Rural directions––for a stronger healthier Victoria Update of Rural directions for a better state of health

Rural directions––for a stronger healthier Victoria

Update of Rural directions for a better state of health ii Rural directions––for a stronger healthier Victoria

If you would like to receive this publication in an accessible format, please phone 03 9096 2007 using the National Relay Service 13 36 77 if required, or email . This document is also available in PDF format on the internet at .

Published by Victorian Government Department of Health, Melbourne, Victoria. © Copyright State of Victoria, Department of Health, 2009 This publication is copyright. No part may be reproduced by any process except in accordance with the provisions of the Copyright Act 1968. Authorised by the State Government of Victoria, 50 Lonsdale Street, Melbourne. Printed on sustainable paper by Energi Print Pty Ltd, 2–4 Emily Street, Murrumbeena 3163. (0220909) October 2009 Rural directions––for a stronger healthier Victoria iii

Contents

Foreword v Vision and principles vii Executive summary 1 Introduction 5 Policy context 6 Changing demographics of rural Victoria 7 Forecast demand for health services 10 Rural directions––for a stronger healthier Victoria 13 Direction 1: Improving the health of rural Victorians 15 Aboriginal health 16 Alcohol and drug services 17 Aged care 18 Cancer services 19 Cardiac services 19 Critical care 20 Emergency care 20 Environmental health 21 Health promotion 22 Hospital Admission Risk Program 23 Maternity services 23 Mental health 24 Neonatal services 25 Oral health 25 Paediatric services 26 Palliative care 26 Primary health care 27 Procedural services 28 Renal dialysis 30 Stroke services 30 Sub-acute services 31 Vulnerable children 31

Direction 2: Supporting a contemporary health system 33 Regional health services 35 Sub-regional health services 39 Local health services 43 Emergency ambulance and patient transport services 48

Direction 3: Strengthening and sustaining rural health services 51 Continuing service enhancement 52 Growing workforce capacity 56 Improving governance and performance 59 Appendix 1: Minimum emergency care 65 Appendix 2: Regional profiles 66 iv Rural directions––for a stronger healthier Victoria

Abbreviations

ABS Australian Bureau of Statistics AHNP Aboriginal Health National Partnership AIHW Australian Institute of Health and Welfare AMWAC Australian Medical Workforce Advisory Committee ARV Adult Retrieval Victoria BNC bush nursing centre BNH bush nursing hospital COAG Council of Australian Governments CPHI Centres for Promoting Health Independence CT computerised tomography GEM geriatric evaluation and management GP general practitioner HARP Hospital Admission Risk Program HARP–BCOP Hospital Admission Risk Program––Better Care for Older People HIP guidelines Health independence programs guidelines HITH Hospital in the Home ICT information and communications technology IMG international medical graduate IT information technology LGA local government area MNCN Maternity and Newborn Clinical Network MPS multipurpose service NEPT non-emergency patient transport PCN Victorian Paediatric Clinical Network PCP Primary Care Partnership RICS rural integrated cancer services RMI Rural Maternity Initiative SACS sub-acute ambulatory care services SCN special care nursery SEIFA Socio-Economic Indexes for Areas SFF Sustainable Farm Families SRHS Small Rural Health Services VMO visiting medical officer VPTAS Victorian Patient Transport Assistance Scheme Rural directions––for a stronger healthier Victoria v

Foreword

When we think of health care, we think of much more than just hospitals. Health promotion, illness prevention, management and active treatment of illness and injury, through to care of the aged and end-of-life care are all active components of the coordinated and connected health system we have in rural Victoria. We have seen much innovation and change in the years since Rural directions for a better state of health was released in 2005. Rural health services have embraced the opportunities to provide better comprehensive care for their communities. The cooperation and coordination between services demonstrates what can be achieved when we work together to support high-quality health care in local communities. Good health care and an increasing focus on illness prevention is a high priority for both the Commonwealth and Victorian Government. The challenges of managing growing demand on the health system as a result of the ageing population and increasing complexity of clients provides us with opportunities to examine how the system can do better. In many ways rural health services lead the way in integrated care, with innovation evident throughout the state. The Government is strongly committed to continuing to improve the health of Victorians. Victoria is well positioned to capitalise and lead the way in the national reform agenda currently being discussed and debated by all governments. As an example, tackling cancer has already been identified as one of our top priorities, with the objective of improving access for all Victorians to the best possible care, informed by world-class research. We know we will only achieve measurable change when improvement in access and outcomes is evident in rural Victoria. Rural health services face a changing world, with impacts of climate change, workforce pressures and population trends presenting both challenges and opportunities. The government will continue to support health services to manage these challenges and ensure communities remain strong and resilient, with an exciting future ahead as health care provision continues to evolve. I am pleased to present Rural directions––for a stronger healthier Victoria, which continues to articulate the government’s vision for a high-quality and sustainable rural health system for the next five years and beyond.

The Hon. Daniel Andrews MP Minister for Health

Rural directions––for a stronger healthier Victoria vii

Vision Principles

To enhance and protect the health Rural health policy directions recognise health care needs are and wellbeing of Victorians living changing and that the system must continue to evolve to better meet in rural and regional areas by those needs. The guiding principles aim to maximise access, quality providing a sustainable rural health and continuity of care, service flexibility, opportunities for service system that is connected, person substitution and diversion as well as optimal use of all resources. focused and provides the right The principles of rural health system planning, development and support in the right place. provision are: • A comprehensive health system is about the full continuum of health––from health promotion, illness prevention and management, active treatment of illness or injury, care for the aged and end-of-life care. • The health system will be person and family centred, with consideration of a person’s needs as these change over time, rather than centred on agencies or programs. • People will have appropriate access to services and contemporary models of care that are both effective and safe. • People will be supported to manage and protect their own health. • Victorians living in rural areas should expect to have the majority of their care needs met by services in their own region. • A comprehensive service system has services working flexibly and in coordinated partnerships, to benefit communities. • Health care will be provided in the most appropriate and least complex setting. • Services should be planned and coordinated within geographical areas to address needs of a broader population. • High-volume, low-complexity services will be provided as close to home as possible, without compromising the quality of care. • Low-volume, high-complexity services will be concentrated in key locations to ensure service quality and sustainability. • Changing models and alternative options for care will increase the need for flexibility in both workforce and physical infrastructure. • Innovation and planning contribute to an improved, sustainable workforce and service system. viii Rural directions––for a stronger healthier Victoria Rural directions––for a stronger healthier Victoria 1

Executive summary

The Victorian Government’s vision for the ongoing support and development of the health system in rural Victoria was outlined in Rural directions for a better state of health,1 released in November 2005. This recognised that a comprehensive health system will provide the right care in the best place to meet community needs. It also recognised that the health system cannot be static but must constantly evolve as service models and options for care progress and change. Rural directions confirmed that the future of health services in Victoria was assured. What was needed was to ensure we have a strong, responsive and sustainable health system, which is able to keep pace with social, economic and service changes and continue to meet contemporary community needs. Rural directions provided an opportunity for all those working with or for rural health services to see how change needed to be supported to continue to meet the challenges faced by the system and how, working together, these can be managed. Rural directions then provided three strategic directions, each containing a number of specific projects, for rural health services to develop and enhance their roles in the system of care across Victoria. Since 2005 work on these projects and programs has advanced, as have developments across the health system both at national and state level. As in the past, the health system continues to evolve and change in response to developments in the evidence base of health care provision and changing community priorities. Rural directions––for a stronger healthier Victoria provides an opportunity to build on what has already been achieved and outlines the next phase of continuing service development. This updated version continues with the three broad directions, but now with a revised focus to update development priorities. The three directions are now: • improving the health of rural Victorians • supporting a contemporary health system • strengthening and sustaining rural health services. Each of these directions again contains a number of strategies and specific projects. Some of these are already underway and others will follow over the coming years. Each strategy will require cooperation between government, health services, professional groups and other stakeholders to achieve success.

1 Department of Human Services 2005, Rural directions for a better state of health, State Government of Victoria, Melbourne. 2 Rural directions––for a stronger healthier Victoria

Direction 1: Improving the health of rural Victorians Direction 1 recognises the continuing development of programs and services that aim to improve the health of all Victorians. As defined in the vision, the health system will be supported and coordinated to provide rural Victorians with access to appropriate high-quality health care in the right place, which is as close to home as possible. There are a number of clinical program areas where service development is proceeding. While service innovations and developments are usually statewide, it is important they are developed cognisant of the uniqueness of rural settings, so opportunities to benefit from improvements in health services and outcomes are applicable regardless of geographic location. Drivers include the need for more services in rural areas and support for sustaining existing services. In both cases the objective is to improve access to appropriate high-quality services to support population health improvements over time. Direction 1 provides a summary of many of the current developments in specific clinical areas, where these impact most directly on rural Victorians. It is not intended to be comprehensive, so provides references for access to further detail.

Direction 2: Supporting a contemporary health system The concept of a structured, integrated public health system throughout rural Victoria was outlined in Rural directions 2005. This acknowledged that, while all health services have a role in providing quality care for the population within their catchment area, a single health service cannot be expected to meet the total health care needs of their community. All health services play an important role within their local communities, but as the demographics and disease burden change over time, medical knowledge increases and new treatment and care modalities are developed, it is important to recognise that health care provision will also change and services need to respond to these changes to preserve quality health care. The integrated health system in rural Victoria consists of regional, sub-regional and local health services. This provides a contemporary health system that is coordinated, connected, patient focused and committed to appropriate evidence-based care. This document details the roles and range of clinical services expected at each level and identifies the role of each agency. This provides clarity for strategic directions and service planning across areas and for each health service. The challenge for all services is to provide health care as close as possible to where people live, while maintaining sufficient volume to ensure appropriate quality service provision. A major theme of Rural directions is partnerships and relationships between services to enhance care for rural Victorians. A coordinated system facilitates quality care by supporting patient pathways and access to appropriate care, wherever that is best provided. Rural directions––for a stronger healthier Victoria 3

Direction 3: Strengthening and sustaining rural health services Development and support for the integrated and coordinated health system required in rural Victoria will be facilitated through many ongoing initiatives and programs, including those outlined in direction 1. Direction 3 summarises the other specific projects, programs and developments that will enable the rural health system to continue to develop in a sustainable way over the next five years. To advance policy objectives, three enablers are identified:

Continuing service enhancement Coordination, collaboration and partnerships are essential to continued sustainability of the health system in rural Victoria. This includes improved area-based service planning and enhancement of capacity at regional and sub-regional health services to augment areas of increasing demand and improve regional self-sufficiency. The leadership role of regional and sub-regional services to provide: clinical and workforce expertise; education and training; mentoring; and coordinated service approaches will be better defined and strengthened. Local health services will be supported to fully embrace opportunities provided by flexible funding to tailor services towards primary and community care. Enhancing capacity also includes redesigning services and systems as models of care and health care provision evolve. The key drivers of capital investment are to either: expand capacity to cater for growth and new service development; renew or replace obsolete infrastructure to mitigate critical risk; or redevelop to enable fit-for-purpose facilities to reflect changing service delivery and models of care. Capital investments in rural Victoria over the coming years will be targeted towards projects that clearly respond to one or more of these drivers. Continuing development of information and communication technology provides opportunities to improve patient care, improve access to care and reduce travel demands for rural Victorians.

