Opening of Conference

5th National Rural Health Conference , South , 14-17th March 1999

Proceedings 5 TH NATIONAL RURAL HEALTH CONFERENCE Opening of Conference

WELCOME: WIRUNA PALYANTJA The Fifth National Rural Health Conference opened with a traditional Aboriginal welcome performed by the Aboriginal dance group Yura. The Chairperson of the National Rural Health Alliance, John Lawrence, thanked the group for their messages and gifts of welcome and at the same time acknowledged the Kaurna people as part of the First Nation of Australia. In his opening address Mr Lawrence reminded delegates that, although the Conference processes would be intense and there remains much to be done to improve health and other services to rural and remote communities, it was important not to lose sight of the positive side of country life: …don’t let us ever forget that most of us have a passion for the bush, its special history, our way of life, the beauty and spirituality, and the determination of those who live there. Many of us have been going through hard times, but please make sure in the next three days we celebrate these qualities, particularly in our health services, that make rural and remote life so satisfying. The Lord Mayor of Adelaide, Dr Jane Lomax-Smith, and the South Australian Deputy Premier, the Hon MP, delivered brief welcoming messages. In welcoming delegates to Adelaide Dr Lomax-Smith emphasised the aptness of holding the National Rural Health Conference in Adelaide given the historically close links that exist between the South Australian capital and rural and remote areas of the State. Mr Kerin welcomed delegates on behalf of the South Australian Government. In his brief address Mr Kerin referred to 's unique situation as a State without large regional centres and the challenges this presented in ensuring the delivery of appropriate health services to rural and remote consumers. He went on to acknowledge that any future regional development planning must be done in a context broader than economic development, it must also deal with issues such as quality of life, access to health services and especially access to primary health care services. The Federal Minister for Health and Aged Care, Hon Dr Michael Wooldridge MP, then presented the opening keynote address. Dr Wooldridge gave delegates an overview of the Federal Government's current policy priority areas in relation to rural and remote health and the rural and remote health workforce. They include: • working to increase doctor numbers in rural and remote areas; • public health; • Aboriginal and Torres Strait Islander health; and • medical research in the broad sense, including Public and Primary Health Care. Dr Wooldridge also summarised some of the recent and proposed policy responses of the Federal Government on rural and remote health issues, including: • Co-ordinated Care Trials; • an achieved increase in doctor numbers in rural areas; • the establishment of University Departments of Rural Health at Broken Hill and Mt Isa;

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• the introduction of John Flynn Scholarships for medical undergraduates; • consideration of the introduction of Medicare payments to psychiatrists for telepsychiatry consultations; and • the establishment of rural retention payments for doctors. The Minister concluded by informing delegates that the Federal Government has appointed Dr Jack Best, Chair of the Strategic Research Development Committee at the National Health and Medical Research Council, to undertake a 'stocktake' of rural and remote health initiatives. A report on the 'stocktake' is due to Government in August 1999. Dr Wooldridge and the Hon Dean Brown MP, South Australian Minister for Human Services, Disability Services and the Ageing, then formally launched the publication: Healthy Horizons: A Framework for Improving the Health of Rural and Regional Australians 1999-2003 (Mr Brown's speech is in Section 2 of these proceedings).

The Hon Michael Wooldridge, Federal Minister of Health and Aged Care presents the Opening Keynote Address

