly in the bush.

And this is where I want to nail SARRAH’s flag to the mast. SARRAH believes it is long past time for excuses about how hard it is to provide services in rural and remote communities.

We are committed to working with you all, and other interested parties, to find the innovative models of service and to display the determination to make the changes people living in rural and remote Australia need.

SARRAH believes that all health professionals – medical, dental, nursing and allied health – must commit to work together to address the maldistribution of health professionals and cross-promote how our partnership is vital to delivering better services, better access to services and better health outcomes.

BUT – we have to do this in partnership with Aboriginal and Torres Strait Islander communities and with their leadership, participation and identification of priorities.

The various components of the health spectrum, primary, medicine and allied all share a responsibility to support each other in pursuing a balanced funding approach from government and in so doing improving patient outcomes and the health and wellbeing of rural and remote communities across the length and breadth of this country.

We recognise and acknowledge that there will always be a hierarchy of need in terms of health service provision and that limited funding will always be prioritised according to that hierarchy of need. Nurses and GPs will always be at the top of that funding tree and from our perspective that’s not a bad thing.

If it meets the most pressing needs of a community then of course that is money well spent.

I am on the record as welcoming the recent budget announcements of more nurses and doctors. But I also am on the record as saying this should be the last federal budget where support for allied health services in rural and remote Australia is virtually non-existent.

The days where medicine, primary and allied see each other as merely competitors for funding need to end. This approach is both time consuming and wasteful. It is also an approach which cannot be described as patient centric.

Significant amounts of money has been invested in nurses and doctors over many years and we see positive results from that expenditure. To my mind, one of the best ways to protect that investment and support the nurses and doctors operating in rural and remote locations, many of whom are feeling stretched and stressed, is to start to fund supporting health services such as allied.

Allied health’s core mission of course isn’t to operate purely as a supporting service but it certainly makes the life of nurses and doctors easier if there are sufficient allied health resources to be able to refer patients to and vice versa.

SARRAH’s most vocal supporters when it comes to funding should be the AMA and the Rural Doctors Association of Australia. Not out of benevolence but out of self-interest and for no other reason than it is within the interests of their members to see appropriate funding go to allied health in the bush.

We at SARRAH are very much focussed on ways to improve on the ground access to allied health professionals. There are a number of projects we are working on to achieve that.

We are all committed to the benefits we see in a rural generalist approach to the delivery of health services. SARRAH is part of the group, led by Queensland Health, working on implementing an Allied Health Rural Generalist pathway, and over the next two years we will be working closely with other jurisdictions and organisations to promote and support greater uptake nationally.

We recently won a contract with the Queensland Government to support the further national development of the pathway and increase the uptake of rural generalist training hopefully leading to greater numbers of generalists practising in the field.

Part of that contract is to undertake some preparatory work on the implementation of the accreditation framework for the pathway which is important work and we’re excited to be adding that to our lead role in developing the pathway nationally.

This is work SARRAH is very much focused on and it’s important to note that this is in the context of a very challenging period for us organisationally following the cessation of funding the NAHSS Scheme.

The administration of that scholarship scheme became a focus for SARRAH which overwhelmed its other responsibilities to the point where the scheme became counterproductive from a SARRAH perspective.

However there’s nothing like a funding cut to focus the mind and since taking this role in December last year and in conjunction with the board, I have refocused and reorganised SARRAH and we are now more than capable of getting some runs on the board.

We are more focused. We are more capable. We are more vocal and we will be strong advocates for allied health in rural and remote Australia and that is something all of us, whether you’re a physiotherapist, a doctor, a nurse, or a humble non-medically trained CEO, can all agree is a good thing.

We are already upping our level of engagement with our stakeholders and kindred organisations. One of our key areas of activity is increasing the levels of awareness of SARRAH and our mission through making much better use of our charity status. SARRAH the charity, will be the vehicle for SARRAH the advocacy body to spread its message and gather support for our mission.

We have members, and we are committed to growing our membership base and enlisting their support for our advocacy campaigns. This isn’t just our individual members but our student members and importantly our corporate members.

And I couldn’t not take the somewhat cheeky opportunity to encourage all of you to jump on our website and join up or make a donation or become a regular contributor.

We have completely revamped our membership offering for corporates with tailored packages that provide genuine, long lasting and mutual benefit being the key feature of those. We want our relationships with stakeholders to be meaningful and we have done away with the old transactional way of doing things.

This is all part of our new approach and all to make sure we are geared up and focused on our important task of waking up one day and knowing that the promise and right of every Australian to accessible, affordable and quality health care doesn’t come with fine print or is contingent on which part of this first world country you live in.

(Last slide) Thank you for the opportunity today to talk about rural health.

I look forward to engaging with all of you to work more collaboratively to serve the people of rural and remote Australia better.

I also hope you have a very successful and productive general meeting and I wish the council well for the future.

Thank you.