Growing workforce capacity Rural health services will be supported to maintain a sustainable workforce through improving recruitment and retention in rural and regional areas and redesigning the workforce to meet changing local needs. As the impact of rural medical schools and other initiatives is felt, there is also the need to prepare for future workforce growth.

Improving governance and performance Governance is critical to providing good, safe care within a sustainable system, in accordance with government policy. A robust governance process is supported through a comprehensive board development program that focuses on governance and legal frameworks, stakeholder engagement, strategy setting, clinical and financial governance, management of risk, group dynamics and current health policy issues. Clinical governance occurs within the context of the broader governance role of boards. An effective system of clinical governance at all levels of the health system is essential to ensure continuous improvement in the safety and quality of care. Along with governance, accountability and performance will be strengthened through expanding benchmarking information available to boards. Appendix 1 provides details relevant to providing high-quality care in emergency or unplanned situations. Appendix 2 then describes each region and identifies the role of each agency within the coordinated health system across rural and regional Victoria. This will support health service strategic planning at the local level. Rural directions––for a stronger healthier Victoria acknowledges the major support all health services provide for their rural communities and recognises how much this contributes to community sustainability. This update is about positioning and supporting services to face the future with confidence.

Rural directions––for a stronger healthier Victoria 5

Introduction

Rural directions for a better state of health was released in November 2005. The document outlined the Victorian Government’s vision for continuing to develop the rural and regional health system. It outlined key directions and provided a framework for development of health services across rural Victoria. Three broad directions were identified, each with a number of specific projects: 1. Promote the health and wellbeing of rural Victorians This was a mix of health promotion, illness prevention and disease management, targeted at particular community groups. 2. Foster a contemporary health system and models of care for rural Victoria This defined a structured, integrated three-tiered rural health system facilitating partnerships between agencies and collaborative patient care. 3. Strengthen and sustain rural health services This outlined the enablers, or the initiatives, that would support and facilitate improved systems and processes. Since 2005 work on these projects and programs has advanced, as have developments across the health system both at state and national level. As always, the health system continues to evolve and change in response to development in the evidence base of health care provision and changing community priorities. Further development of the roles of public health services in rural Victoria was explored in a discussion paper released in 2007. It is now timely to reaffirm commitment to a strong and sustainable Victorian rural health system, in line with the defined vision. Rural directions––for a stronger healthier Victoria continues with three broad directions, but with a revised focus to update developmental objectives and priorities for the next five years. This provides an opportunity to build on what has already been achieved and outline the next phase in the ongoing evolution of the health system in rural Victoria. 6 Rural directions––for a stronger healthier Victoria

Policy context

Since the release of Rural directions in 2005, there has been continued development of policies and programs across the full spectrum of health care. A Fairer Victoria2 is the government’s overarching social strategy for meeting Victoria’s future challenges and improving the lives of all Victorians. It began in March 2005 with the release of Challenges in addressing disadvantage in Victoria (2005) and outlined a range of strategies and initiatives designed to address disadvantage in Victorian communities, including the needs of Victorians in rural and regional areas. It noted that disadvantage can be experienced by people living in communities where life chances are diminished through geographical isolation. Since that time a series of documents have been released: Creating opportunity and addressing disadvantage (2005), Progress and next steps (2006), Building on our commitment (2007), Achievements so far (2008) and Strong people, strong communities (2008). The latest paper is Standing together through tough times, released in May 2009. This continues the government’s commitment to build strong and resilient communities, and has particular relevance given extra pressure on many communities due to the economic downturn. Major investments are targeted to mental health, out-of-home care, disability services and Indigenous health. A fundamental goal of A Fairer Victoria is to reduce health inequalities by minimising and ameliorating the prevalence of key risk factors that contribute to chronic conditions. A broad program of service reform is outlined to reinforce the government’s focus on early intervention and give emphasis to recovery and ongoing social support. The four key priorities areas are: • getting the best start––early years support for children and families most at risk • improving education and helping people into work––reducing educational inequality, supporting young people at risk and reducing barriers to workforce participation • improving health and wellbeing––reducing health inequalities and promoting wellbeing • developing liveable communities––strengthening neighbourhoods and local communities. Health reform is being pursued at both a state and national level, with a priority focus on prevention through promoting good health and wellbeing, primary care as the cornerstone of the health system, and improving the safety and quality of our hospital services. Reforming the health system is underpinned by investing in creation of a flexible and innovative workforce and supported by a robust and accessible e-health system. Reform is essential to meet a range of long-term challenges including access to services, the growing burden of chronic disease, population ageing, service inefficiencies, the escalating costs of new health technologies and community expectations. Since its election in 2007, the Commonwealth Government has embarked on a significant health reform agenda which has culminated in the recent release of the final report of the National Health and Hospitals Reform Commission3, and the National preventative health strategy4 and the draft National primary health care strategy. The recommendations from these reports are currently being discussed and debated by all governments. Notwithstanding any actions that may come out of this work, shared key priorities for national and state governments will continue to be: tackling major access and equity issues that affect health outcomes; improving performance of hospitals and redesigning the health system to better respond to emerging challenges, focusing on prevention,

2 Department of Premier and Cabinet 2005, A Fairer Victoria, Creating opportunity and addressing disadvantage, State Government of Victoria, Melbourne. This has since been updated to: State Government of Victoria 2009, A Fairer Victoria, Standing together through tough times, State Government of Victoria, Melbourne. 3 Commonwealth of Australia 2009, A healthier future for all Australians: Final report of the National Health and Hospitals Reform Commission June 2009, Commonwealth of Australia, Canberra. 4 Commonwealth of Australia 2009, Australia: The healthiest country by 2020––National preventative health strategy, Commonwealth of Australia, Canberra. Rural directions––for a stronger healthier Victoria 7

early intervention for those recently diagnosed, and care management for those with complex needs and who are at risk of hospitalisation. As the reform agenda progresses, documents such as Rural directions will be reviewed and refined to accommodate national reforms that are adopted in the context of broader system improvements. Changing demographics of rural Victoria Population estimates for 2008 indicate approximately 1.42 million people are living in rural and regional areas, which equates to 26.7 per cent of the total population, or more than one in four Victorians. Forecasts indicate the rural population will increase by 1.03 per cent annually, which will result in more than 1.5 million more people residing in rural Victoria by 2018.

Figure 1: Population of rural Victoria 2008––by local government area 8 Rural directions––for a stronger healthier Victoria

The demographic profile of rural Victoria supports a place-based approach to service planning as there is significant variation in communities across the state. There is strong population growth in areas on the metropolitan–rural fringe and in most regional centres and their surrounding areas. Much of the growth is in areas with significant ‘rural amenity’, particularly coastal and riverine locations. There is continuing population decline and ageing in the more traditional farming or production areas in the western part of the state and in smaller towns outside the periphery of regional centres, as has been the trend for the past 50 years.

Figure 2: Map of population growth––population change 2008–2018

The age composition of rural areas is changing, with forecasts indicating the proportion of older people in rural Victoria will increase at a faster rate than in metropolitan Melbourne. By 2018, the age group of 70 years or older will increase to 14 per cent of the rural population, compared with 11 per cent in the metropolitan area. The proportion of working age people between 20 and 40 years is also lower in rural areas, with the resultant impact on workforce. Rural directions––for a stronger healthier Victoria 9

Figure 3: Population by age and gender

  This increasing proportion of the population aged 70 years or over places additional pressure on health services as older people have greater health needs and are major users of health services at all levels. Older people have a greater prevalence of chronic diseases, including cardiovascular disease, cancer, diabetes, renal disease, chronic obstructive pulmonary disease and musculoskeletal conditions such as arthritis. It is forecast that by 2018–19, people aged 70 years and over will consume 49 per cent of all bed days utilised by rural Victorians. According to the Australian Bureau of Statistics (ABS)5 there is also a higher proportion of people with disabilities in rural Victoria, with 209 per 1,000 population compared with the Victoria total of 189 per 1,000 population. The changing age mix will increase demand for services needed to manage chronic and complex conditions throughout rural Victoria. The Burden of Disease Study6 identified living in the country as being associated with a decreased life expectancy, which is largely due to cardiovascular disease, cancers, injuries caused by road and machinery accidents, suicide and drowning. This reduced life expectance for rural populations may be attributable to a combination of socioeconomic factors, health impacts of the long-running drought, access to local services and timely access to life-saving treatment such as resuscitation and surgery. Lack of access to services is compounded by a number of factors. A study by the Primary Health Care Research and Information Service7 demonstrates lack of access to general practitioner (GP) services in rural areas. As an example, the study indicated that in 2006–07 there was one GP for every 1,529 in the Mallee Division of General Practice, compared with a one in 417 ratio in the Melbourne CBD.