2 5 TH NATIONAL RURAL HEALTH CONFERENCE Opening Keynote Address

Hon Dr Michael Wooldridge MP. Federal Minister for Health and Aged Care

Deputy Premier, my colleagues, Health Minister Mr Dean Brown, Ms Lomax-Smith, John Lawrence, ladies and gentlemen, I am delighted to be able to join you for this terribly important Conference It may not surprise you to know that Health is not the most sought after portfolio of government. It is reported that when Jim Bacon announced his new Ministry recently in Tasmania, he was going to tell the Ministers what portfolios they got and then go straight into a press conference. It was reported that the press conference didn't go ahead because the Health Minister had burst into tears and run out of the room and couldn't be found. Perhaps it is uncommon for the Health Minister to get reappointed, but I was delighted to have the opportunity to be Health Minister again in the second Howard Government for two simple reasons: First is, probably like everyone here in the room, I care very deeply about health care in this country; and secondly, Health, perhaps of all portfolios, has enormously long lead times. Things that one might do take a long time to come into fruition, and to have a chance to have a second term as Health Minister gives you the chance to get the benefits, or otherwise, of successes or failures. I said the Health Care System means a lot to me because I am a product of it. It was my basic training, it was my early working life. I think in Australia we are all fortunate to have a very fine health system, in spite of the stresses, strains and criticisms. Can I give you just two simple examples? Someone I know quite well, 12 months ago was involved in a horrific car accident. They were in a coma for several days and sustained very bad trauma to the liver, amongst other things. When they awoke from the coma, they had a round of doctors discussing whether or not this person might be in need of a liver transplant. He rang me up when he was well enough to get on the telephone again and just said, "I've got to tell you, I think the health system is not all that bad when I woke up from the coma to find that the discussion amongst the people around my bed is whether or not I could be provided with a liver transplant". Three weeks ago, I was up at Torres Strait on Moa Island. I was watching some kids playing, young kids running around in nappies. There was a little girl who caught my eye, about 12 months old, I noticed, after looking at her for some time, that she had a scar from her neck right down to her abdomen. I asked what had happened to her. She had been born on Moa Island. She had been blue, particularly sick at birth, and was cared for overnight in a primary health care centre, before she was evacuated to Thursday Island the next morning.

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That afternoon she was in Cairns and 24 hours later, she was in Brisbane receiving open-heart surgery to repair a substantial cardiac defect. It made me think perhaps that things are not too bad when an island child can be evacuated and be receiving advanced cardiac surgery within 36 hours of birth. I talk on many talkback shows. I talk with many hosts and am usually berated about the various failings in the health care system. I have come up with a standard response - I say to the host, "That's fine, tell me somewhere else in the world you'd rather be sick." I haven't yet had a reply. Therefore, by and large, we have a health system of which we can be proud. Where it does fail though, is in its responsibility to many areas in rural and remote Australia. It's sad that the little Islander girl had a better chance of getting open-heart surgery than she did at getting basic primary health care. Being Health Minister gives one the privilege of at least setting one's own priorities. I have four main priorities that I am trying to pursue these next three years - medical numbers in Rural Australia, Public Health, Aboriginal Health, and Medical Research. Perhaps those four together encapsulate the challenge of rural and remote health in Australia. I'll talk about what is happening in each of those areas. The number of doctors in rural Australia rates as the continual contentious political issue. I talk of doctors, not in any sense that they are the only important health professionals, or even the most important health professionals in rural Australia, but because the Commonwealth of Australia has a specific responsibility for doctors and Medicare. We don't have direct responsibility for nursing or other allied health professions. We made a very simple mistake in Australia some 40 years ago. Up until 1956 you could matriculate and walk into Medical School with no restrictions. The first quota was introduced by the University of Melbourne in 1956. By 1966 you needed three A's to get into Medical School. By 1976 you needed 4 A's and by 1986 you needed five A's. As we made it harder and harder for young people to get into medical school, we also progressively excluded country kids as medical students. You can't convince me that a child educated in rural Australia does not have a degree of educational disadvantage. So while 25 per cent of children live and are educated in rural Australia, at the University of Sydney only five per cent of their intake have a rural background. We know that if you come from rural Australia the chances of going back to rural Australia are 45 per cent. If you come from urban Australia, the chances of going to the country are five per cent. So it's absolutely clear cut why we have the problem we have today, because in the last 40 years we haven't been allowing enough country kids into medical schools. Now there is no simple fix for this. There is no overnight solution. I'm immensely heartened that many universities in Australia, but not all, are taking this issue seriously, that they need to attract country students into medicine. The University of Melbourne has changed its selection criteria dramatically for this year's intake. They have a higher proportion of country students as a result of this change, so we can expect when this year's students graduate as a class of 2004, and they will be completing their post graduate training in the year 2009, there will be many more committed doctors to go to rural Australia. However, that's an enormously long lead- time.

4 5 TH NATIONAL RURAL HEALTH CONFERENCE One of the first big fights I had as Health Minister, and I tend to have quite a few of them, was over the issue of Medicare provider numbers. You might remember that in 1996 I had demonstrations against me in every capital city in Australia over the issue of provider numbers. One of them I remember because my son at the time was five years old. He came in to breakfast, he was very excited and said, "Daddy, Daddy you'll never guess what I saw last night!" I said, "I don't know Ed, what is it?" "I saw people on television and they had this big banner and it had 'Wooldridge' written on it!" Very fortunately, he couldn't read what else was written on it. But the fact is, in the last two years since that legislation was passed, the number of doctors practising in rural Australia based on Health Insurance Commission figures has gone up by 7.2 per cent. The number of doctors who practise in remote Australia has gone up 21.5 per cent. Now that overstates the overall effect because it's not full time equivalent figures. Much of it is locum work. The fact is we are providing much better locum relief for our local doctors, and the full time equivalent numbers of doctors in rural and remote Australia for each of the last two years has gone up. This is reversing the change and direction of a generation for the first time ever as a direct result of that legislation being passed. Today we have operating University Departments of Rural Health, in Broken Hill and Mount Isa. This was something that we conceived and took to the 1996 election. Those two are in operation. Whyalla, Launceston, Geraldton and Shepparton we hope will be getting under way in the next 12 months. Broken Hill has had a Professor of Surgery for the last 12 months. This person was the head of the Unit at the Alfred Hospital in Melbourne. Before his retirement he wanted to spend 12 months in rural Australia. Broken Hill has never had a surgeon of that calibre. Broken Hill today has a Professor of Medicine. Three weeks ago, as part of my trip to the Torres Strait I opened the Mt Isa Centre for Rural and Remote Health. This year 80 medical students, 75 nursing students and 45 allied health students will be doing a portion of their training at this centre, in rural Australia. Last Christmas 450 medical students around Australia, rather than working on a building site or a foam rubber factory (both of which I had to do on holidays as a medical student) worked with John Flynn Scholarships in rural and remote Australia. Next year the number of scholars will plateau at 600 medical students. They will be taking up a scholarship for four years, each Christmas they go back into the same community to better understand rural health practice. We hope to start a clinical school of the University of NSW in Wagga where 25 per cent of all their students will train at Wagga for their clinical training. In order to keep what we've got, next year we will be introducing rural retention payments for General Practitioners. We'll actually be giving Doctors staying in a rural community payment to recognise the service they have provided. This recognises the simple fact that it is easier to keep the doctors you've got rather than trying to attract new ones.

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Within 12 months, with the help of the Royal Flying Doctor Service, we will be flying female GPs into and out of communities on rotation so that country women can have access to female GPs, something that city people take for granted. So all these things are slowly turning around a generation of decline. I fully concede it may not be enough. I am still outraged at the number of Universities that exclude rural kids from medical school training. I have every intention over this year of seeing that change. And all of this may sound like a long way off. It will be in 2009 before the University of Melbourne's changes start to be felt in rural Australia. I keep telling myself I wish someone had done this ten years ago, and maybe we wouldn't have the problems we have today. Of course, doctors are one end of the health spectrum. Public Health or Population Health is perhaps the other end, although of course, the two are terribly interlinked. We have a health care system in Australia that is focussed on treating illness rather than preventing illness or better managing chronic illness, but this too is changing. We now have thirteen Co-ordinated Care Trials up and running around Australia, two of them in South Australia. These trials aim to try to better manage chronic illness, to see if we can substitute 'in hospital' services for 'out of hospital' services. The first one, HealthPlus, was launched here in Adelaide. At the launch I met a man called John Williams. He was a retired bank manager and he had very severe asthma. So severe that he had had on average three admissions to hospital for every year of his life. He had never had a year where he had not been in hospital. We ran him as part of a pilot to see if we could better manage his asthma, and keep him out of hospital; working with his General Practitioner, and actually better educating him. During the previous 12 months, he has had the first year of his life where he had not been in hospital. He is an educated man, who has operated at a high level in society, but it took him until 63 years of age to access the information that he needed to manage his illness. What's this got to do with rural Australia? Well, today on the Eyre Peninsula in South Australia, the HealthPlus trial is suggesting that the incidence of hospitalisation, youth diabetes, or chronic cardiovascular illness amongst that community is down 15-20 per cent since mid 1997. At Ceduna, an Aboriginal population, a co-ordinated care approach has meant that where previously there was one and a half hospital admissions per person per year for that community, the number has dropped one third in the last 18 months. Therefore, we've shifted the focus in these communities, treating illness by trying to prevent it or if we can't prevent, better manage illness in those populations. This is a dramatic change to the way that we undertake health care in this country. There are some positive things in Public Health. Recently the Australian Institute of Health and Welfare released a report that showed that 55 per cent of all women in rural and remote Australia were receiving regular breast screening, comparable with the rest of the population. 70 per cent of women in rural and remote Australia over 18 years of age were having a pap smear every two years, again comparable with the rest of Australia. So there are challenges, there are also areas where we are not doing too badly.