5 Australian Bureau of Statistics 2003, Small Area Estimates, Disability Synthetic Estimates, ABS, Canberra. 6 Australian Institute of Health and Welfare 2007, The burden of disease and injury in Australia 2003, AIHW, Canberra. 7 Primary Health Care Research and Information Service. See . 10 Rural directions––for a stronger healthier Victoria

Data from the Socio-Economic Indexes for Areas (SEIFA)8 also indicates there is lower socioeconomic status in much of rural Victoria, impacting on the ability of people to pay for alternative services, if they are available. The index of relative socioeconomic disadvantage measure is 998.88 for rural Victoria compared with 1,020.56 for metropolitan areas. Rural populations experience higher unemployment and greater relative numbers of low-income households compared with metropolitan populations. While Victoria may not appear to have the same remote communities as are found in states with a larger geographic area, there are still many communities in locations where access will be limited due to distance and terrain. This is particularly true of the western Mallee areas and mountainous areas in the east of the state. In these communities local health services play a critical role in providing health and community care. Forecast demand for health services Service change Analysis of rural health service activity shows continuing growth in separations of approximately 9 per cent between 2004–05 and 2008–09. The majority of this has been in same-day separations, including renal dialysis, gastroenterology and cardiology. Estimates of future demand expect this trend to continue, with an approximately additional 200,000 separations by 2018–19. During the same time, patient days have largely remained steady. However, inpatient bed days are estimated to increase, with approximately 350,000 additional patient days expected by 2018–19. This is being driven by the factors described previously, including population growth, the increasing proportion of the aged population and the generally lower health status of rural Victorians. Other factors include greater community expectations and the availability of more treatment options as medical technology improves. The continuing growth in separations and bed days will be across the full range of specialties, with seven specialties accounting for the majority of forecast growth in both separations and days. The specialities demonstrating continuing growth based on current service mix are: • renal dialysis • general medicine • gastroenterology • cardiology • general surgery • orthopaedics • oncology/radiology. This growth in demand will result in a need for additional beds and related resources in the areas of population growth, which are primarily regional centres and areas of rural amenity. While the need for additional resources presents a challenge for those areas, there are also rural areas where population and therefore demand is not increasing. In these areas the challenge is to change service mix and models of care in response to changing community circumstances. This can mean an increased focus on primary care services, ambulatory care and enhanced management of chronic conditions.

8 Australian Bureau of Statistics 2006, SEIFA: Socio-economic indexes for areas, Current release, ABS, Canberra. Rural directions––for a stronger healthier Victoria 11

Service utilisation Service utilisation is a measure of access to services, with one of the service development principles being that Victorians living in rural areas should have access to an appropriate level and mix of health services. While total service utilisation for rural residents is comparable with metropolitan residents, there is variation in rates across both geographic and specialty areas. This could be the result of either excess service provision in some high-utilisation areas or inadequate access in low-utilisation areas. While rural residents have access to acute hospital beds, in many cases these are in small local health services without access to the full range of services and specialist support. Metropolitan areas have greater access to specialists and facilities in larger health services and greater access to private health services. There is also variation in utilisation rates between rural regions indicating that, even within rural Victoria, access to some services is limited depending on where people live. Clinical services where a lower rural utilisation rate is apparent include mental health, sub-acute, diagnostic GI endoscopy, renal medicine, renal dialysis, non-subspecialty medicine and urology. For these clinical groups, service utilisation will be improved over time through increased provision of services in rural areas and through enhanced referral pathways.

Regional self-sufficiency Another principle of service development is that rural Victorians should expect to have the majority of their health care needs met either within their own or a neighbouring area, with the regional or sub-regional health services able to meet the majority of complex care needs. Regional self-sufficiency is a measure of the proportion of health care provided by services within the area or region in which the patient resides. This is most easily calculated for inpatient care. In 2008–09 there were 57,600 separations of rural Victorians from metropolitan public health services. While much of this activity was for complex procedures or care, there is scope to improve access to services where this can be appropriately provided at a regional level. Rural self-sufficiency has been continually improving over time. However, there are some clinical specialties where regional self-sufficiency needs to continue to improve, namely cardiac, sub-acute, renal dialysis and cancer treatment. As resources and service options become available, growth will be supported in these specialty areas.

Rural directions––for a stronger healthier Victoria 13

Rural directions––for a stronger healthier Victoria

This Rural directions update provides an opportunity to revisit the three directions of the earlier version and build on what has already been achieved. The original three directions have now been modified to reflect the next stage of development: 1. improving the health of rural Victorians 2. supporting a contemporary health system 3. strengthening and sustaining rural health services. Each of these directions again contains a number of strategies and specific projects. Some of these are already underway and others will follow over the coming years. Each strategy will require cooperation between government, health services, professional groups and other stakeholders to achieve success. Direction 1: Improving the health of rural Victorians Rural directions––for a stronger healthier Victoria 15

Direction 1: Improving the health of rural Victorians Rural directions 2005 recognised that while the health of Victorians living in rural areas was very good overall, there were some groups of people where health status was lower than acceptable. A major focus of direction 1 was improved management of chronic and complex disease, to better meet the needs of identified patient groups. A range of initiatives and programs focusing on health promotion and illness prevention were described. Improving the way chronic disease is managed is now a major driver at both the federal and state levels of government. The Commonwealth Government has developed the National chronic disease strategy9 and the Enhanced Primary Care Program10 to provide more preventive care for older Australians and improve coordination of care for people with chronic conditions and complex care needs. The National Health Reform Commission has also been formed in response to the recognised importance of primary care in reforming the health system. The Victorian Government has introduced a range of interventions aimed at primary prevention, early detection and intervention for people at risk and effective disease management. The approach developed aims to: • better integrate services around the needs of individuals • shift the balance from responding to illness to preventing it by keeping people as healthy as possible • focus on Victoria’s most disadvantaged people and places • work across a person’s lifespan • achieve the best value from state, national and private investments. The aim is to strengthen the health system’s response to chronic disease by working to reduce its onset and to improve the quality of life for people with a chronic disease. Some specific initiatives include: • integrated chronic disease management • early intervention in chronic disease in Community Health • diabetes self-management program.11 Reviewing direction 1 now provides an opportunity to refocus on the continuing development of programs and services that aim to improve the health of all Victorians. By addressing some of the areas where access and opportunity are currently limited, the health and wellbeing of rural Victorians can be improved and local community services promoted. As defined in the vision, the health system will be supported and coordinated to provide rural Victorians with access to appropriate high-quality health care as close to home as possible. There are a number of clinical program areas where service development is proceeding. While service innovations and developments are usually statewide, it is important they are developed cognisant of the uniqueness of rural settings to ensure opportunities to benefit from improvements in health services and outcomes are applicable regardless of geographic location. Drivers include the need for more services in rural areas and support for sustaining existing services. In both cases the objective is to improve access to appropriate high-quality services to enable population health improvements over time. This section is intended to provide only a summary of current developments in specific clinical areas and is not comprehensive. Further details of each development should be obtained from the program area responsible, with references provided.

9 National Health Priority Action Council (NHPAC) 2006, National chronic disease strategy, Australian Government Department of Health and Ageing, Canberra. 10 Details available online at . 11 Further details of these initiatives can be found online at . 16 Rural directions––for a stronger healthier Victoria

Aboriginal health Improving the health of Aboriginal Victorians is a major service priority, with almost half the Victorian Aboriginal population located in rural areas. The life expectancy of Aboriginal people is estimated to be approximately 11 years lower than for the total Victorian population. Life expectancy is influenced by a number of factors, including rates of morbidity and access to appropriate services.12 Aboriginal people have generally poorer health than non-Aboriginal people and are more frequently hospitalised. Diabetes, renal failure, cardiovascular diseases and respiratory diseases are the most common chronic conditions and among the most common causes of death. Aboriginal people also often develop chronic diseases at an earlier age than non-Aboriginal people. The Aboriginal population is younger than the non-Aboriginal population. Almost half the Aboriginal population is aged less than 20 years, while this represents only a quarter of the non-Aboriginal population. Fourteen per cent of the non-Aboriginal population is aged over 65 years, whereas only 4 per cent of the Aboriginal population is over 65. Services for children and young people are therefore particularly relevant to the Aboriginal community. However, the aged population is increasing in number and it is anticipated that demand for services such as hospital admissions and Home and Community Care will increase accordingly. A significant initiative to improve the health and welfare of Aboriginal people is Closing the Gap in Indigenous Health, a national program to provide a package of reforms to overcome Indigenous health disadvantage. The Aboriginal services plan 2008–201013 identifies how the physical, spiritual, cultural, emotional and social wellbeing of Aboriginal Victorians will be supported and improved. Specific priority areas are highlighted to improve outcomes and help bridge the life expectancy gap between Aboriginal and non-Aboriginal people and improve quality of life for Aboriginal people in Victoria. The plan supports policy and program development across: health; mental health; drug and alcohol; aged care; disability; housing; and children’s, youth and family services. This supports enhancement of cultural competency of all health services, to ensure specific needs of Aboriginal people are recognised and built into mainstream service provision. Making a measurable improvement for Aboriginal people remains the central focus. A more recent development has been the Aboriginal Health National Partnership (AHNP), a partnership between the federal and state governments to close the gap in Indigenous health outcomes. The national partnership is centred on five priority reform areas: • tackling smoking • primary health care services that can deliver • fixing the gaps and improving the patient journey • healthy transition to adulthood • making Indigenous health everyone’s business. State governments have developed implementation plans to outline how each jurisdiction will respond to the five priority reform areas under the AHNP. The Victorian statewide implementation plan was developed in partnership with the Aboriginal community, through broad consultation with the Victorian Advisory Council on Koori Health.