6 5 TH NATIONAL RURAL HEALTH CONFERENCE The third area we are trying to focus on is the area of Aboriginal Health. No identifiable group in the Australian population deserves to have the health status that Aboriginal Australians have. It's not been from a lack of good will in the past - but things have failed to get better. The first question I had to ask myself as Minister was, what went wrong in the past because I was determined not to repeat past mistakes. In 1990 we had a National Aboriginal Health Strategy. It put half a billion dollars of additional money into Aboriginal Health, and when it was reviewed in 1994 by Steve Gordon in the Aboriginal and Torres Strait Islander Commission (ATSIC), the most charitable thing he could say about it was in some parts of Australia we could find some evidence that it existed. I think the answer lies in fairly plain mundane issues. The first is that a number of different levels of Government and organisations were working completely at cross- purposes. Commonwealth Government, State Government, ATSIC, Aboriginal Medical Services, were working without any idea of what the other was doing, without any involvement in each other's planning process. In some parts of Australia, State or Territory Governments refused to talk to some Aboriginal Organisations. We now have a framework agreement for every State and Territory Government in Australia and a Regional Agreement recognising specific or special features of the Torres Strait in Australia. South Australia, I am pleased to say, was the first to sign. Of itself this doesn't translate to funding, but it does mean that all the parties involved in Aboriginal Health agree to a process where we get around a table and share common planning processes, so that at least we are all informed and, where possible, work together. As Puggy Hunter, the Chair of the National Aboriginal Community Controlled Health Organisation (NACCHO) said: for the first time we were all in the same car going in the same direction. The second thing happened in Cairns in 1997. All of the Country's State and Territory and Commonwealth Health Ministers agreed that in the future we would set common targets to be reported against, and be prepared to open to the light of public exposure as success or failures. Again that may not sound much, but it does mean in the future, Government Ministers won't be able to hide from their failures, and may get credit for their successes, rather than everyone else pointing to each other. We are saying that we are all responsible. Along with this, from a Commonwealth level there is a very substantial increase in resources. Funding today is 50 per cent higher than it was three years ago, and the funding is making a difference on the ground. I was staggered to find that when I came to Government, there were 35 communities in Australia with as many as 1,000 people in them that had no access to primary health care whatsoever. Today we have funded basic primary health care in every one of those 35 communities. That means that a good number of communities now have a chance to access services in preventative care in a way that was unimaginable three years ago. There's naturally a dramatic amount more to do. Recently, Hugh Taylor, Professor of Ophthalmology in the University of Melbourne, gave me a report that in fact said in most parts of Australia, Aboriginal Eye Health is no better than it was 25 years ago, and in some places we are clearly worse. Many Australians think that with the fine work of Fred Hollows this problem has been solved. The fact is,