12 Department of Human Services 2008, Aboriginal services plan, key indicators 2006–07, State Government of Victoria, Melbourne. 13 Department of Human Services 2008, Aboriginal services plan, January 2008–December 2010, State Government of Victoria, Melbourne. Rural directions––for a stronger healthier Victoria 17

Service development priorities are: The Aboriginal services plan 2008–2010 plan commits the department to: • developing and implementing evidence-based approaches to improve outcomes • coordinating effort across the department and in conjunction with Aboriginal organisations to develop programs and interventions that help build strong and functional Aboriginal individuals, families and communities • maintaining a focus on improving the physical, mental and spiritual health and wellbeing of Aboriginal people • working with other government agencies and sectors towards common goals • maintaining and improving strategies for respectful engagement designed to build the capacity of Aboriginal people and organisations. Closing the Health Gap committees will be established in each region to help develop regional implementation plans. These will address the five priority areas of the AHNP and statewide plan and describe initiatives to occur within the region over the next four years to address Aboriginal disadvantage. Achievements in Closing the Gap in Indigenous Health will be made by: • effective health promotion focusing on young people, adults and elders through outreach and activity-based physical fitness and lifestyle mentoring with a focus on reducing the burden of disease from smoking, obesity and lack of exercise • building resilience and strengthening community supports and activities for young people to improve their health and wellbeing and make a healthy transition to adulthood • better and more effective management of chronic disease through Aboriginal-controlled health care settings and mainstream services through expanding Aboriginal health promotion and chronic care partnerships as well as expanding the Improved Care for Aboriginal and Torres Strait Islander Patients program • better utilising existing primary care and hospital services through introducing cultural competency frameworks and more rigorous performance monitoring and outcome accountability • a stronger and better trained workforce in Aboriginal community-controlled organisations and community health services. Reference: www.health.vic.gov.au/koori/health-partnerships

Alcohol and drug services A new blueprint for alcohol and other drug treatment services 2009–2013 was released in December 2008. The blueprint outlines the Victorian Government’s vision for a client-centred and service-focused reform agenda for alcohol and other drug treatment services. The blueprint’s priorities are to create a system characterised by: • a client-centred approach • interventions to reduce the harmful impacts of alcohol and drug use on children and families • seamless access to treatment with ‘no wrong door’ • high-quality and effective services that cease or reduce drug use • prioritising prevention and early intervention. 18 Rural directions––for a stronger healthier Victoria

Service reform will promote services that respond to the needs of disadvantaged clients and communities with a focus on: • families and children • vulnerable young people • culturally and linguistically diverse communities • older people • Indigenous clients • clients with complex conditions. Reference: http://www.health.vic.gov.au/drugservices/downloads/blueprint09-13.pdf

Aged care Australia’s population is ageing. By 2021, the total number of Victorians over the age of 70 will almost double to about 730,000 with an increased proportion in rural areas compared with metropolitan Melbourne. While many older people remain well for most of their lives, those who do need extra care will expect a greater range of service options, including services to support them to remain at home for as long as possible. With this changing dynamic, it is important that health services respond and increasingly tailor services to the diversity of needs and expectations among older Victorians. While community-based options expand, there will remain the need to provide residential aged care to many older Victorians. The aged care system in rural Victoria is unique in that the majority of public health services are significant providers of residential aged care. In many rural communities, while non-government providers will meet expanding need for residential aged care services, the public sector will continue to play a significant role in ensuring that access to residential aged care remains an option. For many rural health services, particularly local services, aged care and care of older people through community-based primary care makes up the largest component of their service mix. Details of the role these health services play in providing aged care is outlined in the Victorian Government’s residential aged care policy,14 released in 2009. Service development priorities are: The Victorian Government’s residential aged care policy 2009 includes five directions for public sector provision: • facilitating access to residential aged care services in rural and regional areas • improving care and access to client groups with specialised care needs • ensuring service and workforce configurations are responsive to changing care preferences • promoting innovation in service provision • supporting ongoing development of the sector through initiatives that enhance residents’ quality of life and improve organisational performance. Implementation of the policy will involve a range of initiatives such as development of a public sector residential aged care service planning and development framework to guide health services to develop high-quality services consistent with these policy directions. Reference: www.health.vic.gov.au/agedcare

14 Department of Human Services 2009, The Victorian Government’s role in residential aged care––Victorian Government residential aged care policy, State Government of Victoria, Melbourne. Rural directions––for a stronger healthier Victoria 19

Cancer services Rural Victorians now have improved access to cancer services as a result of the cancer reform agenda that began in 2003. This has aimed to improve the planning and delivery of treatment and support, so that the appropriate care is provided in a timely manner as close to home as possible. One of the important components of the reform agenda was establishing rural integrated cancer services (RICS) in each region to drive change at the local level. Cancer survival rates in Victoria are lower in rural areas (59 per cent at five years from diagnosis) than in metropolitan Melbourne (62 per cent at five years).15 Accessibility to cancer services locally has led many rural cancer patients to seek treatment at more distant health services, delay, or not complete treatment. Victoria’s cancer action plan 2008–201116 was released in 2008. This set out a vision for reducing the burden of cancer and represents the next phase in the ongoing reform process. The highlights include four action areas, being: • reducing major cancer risk factors in the population and maximising effective screening • ensuring rapid translation of research into effective treatment and clinical care • investing in innovative treatments and technologies and sustainable integrated care systems • supporting and empowering patient and carers throughout their cancer journey. There is now radiotherapy capability in each rural region, with growth in demand continuing. Future funding growth will target expanding linear accelerator capacity in areas of clear population need. Service development priorities are to: continue the work of the RICS to improve service access, effectiveness and efficiency through four key priority areas for service improvement: multidisciplinary care; care coordination across the cancer pathway; supportive care; and reducing unwanted variation in practice through quality monitoring and support develop the cancer service capability framework, which will build on the integrated services model to guide health service planning in cancer and support linked cancer treatment and referral pathways across metropolitan and regional cancer services expand chemotherapy and radiotherapy services and increased regional self-sufficiency increase specialist oncology trained staff and increased workforce capacity working in regional Victoria roll out digital mammography across Victoria to support increased capacity for breast cancer screening. Reference: www.health.vic.gov.au/cancer/vcap

Cardiac services Coronary heart disease is the most common cause of death in Australia. Evidence from the Australian Institute of Health and Welfare (AIHW)17 and the Victorian Burden of Disease Study18 indicates that death rates and burden of disease is higher among populations in regional and remote areas compared with major cities and among socioeconomically disadvantaged groups, particularly Indigenous Australians. Access to cardiac services and therefore treatment is a major issue for regional and remote areas. There are currently comprehensive cardiac services, including catheterisation laboratories at Barwon Health and Bendigo Health. Residents from other rural regions have to travel considerable distances to access care, which can have a direct impact on health outcomes.

15 Source: ABS and AIHW stats, AMWAC report 2000, Cancer services framework for Victoria 2003 16 Department of Human Services 2008, Victoria’s cancer action plan 2008–2011, State Government of Victoria, Melbourne. 17 Details available online at . 18 Department of Human Services 2005, Victorian Burden of Disease Study, Mortality and morbidity in 2001, State Government of Victoria, Melbourne. 20 Rural directions––for a stronger healthier Victoria

While it is remains appropriate that complex cardiac surgery be provided through hospitals in metropolitan Melbourne, there is significant scope to improve comprehensive diagnostic and interventional cardiac services in regional areas. Service development priorities are to: develop a cardiac strategy during 2009–10 to address improved access to the full range of services across the care continuum improve the way patients presenting with acute coronary syndrome, in particular ST-elevation myocardial infarction are managed (this includes thrombolysis or primary percutaneous coronary intervention and the infrastructure required to support each treatment modality) expand regional cardiac services to improve access to fast and accurate diagnosis and treatment for rural residents improve access to cardiac rehabilitation services. Reference: www.health.vic.gov.au/clinicalnetworks/cardiac

Critical care Critical care is provided across rural Victoria, with 11 health services having intensive care units and 13 having coronary care units. Advice, referral and patient transfers to and between appropriate services are managed by Adult Retrieval Victoria (ARV). Some of the challenges faced by rural health services include: attracting sufficient clinical staff access to critical care in high-acuity metropolitan health services when required (transfers are organised in conjunction with ARV). There is no intention to increase the number of critical care units in rural Victoria, but some existing units will need to expand in accordance with total service expansion and redevelopment. Maintenance of a sufficient critical mass of services is required to support ongoing recruitment and retention of experienced clinicians. Service development priorities are to: increase critical care capacity at regional health services through targeted expansion of existing units in accordance with increasing demand and total service expansion continue to support and develop high dependency units in sub-regional health services without a critical care unit improve access to high-acuity critical care in metropolitan health services develop telehealth options to support regional critical care services remotely from metropolitan specialist services. Reference: www.health.vic.gov.au/criticalcare

Emergency care Timely and appropriate emergency department treatment is an important government service provided for all Victorians. Patient demand for emergency department care is increasing as a result of an ageing population, a rise in the number of people with chronic disabilities, declining public access to GPs and new technologies that enable treatment for previously untreatable diseases and conditions. In addition to increasing demand for emergency or unplanned care, this has also resulted in an increase in the severity of presentations. The capacity of public health services to respond to emergency and unplanned presentations varies throughout rural Victoria. Sixteen regional, sub-regional and larger local health services have comprehensive 24-hour emergency departments with medical and nursing staff on-site. The majority of local health services have nursing staff available on-site with doctors available on call. In bush nursing centres (BNC) remote area nurses are available to respond to emergencies. Rural directions––for a stronger healthier Victoria 21

A number of initiatives are being supported to improve emergency department services, facilities and waiting times. One example is Better faster emergency care,19 which set the policy directions to support continued reform. The policy framework identifies 10 key priorities to further improve emergency care and access, including improving the coordination between emergency departments and ambulance services. The Emergency Care Improvement and Innovation Clinical Network has also been established, with a key area of focus being enhancing the use of evidence-based care to reduce variation in clinical practice. The challenge for some smaller local health services is maintaining the capacity to respond to unplanned and emergency presentations, particularly after hours. In 2007 an expert advisory group defined the minimum level of safe, appropriate and high-quality emergency care required from all public health services in rural Victoria providing acute care. These minimum emergency care specifications are provided as Appendix 1. Health services are being supported to maintain this minimum level of care via projects that enhance the clinical role of nurses through training and development. The Rural Collaborative Practice Model provides an opportunity to support health services and focuses on providing emergency care through collaborative working arrangements between doctors and nurses so patients have access to appropriate high-quality and safe emergency care. Service development priorities are to: enhance sustainability of rural emergency services through supporting the clinical role of nurses in providing emergency care develop telehealth links between rural and regional and/or metropolitan specialist services for remote support of emergency services improve the patient experience in emergency departments through implementing the recommendations of Better faster emergency care19 continue service improvements to implement new models of care and improved patient flow initiatives, including consideration of observational models of care in sub-regional health services. References: www.health.vic.gov.au/emergency www.health.vic.gov.au/clinicalnetworks/emergency

Environmental health Environmental health is those aspects of human health determined by physical, chemical, biological and social factors in the environment. Environmental health programs identify, assess and manage the public health risks associated with environmental factors arising from air, land or water as well as radiation and other poisonous substances. This is achieved through: administering regulatory, statutory and policy functions; risk assessments and research; raising community and stakeholder awareness and knowledge; and building the capacity and capabilities of stakeholders to facilitate effective risk management. The Environmental Health Committee is a subcommittee of the Australian Health Protection Committee, and has responsibility for providing agreed health policy advice, implementing the National environmental health strategy 2007–201220 in consultation with key players, and developing and coordinating research, information and practical resources on environmental health matters at a national level.

19 Department of Human Services 2007, Better faster emergency care, State Government of Victoria, Melbourne. 20 Department of Health and Ageing 2007, National environmental health strategy 2007–2012, Australian Government, Canberra. 22 Rural directions––for a stronger healthier Victoria

The service development priority is to: develop an environmental health workforce strategy. (The Victorian Department of Health is project managing this work on behalf of the Environmental Health Committee.) Reference: www.health.vic.gov.au/environment

Health promotion Health promotion and illness prevention is a major focus of both levels of government and an integral component of a comprehensive health system. To ensure the health system remains sustainable in the future, health promotion, illness prevention and better illness management is essential to manage the increasing service demand evident as numbers of older people and people with chronic disease increase. It is also important that individuals are supported to retain good health for as long as possible. The Commonwealth Government has established the Health Prevention National Partnership, with funding provided over six years to improve the health of all Australians. Under the partnership, the Commonwealth will invest in preventative health activities including: • increased access to services for children to increase physical activity and improved nutrition • healthy workers and communities programs • a national campaign to increase public awareness of the risks associated with lifestyle behaviours and their links to chronic disease. The Commonwealth Government has also established the Preventative Health Taskforce to help develop a national preventative health strategy. The aim of the strategy will be to combat chronic diseases caused by preventable risk factors. The taskforce is initially focused on its three priority areas of obesity, tobacco and excessive consumption of alcohol. Victorian health promotion priorities have been identified for 2007–2012. The overarching aim of these priorities is to improve overall health and reduce health inequalities, through a holistic approach to health. The seven priority issues are: • promoting physical activity and active communities • promoting accessible and nutritious food • promoting mental health and wellbeing • reducing tobacco-related harm • reducing and minimising harm from alcohol and other drugs • safe environments to prevent unintentional injury • sexual and reproductive health. In addition to programs designed to support local communities, there are a number of statewide priorities with a particular focus on rural populations. This includes the Victorian Women’s Health Program, Koori and Indigenous health programs and a range of programs for older people. Of particular relevance to rural areas is the very successful Sustainable Farm Families (SFF) Project, which has engaged consumers (farming families) in decision making about their family health, wellbeing and safety. After three years the project has demonstrated significant change in the health status of farmers, based on a comprehensive framework of community health promotion. The program has been led by Western District Health Service, Hamilton. Rural directions––for a stronger healthier Victoria 23

The service development priority is to: continue to develop ongoing health promotion programs and activities as collaborative projects involving a range of stakeholders. Many projects are facilitated by Primary Care Partnerships (PCP). Reference: www.health.vic.gov.au/healthpromotion SFF reference: www.sustainablefarmfamilies.org.au

Hospital Admission Risk Program Hospital Admission Risk Programs (HARP) manage people with defined chronic diseases and complex needs who frequently use hospitals or at risk of hospitalisation and aims to reduce avoidable hospital use. Regional health services are HARP sites. In 2007 HARP was expanded into 13 rural health services through the HARP Better Care for Older People (HARP–BCOP) initiative. This is also supported federally through the Council of Australian Governments (COAG) Long Stay Older Patient’s initiative until the end of the 2009–10 financial year. HARP–BCOP sites are sub-regional or local health services. In September 2008 the Health independence programs guidelines21 (HIP guidelines) were launched to provide direction for, and facilitate the alignment of, post-acute care services and sub-acute ambulatory care services (SACS), including centre-based, home-based and specialist clinics and HARP services. Service development priorities are to: implement the HIP guidelines: these guidelines provide health and community services with direction for more closely aligning health independence programs (common policy and procedures between these programs will ensure a less complicated journey for people who require multiple health services) develop strong links between HARP, HARP–BCOP and Early Intervention in Chronic Disease sites (this will facilitate improved patient management by improving skills to maintain health, reducing preventable deterioration and preventing emergency health crises by providing alternatives to hospital treatment) develop the HARP respiratory and diabetes services in accordance with the department’s directives following the HARP Chronic Respiratory Disease Service Development Project and HARP Diabetes Service Development Project continue to expand HARP models of care for chronic and complex care target groups. Reference: www.health.vic.gov.au/harp-cdm

Maternity services Forty rural public health services across 43 campuses and five private hospitals provide birthing services in rural Victoria. A further seven health services provide a level 1 service, where pregnancy and post-birth care is provided locally, with the birth supported at a larger neighbouring service through a partnership model. In 2008–09 these rural agencies supported 17,709 or 25 per cent of total Victorian births. This demonstrates a stabilisation of birth numbers as in 2007–08 there had been 17,588. The Rural Maternity Initiative (RMI) provides support for introducing continuity of midwifery models of care and service sustainability. There are various examples of collaborative arrangements between services, which have been driven by services and practitioners at the local level. From 2009–10 the RMI is focused on developing more formal collaborative arrangements between services, area-based models, or clinical networks which will involve all health services in an area working together to sustain a comprehensive maternity service.

21 Department of Human Services 2008, Health independence programs guidelines, State Government of Victoria, Melbourne. 24 Rural directions––for a stronger healthier Victoria

Service development priorities are to: further develop collaborative models and area-based clinical networks supported through the RMI develop sub-regional models of care supported through encouraging sub-regional health services to take a more active role in supporting local services within their areas improve perinatal outcomes and reduce variation in clinical practice through the leadership and guidance of the Maternity and Newborn Clinical Network (MNCN) develop the statewide maternity and newborn capability framework, reflecting evolution of the Rural birthing services planning framework22 work to develop area-based networks (through the MNCN) to foster collaboration between metropolitan and rural birthing services (the networks will enhance expertise and training, increase consistency of practice and improve coordination and continuity of care) continue to roll out the statewide newborn hearing screening program, with all newborns to receive hearing screening by 2011 continue to support professional development in maternity through the Maternity Education Program and Maternity Workforce initiatives. Reference: www.health.vic.gov.au/maternitycare

Mental health Because mental health matters––Victorian mental health reform strategy 2009–201923 was released early 2009. The strategy’s vision is to ensure all Victorians have the opportunities they need to maintain good mental health while providing access to timely, high-quality care for those with a mental illness and supporting them to live successfully in the community. Because mental health matters is based on the four core elements of prevention, early intervention, recovery and social inclusion. The objectives of the strategy include: supporting participation in the community through new care coordination arrangements and flexible support packages reducing inequalities through service redesign and partnerships to provide culturally responsive mental health care for Aboriginal people, migrant and refugee communities building a sustainable, innovative workforce through targeted recruitment and retention activities fostering partnerships and accountability through local planning and service coordination and streamlining components of the mental health service system. The service development priority is to: implement the mental health reform strategy. Reference: www.health.vic.gov.au/mentalhealth

22 Department of Human Services 2005, Rural birthing services––a capability based planning framework, State Government of Victoria, Melbourne. 23 Department of Human Services 2009, Because mental health matters––Victorian mental health reform strategy 2009–2019, State Government of Victoria, Melbourne. Rural directions––for a stronger healthier Victoria 25

Neonatal services Demand for neonatal services in Victoria has increased steadily over recent years, in line with the increase in birth rate as well as an increase in the number of newborns requiring complex care. Much of this increased activity is attributed to a growing proportion of first-time mothers aged over 35 years with associated health risks, including low birth weight, preterm and caesarean births as well as increasing birthing intervention rates. The neonatal service system in Victoria comprises four neonatal intensive care units in metropolitan Melbourne, 20 publically funded special care nurseries (SCNs) and the Newborn Emergency Transport Service. Of the 20 SCNs, 11 are in rural Victoria: at each regional health service and six of the larger sub-regionals. Current program objectives include developing a neonatal service capacity and planning framework to provide the basis for developing a sustainable service system to meet community needs. This work is being carried out in consultation with key stakeholders, including regional health services. The service development priority is to: develop a neonatal service capacity and planning framework that will: • deliver high-quality, timely and coordinated care • provide the most appropriate level of care • meet current and future service demand. Reference: www.health.vic.gov.au/neonatal

Oral health Victoria’s oral health services are a vital component of the Victorian health system. Public dental care is predominately delivered through 70 community-based dental clinics, of which 37 are located in rural and regional Victoria. The Victorian strategy Improving Victoria’s oral health24 proposes a vision and set of principles to guide the development of oral health care to 2011. The establishment of La Trobe University’s dental school in Bendigo has paved the way for an increase of dentists trained in rural Victoria. The Bachelor of Health Science Dentistry/Master of Dentistry at the Bendigo Campus commenced in 2008 and will play a critical role in providing public dental health in rural and regional Victoria through supplying an increased workforce available for public service delivery to regional communities. In addition to the strategy for service provision, fluoridated drinking water helps provide protection against tooth decay and is a safe and effective way of allowing widespread access to the benefits of fluoride. The extension of water fluoridation is a key strategy to reduce the burden of chronic disease and to close a critical gap in the dental health of children living in rural Victoria. Much of rural Victoria has a fluoridated water supply but there remain areas yet to be fluoridated, resulting in preventable hospital admissions for treatment of dental decay. Service development priorities are to: commission water fluoridation in Ballarat, Colac, Geelong, Hamilton, Kerang, Mildura, Swan Hill and Yarrawonga continue to reduce oral disease by extending water fluoridation develop regional, area-based oral health planning to identify strategies to reduce dental waiting times across rural Victoria. References: www.health.vic.gov.au/dentistry www.health.vic.gov.au/environment/water/fluoridation