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25 years on we are no better off, and we are arguably worse off. I was meeting at the Royal Australian College of Ophthalmologists just last week to discuss how they might help us in remedying that. Sexually transmitted diseases remain a problem in much of remote Australia. This is a function of poor access to basic primary health care, and poses a great threat to HIV transmission. HIV is rapidly expanding in the Western Province Region of Papua New Guinea. In Indonesia, after Jakarta, the second highest incidence of HIV is not from Bali or near spots where we would know, it's a little village called Mwaki in South East Irian Jaya, close to the Australian border. Clearly, this remains a focus for concern in our area. Nevertheless, it is not all hopeless, we have some reason for optimism. The fourth priority I mentioned was medical research. Medical research perhaps may not seem to fit in necessarily with rural and remote health. By research I think much broadly than looking down test tubes and microbiology. Public Health research in Australia is advancing. The National Health and Medical Research Council has just recently established a Rural Health Research Committee, and that's going to draw up a national agenda that they intend to fund over the coming years. Much has happening in Rural Health. Today we are in the age of Internet, relative time satellite and Telenet. Australia led the world in the 1920s when Alfred Traeger developed the pedal radio that allowed the Royal Flying Doctor Service to come into being, and just as we led the world there, we are leading the world with telemedicine. In psychiatry, for example, we now have telemedicine operating between Melbourne and Gippsland and a number of other parts of Australia. I am looking to make telepsychiatry accessible on the Medicare Benefits Schedule. Medicare Easyclaim is now in over 500 pharmacies in rural and remote Australia, in places we could never put a Medicare office. It is not as good as a Medicare office, but for those 500 communities it is something. My own Department now has a Rural Health Branch to give greater focus to rural health medicine rather than have it spread across a number of divisions. And in an attempt to try and provide ongoing leadership and draw together what is a very large range of programs and activities at a Commonwealth level, last week I appointed Dr Jack Best, who is Chair of the Strategic Research Development Committee at the National Health and Medical Research Council, to do a stock take. This stock take will have a look at what we are doing well, have a look at where we need to do better, to see what changes we need to make, and he will be reporting back to us by August this year. Immediately after this opening ceremony, Dean Brown and I will be releasing a document, "Healthy Horizons", where all Territory and Commonwealth Governments have got together to look at future directions for Rural Health. A healthy workforce will continue to be vital for Rural Australia. Primary Health Care will become a greater focus; we will address Aboriginal health and we will be using technology to take advantage of our ingenuity in technology. I think all that gives me cause for hope. There are 900 people here in this conference in 1999. Some of you would have been at the first conference in Toowoomba in 1991. Think what's been achieved in 8 years. In 1991 the Rural Doctors Association of Australia, the Council of Remote Area Nurses of Australia (CRANA) and the Australian Association of Rural Nurses got together and 300 people met in Toowoomba.

8 5 TH NATIONAL RURAL HEALTH CONFERENCE This was a great achievement, although I suspect those who were there will think the organisation of this conference is probably a little bit better than that one. You certainly won't have to be running from shed to shed, which is how the Toowoomba Conference was described to me. What a change in eight years. Rural Health is a mainstream health issue today. What about the activity of many individuals in this room, and the organisations you represent. I personally am proud of what I have been able to achieve in three years as Health Minister. 450 John Flynn scholars, scholarships for Rural and Remote Area Nurses, Co- ordinated Care Trials, a 50 per cent increase in Aboriginal Health Funding, Framework Agreements in every State and Territory, Regional Health Service Centres, GP Retention Grants, female doctors flying in and flying out, a clinical school at Wagga, commitment to a new Medical School in Townsville, and a first ever two year increase in GP numbers in rural Australia, but that's a very small part of the story. Those people on the ground, the doctors, nurses and the allied health professionals, are those who make it happen. Their organisations are the ones that try to change. Their organisations are the ones that mean political leaders can no longer afford to ignore rural health. This must alone give great cause for optimism. People in rural and remote Australia have the right to expect what every other Australian takes for granted. That is, access to good, basic, primary health care. That, for a long time, has been a dream and it's slowly starting to happen. There is a lot more to be done, and our efforts perhaps have not always been heard. As Commonwealth Health Minister, I can only do what I can with the input, advice, lobbying, criticism, encouragement, and support of those people and their organisations who are doing it on the ground. Conferences like this do have their effect. The Healthy Horizons document, which I will launch with Dean in a moment, is heavily influenced by what you did in 1997. Just as what you do over the next few days will influence the development of Rural Health Policy in the future. So your work is important, your work does make a difference. So I remain an optimist and I would like to say thank you for the help, assistance, advice and support. I look forward to hearing your deliberations. I am delighted to declare this Conference open, and I look forward very much to hearing what you come up with in the coming few days.

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