24 Department of Human Services 2007, Improving Victoria’s oral health, State Government of Victoria, Melbourne. 26 Rural directions––for a stronger healthier Victoria

Paediatric services Most Victorian children enjoy good health, but this is not shared equally across the community and groups of vulnerable children continue to experience poorer health outcomes. One of these groups of vulnerable children is those living in rural and remote communities, with limited access to services.25 Paediatric service development will be driven by the Strategic framework for paediatric services in Victoria.25 This has been developed to provide a shared vision, principles and priorities that will guide the future planning and development of high-quality paediatric health services in Victoria. In rural Victoria, regional and the larger sub-regional health services are the principle providers of specialty paediatric services. The paediatric patient profile is changing due to increases in survival and outcomes, acuity, complexity and chronicity of paediatric patients. This has resulted in an increase in paediatric sub-specialisation and volume shift to specialty services. Some of the additional challenges faced by rural health services include: • ensuring that paediatric services are appropriate and child and family focused • workforce shortage, notably of paediatricians and advanced specialist training positions • access to secondary consultation and specialist paediatric health services when required • providing appropriate community-based paediatric care. Service development priorities are to: establish the Victorian Paediatric Clinical Network (PCN) to progress the priorities arising from the development of the Strategic framework for paediatric services in Victoria25 (the PCN will progress a coordinated approach to planning, development and delivery of statewide paediatric services in order to meet the increasing demand for both specialist and general services) conduct paediatric health service mapping and clinical service capability assessments to identify priorities for capacity, infrastructure and service development strengthen existing regional networks and network rural health services through a paediatric hub-and-spoke model with one or two metropolitan tertiary paediatric hospitals to support shared service models establish Victorian Paediatric Rehabilitation Services in each region. Reference: www.health.vic.gov.au/clinicalnetworks/paediatric

Palliative care While general health care services are often involved in caring for people with a terminal illness, the Palliative Care Program provides specialist services that address specific issues such as managing pain and other symptoms associated with a terminal illness and to provide psychological, social and spiritual support where required or if requested. The Palliative Care Program aims to achieve an integrated service across all aspects of care. The Strengthening palliative care policy 2010–2015 will be developed in two stages during 2009. Stage 1 will evaluate the implementation of the principles and actions outlined in Strengthening palliative care 2004–2009 and identify recommendations for changes. Stage 2 will identify the key priority areas for 2010–2015 and identify practical approaches for implementing policy objectives at the service level. The refreshed version of the Strengthening palliative care policy will be launched in May 2010.

25 Department of Human Services 2009, Strategic framework for paediatric services in Victoria, State Government of Victoria, Melbourne. Rural directions––for a stronger healthier Victoria 27

Other priorities include developing a service delivery framework as a consistent basis for providing high-quality palliative care across the state. This will support a collaborative approach between generalist health care providers and specialist palliative care services that promotes appropriate care based on the needs of the patient and their family. Service development priorities are to: expand the Victorian rural palliative care nurse practitioner program, which aims to implement nurse practitioner models in rural palliative care (the following auspicing agencies have proposed innovative and collaborative service model development for their regions: Ballarat Health, Barwon Health, Bendigo Health, Central Gippsland Health Service and Northeast Health Wangaratta) develop a service delivery framework for palliative care services. Reference: www.health.vic.gov.au/palliativecare

Primary health care Primary care services are a major component of health service delivery in rural Victoria, so strengthening primary care is critical to meeting the challenges faced by the health system. Primary health care is primarily the responsibility of the Commonwealth Government, but the Victorian Government does have a role in delivery of some services and initiatives aimed at protecting or promoting the health of the population, through the community health sector. The need for reform within the Australian health system has been recognised at the Commonwealth level by the establishment of the National Health Reform Commission. Reform is essential to meet a range of long-term challenges including access to services, the growing burden of chronic disease, population ageing, services inefficiencies and the escalating costs of new health technologies. The Health Reform Commission has strongly reinforced the importance of primary care in reforming the health system, with investment in this area a way of improving access to appropriate care for individuals. This can also reduce the growing burden of chronic disease on hospitals, as the primary care system is where chronic disease should be properly managed. The Commonwealth Department of Health and Ageing has recently released Building a 21st century primary health care system: A draft of Australia’s first national primary health care strategy,26 following a year-long process of discussion and consultation with a wide range of stakeholders. Two other key health reform papers have also been released: the recommendations from the National Health and Hospitals Reform Commission27 and the recommendations from the National Preventative Health Taskforce.28 All three documents provide a background to Commonwealth–state negotiations about health reform in Australia. The draft primary health strategy identifies five key building blocks considered essential to a responsive and integrated primary health care system for the 21st century: • regional integration • information and technology, including eHealth • skilled workforce • infrastructure • financing and system performance.

26 Commonwealth of Australia 2009, Building a 21st century primary health care system: A draft of Australia’s first national primary health care strategy, Commonwealth of Australia, Canberra. 27 Commonwealth of Australia 2009, A healthier future for all Australians: Final report of the National Health and Hospitals Reform Commission June 2009, Commonwealth of Australia, Canberra. 28 Commonwealth of Australia 2009, Australia: The healthiest country by 2020––National preventative health strategy, Commonwealth of Australia, Canberra. 28 Rural directions––for a stronger healthier Victoria

Key priority directions for change are then identified in the draft strategy: • improving access and reducing inequality • better management of chronic conditions • increasing the focus on prevention • improving quality, safety, performance and accountability. In the face of this significant emphasis on primary health care by the Commonwealth Government, Victoria has released a discussion paper Primary health care in Victoria: A discussion paper.29 This paper promotes a comprehensive view for the future of the primary health care system in Victoria for discussion and debate. The paper: proposes overarching priorities for action to reform and develop primary health care; outlines a population-focused response to improve access, integration, service delivery and performance monitoring models; outlines specific workforce initiatives; and provides the context and guiding principles for further developing primary health care in Victoria. Service developments priorities are to: action areas for continuing development identified in the discussion paper include: implementation of better integrated chronic disease management models to reduce hospital use; focus on delivering outcomes and better measurement of these outcomes; and developing new workforce models to respond to changing community demographics and needs continue to develop and strengthen partnerships between health services, general practice, other health stakeholders and communities. Victorian reference: www.health.vic.gov.au/pchtopics National references: http://www.yourhealth.gov.au/internet/yourhealth/publishing.nsf/Content/NPHCS http://www.health.gov.au/internet/main/publishing.nsf/Content/nhrc-1 http://www.preventativehealth.org.au/internet/preventativehealth/publishing.nsf/Content/ national-preventative-health-strategy-1lp

Procedural services Providing timely and high-quality emergency and elective surgery is a critical component of comprehensive health care provision and a high priority for the community. Service provision in many rural health services has been changing over time in response to changes in technology, demand and a health service’s capacity to deliver procedural services. The Rural procedural services planning framework30 was released in January 2007 and is particularly relevant to smaller health services where it provides the opportunity to review procedural services in accordance with service capability. To complement the planning framework, a companion document31 has been developed to outline the principles for defining the scope of clinical practice of GP surgeons. This guide is designed to assist health services with credentialling and defining scope of practice and with determining requirements for continuing professional development. A challenge for many rural health services can be determining the best mix of procedural services to be provided. As with maternity care, there are opportunities for health services to work together to provide coordinated procedural

29 Department of Human Services 2009, Primary health care in Victoria: A discussion paper, State Government of Victoria, Melbourne. 30 Department of Human Services 2007, Rural procedural services planning framework, State Government of Victoria, Melbourne. 31 Department of Health 2009, Rural procedural services––principles for defining the scope of clinical practice of GP Surgeons, State Government of Victoria, Melbourne. Rural directions––for a stronger healthier Victoria 29

services across a regional or sub-regional area. This is particularly relevant in specialties where volume at individual health services is comparatively low, so it should be possible for health services within an area to define a complementary service mix, rather than each try to offer a wider range than is sustainable in the long term. This cooperative arrangement is also a way of improving access for patients, and improved management of waiting lists. In some circumstances procedural services may be more efficiently provided by local health services (where capability can be demonstrated) in cooperation with the sub-regional or regional service, rather than by referring patients to the larger services for treatment. This cooperative arrangement will also support the regional and sub- regional health services to meet increasing demand and assist with retaining a specialist workforce. The department has developed an integrated strategy Patient-centred surgery: Strategic directions for surgical services in Victoria’s public hospitals 2010–201532 to outline key reform directions for surgical services over the next five years. This document provides: a consistent understanding of key issues and challenges in the current system; identifies good practices and innovations already occurring; and identifies broad strategies that will underpin planning and development. In the context of surgery, patient-centred care is safe, effective, respectful of personal needs and choices, and provided at the right time in the course of the person’s condition. The strategic directions reflect the whole patient journey, including referral, assessment, surgery and recovery, with the focus on providing patient-centred care. Service development priorities are to: guide the range of procedures usually associated with GP surgeons within the rural procedural framework enhance access to sustainable and safe procedural services within regions through collaborative models, shared service arrangements and regional and sub-regional leadership improve waiting list management, reduced waiting times and additional surgical throughput though targeted funding introduce or encourage new approaches to the care of surgery patients––a range of work has been undertaken in Victoria including: • establishing new models of surgical care, such as the 23-hour procedure units for surgical patients whose expected episode of care can be delivered within 23 hours • developing streamlined models of care for particular conditions which streamlines the patient journey, tailors care to the individual patients and reduces unnecessary follow-up appointments • developing guidelines to support best practice in caring for particular patient groups • using private sector capacity for a limited number of elective surgery procedures under the Public Private Elective Surgery Initiative (this targets patients from particular specialties who have waited longer than the clinically recommended time). address other waiting list management and prioritisation issues to increase access to elective surgery at regional and sub-regional services including: • the Elective Surgery Access Service, which aims to provide a streamlined system for transferring elective surgery patients from health services that are unable to treat them within clinically appropriate timeframes, to health services with the capacity to offer rapid treatment. Four metropolitan hospitals have received extra funding to treat additional patients referred to them as part of this service • specialty-specific prioritisation models, for example, the Osteoarthritis Hip and Knee Service that aims to improve the management of patients referred for joint replacement surgery and prioritise the waiting list according to clinical need

32 Department of Health 2009, Patient centred surgery: Strategic directions for surgical services in Victoria’s public hospitals 2010–2015, State Government of Victoria, Melbourne. 30 Rural directions––for a stronger healthier Victoria

• the Elective surgery waiting time website, which is targeted at patients and referring practitioners and provides information about waiting times for individual procedures at health services • reviews of the range of surgery that will be offered to public patients to ensure that priority is given to the most appropriate and necessary surgical procedures. References: www.health.vic.gov.au/surgery www.health.vic.gov.au/ruralhealth

Renal dialysis Renal dialysis services are forecast to experience significant demand growth with approximately 60,000 additional separations by 2018–19. In addition to this growth, renal dialysis is a service where there is potential to enhance service access for rural Victorians. Victoria has a two-tiered service system, with most clinical management being provided at major hubs and dialysis provided through a network of satellite services linked to each hub. Renal services in rural regions will be strengthened to increase the capacity of regional health services. This will benefit rural Victorians by reducing the need to travel to the Melbourne-based hubs as frequently to receive care. Enhanced regional services will develop over time as opportunities to expand service models and meet increasing demand indicates. Service development priorities are to: improve access for rural patients through expanding renal dialysis capacity and services throughout rural Victoria increase home haemodialysis rates improve forecasting capacity. Reference: www.health.vic.gov.au/renaldialysis

Stroke services The Stroke care strategy for Victoria33 was released in 2007. It outlines a planning framework for how stroke services should be organised to enhance care throughout Victoria. The strategy includes a range of recommendations, including that there should be at least one level 3 acute stroke service within each rural region. The department has established the Stroke Clinical Network which will be responsible for implementing the recommendations. Stroke Clinical Network Facilitators will support local service improvements within each region. Service development priorities are to: develop all regional health services to level 3 acute stroke service capacity improve access to coordinated stroke care within each region through developing guidelines strengthen linkages between acute services of different complexity and between acute and sub-acute services develop telehealth systems and processes to improve rural access to specialist management and care. Reference: www.health.vic.gov.au/clinicalnetworks/stroke

33 Department of Human Services 2007, Stroke care strategy for Victoria, State Government of Victoria, Melbourne. Rural directions––for a stronger healthier Victoria 31

Sub-acute services Sub-acute services consist of admitted rehabilitation, geriatric evaluation and management (GEM), restorative care and SACS with an increasing focus on the ambulatory component over recent years. Utilisation of sub-acute services within the regional cities of Geelong, Ballarat and Bendigo is comparable with metropolitan residents, but in other rural areas utilisation rates for sub-acute services is considerably lower. The lack of access means rural Victorians who could potentially benefit from sub-acute care are either not receiving services or are having to travel significant distances to access a service. A sub-acute service planning framework for Victoria is being developed to guide planning towards improving equity of access and consistency of service quality. Service development priorities are to: enable reasonable regional access and capacity for inpatient rehabilitation, GEM and ambulatory care services through developing level 4 services at the regional health services and at least one level 3 service at the sub-regional health service level in each rural region improve access to community rehabilitation services through progressively developing SACS, giving priority consideration for new services to catchment populations of more than 20,000 people. Reference: www.health.vic.gov.au/subacute

Vulnerable children The Vulnerable Children in Acute Health project is a statewide project that aims to promote the vital role acute health services play in protecting vulnerable children and in promoting health outcomes that are focused on the safety, wellbeing and development of the child. Ensuring that vulnerable children are protected should form part of a health service’s quality of care initiatives and ongoing education and training for health staff in this area should be a priority for every health service. The framework, Vulnerable babies, children and young people at risk of harm: Best practice framework for acute health services,34 provides resources and an implementation guide to assist health services to develop responsive services to vulnerable children. The service development priority is to: ensure all staff complete the new online interactive education resource titled Health professionals working together to keep children safe (available at www.vfpms.org.au/childrenatrisk). Reference: www.health.vic.gov.au/childrenatrisk

34 Department of Human Services 2006, Vulnerable babies, children and young people at risk of harm––Best practice framework for acute health, State Government of Victoria, Melbourne. Direction 2: Supporting a contemporary health system Rural directions––for a stronger healthier Victoria 33

Direction 2: Supporting a contemporary health system Rural directions 2005 outlined the concept of a structured, integrated public health system throughout rural Victoria. It acknowledged that, while all health services have a role in providing quality care for the population within their catchment area, a single health service cannot be expected to meet the total health care needs of their community.

There are 69 public health services providing care at 97 campuses across rural Victoria. The majority of these provide a comprehensive range of services across primary, community, acute and residential care within a single health service. A further 16 independent community health services, five stand-alone public residential aged care facilities and 15 bush nursing centres also defined as local health services. There are also 21 private hospitals and day procedure centres in rural Victoria, seven of which are bush nursing hospitals.

Rural directions 2005 outlined a three-level health service structure consisting of regional, district (now sub-regional) and local health services. The detailed roles and clinical services expected at each level were further defined in a discussion paper released in 2007. This provides a contemporary health system that is coordinated, connected, patient focused and committed to appropriate safe, high-quality and evidence-based care. The concept of the three levels has been well embraced and rural health services now recognise their role in providing a modern collaborative and coordinated system. The system structure has also been adopted within the department for development and planning in specific program areas. Differentiating between levels meets a number of objectives such as to: assist with delineating the range and complexity of health care to be provided at each level, which can then support quality health care and sustainability of appropriate services assist with strategic service planning for both a geographic area and individual health services provide a platform for service development. (As specialty services and models of care evolve and develop, a variable role for each level of health service can be defined.) The range and complexity of care provided by rural health services varies from the medium- to low-complexity, high- volume services that should be provided as locally as possible, to services that are for more complex conditions. These are usually of lower volume in a local area, require a greater level of expertise, specialised workforce or technology and are more efficiently and effectively provided in a smaller number of larger services where workforce and infrastructure can be sustainably provided. The challenge is to provide services as close as possible to where people live while maintaining sufficient volume to ensure appropriate quality service provision. The changing nature of health care, with increasing emphasis on health promotion and preventing deteriorating illness, also continues to change the range of services provided. A major theme of Rural directions is that of partnerships and relationships between services to enhance care for rural Victorians. A coordinated system facilitates quality care by supporting patient pathways and access to appropriate care, wherever that is best provided. The role of statewide specialist services in metropolitan Melbourne is also recognised, with partnerships and referral arrangements between all health services essential for efficient delivery of good patient care. 34

Figure 4: Regional and sub-regional health services Ruraldirections––for astronger healthier Victoria This map identifies regional and sub-regional health services, with shading to identify travel distances. This demonstrates that the majority of the population of rural Victoria is less than 100 kilometres from a major health service provider, but there are pockets of more isolated areas in Gippsland and the Mallee. Rural directions––for a stronger healthier Victoria 35

Regional health services

Regional health services are the key specialist service resource for each region Regional health services are the key service providers and specialist resource centres for each region. They are located in the largest population centres of their respective regions, so have a combination of roles. They are primarily responsible for meeting the health needs of their own local community and have the resource and population base to be able to provide services at a more complex or specialist level. With this capacity to provide specialist services and complex care, they provide leadership and are a resource for other health services in the region. A key strategy to increase regional self-sufficiency is to enhance the capacity and development of new service models within regional health services to respond to growth and changing demand. This may include providing services where adequate patient volume is required to retain a skilled clinical workforce and therefore a high-quality service. Significant and expensive new services or technology will be confined to regional health services, where this requires development of clinical expertise to operate, or where a critical volume is required to ensure viability. Service examples include radiotherapy and cardiac services development, where expectations are that the regional health services will provide a level of care for the entire region. As regional health services are a point of referral for complex care, they need to take a leadership role to facilitate partnerships and work collaboratively with both sub-regional and local health services within their region and with specialist statewide services in metropolitan Melbourne. The designated rural public health services form this group.

Table 1: Regional health services

Region Estimated resident population* Regional health service

Barwon-South Western 365,696 Barwon Health––Geelong

Gippsland 255,485 Latrobe Regional Hospital––Traralgon

Grampians 220,160 Ballarat Health Services

Hume 267,596 Albury Wodonga Health Goulburn Valley Health––Shepparton

Loddon Mallee 311,855 Bendigo Health

* Source: Australian Bureau of Statistics, 2008

Role expectation Regional health services provide a comprehensive mix of clinical services, with acute medical and surgical services at all but the highest level of complexity. They are the principal regional providers of both specialist and comprehensive general health care including acute, sub-acute, mental health, aged and primary health services. A range of clinical specialties form the core services expected of a regional health service. Many of the core services have service guidelines developed to support quality care at defined levels. As other specialty areas develop planning frameworks and service guidelines, these roles will continue to evolve. 36 Rural directions––for a stronger healthier Victoria

Regional health services can be expected to provide: 24-hour emergency departments on-site with a full complement of clinical staff operating as regional trauma centres35 within the state trauma system and a point of contact for clinical advice and support for other health services within the region (as technology advances this will include telehealth capacity and support between emergency services) capacity to support adult retrieval service workforce a level 3 acute stroke service36 with the necessary infrastructure to support emergency or high-level stroke care (this includes providing thrombolysis) level 4 procedural services37 (the highest level of complexity for rural health services) level 4 birthing services38 providing for both primary and secondary levels of care39 (this may include intrapartum support for neighbouring local health services with level 1 or level 2 birthing services) level 2 neonatal care including a high dependency special care nursery40 critical care for adults, including a level 3 intensive care unit41 specialist care for time critical services (this should also include providing advice and support for other health services within the region to enhance regional self-sufficiency) comprehensive cardiac services including a minimum level 2 coronary care unit37 with progressive development of cardiac angiography, catheterisation and interventional cardiology cancer treatment, with radiotherapy and related services provided as part of a comprehensive cancer service (this includes a lead role in the work of regional integrated cancer services) designation as a referral centre for pandemic influenza infection42 level 3 palliative care43 for inpatient and level 2 for community care, with links to the regional palliative care consultancy service major sub-acute services for their region including inpatient and ambulatory rehabilitation (including paediatric) and GEM services, with support for outreach throughout the region (regional services have the major role in centres for promoting health independence (CPHI) for continuing care) hospital in the home (HITH) services renal services including haemodialysis principle area mental health services for their regions that offers a comprehensive range of both inpatient and community mental health services

35 State trauma system, Department of Human Services. See . 36 Defined by Stroke care strategy for Victoria, Department of Human Services, 2007. 37 Defined by Rural procedural services planning framework, Department of Human Services, 2007. 38 Defined by Rural birthing services––a capability based planning framework, Department of Human Services, 2005. 39 Defined by Future directions for Victoria’s maternity services, Department of Human Services, 2004. 40 Defined by Neonatal services guidelines, Department of Human Services, 2005. 41 Critical care services, Department of Human Services, see . 42 Department of Human Services 2007, Victorian health management plan for pandemic influenza, State Government of Victoria, Melbourne. Available on at . 43 Department of Human Services 2004, Strengthening palliative care: a policy for health and community care providers 2004–2009, State Government of Victoria, Melbourne. Rural directions––for a stronger healthier Victoria 37

dental services––either directly or through referral arrangements residential aged care and community care for the aged and people with disabilities and complex conditions (regional health services may have an additional role as providers of transition care and support of the aged care assessment service) prevention, disease management and strategies to support improving health status (the regional role includes taking a lead role in facilitating partnerships and developing programs and tools that can be shared across the sector).

Clinical support Regional health services have a comprehensive range of diagnostic support services on-site and available 24-hours a day. This includes pharmacy, pathology, radiology, nuclear medicine and echocardiography. Capacity for scanning with 32 or 64 multi-slice computerised tomography (CT) should be available, together with magnetic resonance imaging. Ongoing investment in technology will include enhancing telehealth, which provides opportunities to improve communication with other health services, providing clinical training and the capacity to support local health services with the provision of clinical advice. This will be addressed further in direction 3. Other technology includes direct clinical applications such as digital radiology.

Workforce Regional health services are the major specialist service providers for their regions, with medical care provided by specialist physicians and surgeons. Salaried positions are required to support key clinical specialties, in accordance with service guidelines. This includes emergency medicine, intensive care, obstetrics, paediatrics, geriatrics and/or rehabilitation, nephrology and a range of procedural specialities. This enables regional services to provide a level of clinical expertise appropriate to their role as a referral source for the region. This clinical mix also supports the teaching, training and mentoring role expected of these agencies, as regional health services will have the specialist staff to provide for training in accordance with professional college requirements. Regional health services are expected to employ a full range of allied health professionals so shared service model opportunities exist where these can provide a support or outreach role for local health services within the region.

Clinical teaching and training Regional health services play a significant leadership role in rural workforce development and staff education, training and research from undergraduate through to specialist postgraduate levels and in all disciplines. They have important links with university departments, particularly with departments of rural health and rural clinical schools. Regional health services offer a key role in providing undergraduate placements through a wide range of hospital and ambulatory disciplines. Regional health services will also continue to support postgraduate medical training from postgraduate year 1 through to registrar level in a range of specialty areas, including GP proceduralists, emergency care and obstetrics. For nursing and allied health professionals, regional health services are direct providers of education and training within their regions and provide clinical placements. Placements for training of nurses will include general nursing and specialty areas such as midwifery. This training role supports the development of strong relationships and networks between services and clinicians that can also support ongoing cooperation and sustainability. 38 Rural directions––for a stronger healthier Victoria

Regional health services also enhance ongoing service provision through participation in research programs, including clinical trials. Expansion of telehealth will be another means of enhancing clinical teaching and training and supporting education opportunities throughout the region.

Regional relationships Regional health services are expected to take a leadership role within their respective regions. This includes providing clinical advice and specialist support, as required, to sub-regional and local health services. This also involves developing collaborative relationships with these health services to support service provision through improved coordination and outreach. Where regional health services have developed clear collaborative relationships with sub-regional and local health services, there will be opportunities to share resources, including the specialist clinical workforce. Regional services should take a lead role in appointing specialists who could then work across a number of health services in a sub-regional or regional area. This can include shared appointments to provide clinical expertise such as emergency, obstetrics and procedural specialties and area-based directors of medical services to support local health services. Service capability would need to be demonstrated at each health service and appropriate contractual arrangements put in place. This provides a greater opportunity for long-term sustainability of specialist services and would provide a more coordinated service than is possible when agencies act independently. Regional health services participate in retrieval services as required and receive patient transfers from sub-regional and local health services within the region, when a more complex level of care is required. The clinical workforce will therefore reflect this level of expertise. Within a coordinated system, the return of the patient to appropriate local services when their clinical condition stabilises will support the vision of providing the right care in the right place. Regional health services will also take a proactive leadership role in the quality of service provision throughout the region. This may range from support for developing and promulgating evidence-based clinical guidelines and practices, to support for improved coordination between agencies and advice on effective clinical governance to ensure service quality and safety. Recognising that a population’s health is broader than the delivery of hospital-based services and at times requires a whole-of-health approach, regional health services are expected to collaborate and partner with a wide range of service providers to facilitate comprehensive care planning and delivery. Such coordination and connected care delivery may be required for a range of complex conditions or situations including primary care, mental health, alcohol and drugs, child protection and housing. Rural health alliances involve rural health services working together to meet their ICT service needs. All publicly funded health services under the Health Services Act (1988) are participants in the alliance for their region, and the regional public health services are required to be the lead agency and fund holder of their alliance. Rural directions––for a stronger healthier Victoria 39

Sub-regional health services Sub-regional health services are major service providers and support services in large rural areas Sub-regional44 health services are major health providers in medium to large Victorian towns with populations of between approximately 10,000 and 30,000. They also have a broader geographic focus and provide a range of services to meet the health needs of both their local population and a wider catchment community, which can vary between 55,000 and 80,000 people. The wider catchment is not fixed and may also vary by service type. As with regional health services, sub-regional health services have a support role and provide a point of referral for the local health services within their area. These health services provide much the same range of core clinical services as regional services and the larger agencies provide many at the same level of complexity. The number of sub-regional health services varies by region, depending on the history, geography and demography of the regional area. For the purposes of service planning and development, sub-regional services are identified as a single group, but there is significant variation within the range of agencies and this is expected to remain. The geography of each region and the variation in population centres related to each agency has an impact on service profiles. The larger agencies are more likely to be able to support services requiring a critical mass of clinicians, such as critical care. Intensive care capacity then impacts on the ability to manage emergencies and the type of surgical services offered.

Table 2: Sub-regional health services

Region Regional health service Sub-regional health service

Barwon-South Western Barwon Health––Geelong South West Healthcare––Warrnambool Western District Health Service––Hamilton

Gippsland Latrobe Regional Hospital Bairnsdale Regional Health Central Gippsland Health Service––Sale West Gippsland Healthcare Group––Warragul Bass Coast Regional Health*

Grampians Ballarat Health Services Wimmera Health Care Group––Horsham

Hume Albury Wodonga Health Northeast Health Wangaratta Goulburn Valley Health––Shepparton

Loddon Mallee Bendigo Health Mildura Base Hospital Echuca Regional Health Swan Hill District Health

* Over time, Bass Coast Regional Health will be developed to a sub-regional health service. Demographic change and population growth in the Bass Coast Shire has been significant, leading to increasing service demand.

44 When Rural directions was released in 2005, these services were described as ‘district’ but with subsequent review the descriptor ‘sub-regional’ seems to more accurately describe their role. 40 Rural directions––for a stronger healthier Victoria

Role expectation Sub-regional health services are major providers of a range of clinical specialties within areas and provide a comprehensive mix of clinical services. Acute medical and surgical services are provided at a moderate to high level of complexity. These services are a point of referral for care within the sub-regional area, with procedural and surgical services provided by a mix of GPs and specialists. They have a role in providing clinical advice and support to local health services within the surrounding area and working relationships with the regional health service, other health services within their geographic area and with metropolitan services as appropriate. Sub-regional health services work with the regional health service when new clinical services or programs are being developed. This is relevant when a broader distribution of services is required.

Sub-regional health services can be expected to provide: 24-hour emergency departments on-site and a full complement of clinical staff that, as a minimum, provide urgent care services (some are defined as regional trauma services within the state trauma system) a level 2 acute stroke service capable of providing emergency or high-level stroke care level 3 procedural services as a minimum (preferably level 4) level 3 birthing services as a minimum (preferably level 4) providing for both primary and secondary levels of care (this may include intrapartum support for neighbouring local health services with level 1 or level 2 birthing services) neonatal care, ideally at level 2 with a low- or high-dependency special care nursery critical care for adults, with an intensive care/coronary care unit to at least level 2 (there is no intention at this time to increase the total number of intensive care or critical care units; the sub-regional health services currently without this level of service will provide high-dependency nursing care) cancer treatment including chemotherapy (radiotherapy will not be provided on-site, but there may be potential for remote assessment and planning through telehealth; sub-regional services are key participants in the regional integrated cancer service) renal dialysis as a satellite service level 2 palliative care for inpatient care and community care and a cooperative working relationship with the regional palliative care consultancy service sub-acute services, including at least one inpatient and ambulatory rehabilitation service and at least one GEM service within a region (they will have a role in providing integrated services, with links to CPHI) HITH services a range of community mental health services in conjunction with the regional area mental health service, including emergency assessment and management dental services––either directly or through referral arrangements residential aged care and community care for the aged and people with disabilities and complex conditions (which is provided by almost all health services at all levels) prevention, disease management and strategies to support improving health status, which is the responsibility of all health services. Rural directions––for a stronger healthier Victoria 41

Clinical support Sub-regional health services have a comprehensive range of diagnostic support services available, including CT scanning and pathology. Pharmacy is provided on-site. Telehealth provides opportunities to improve communication with other health services, provide clinical training and the capacity to support local health services, through both providing clinical advice and direct clinical applications such as digital radiology.

Workforce Sub-regional health services are specialist service providers for their area. For this medical care, health services rely on specialist physicians and surgeons, with GPs also available for support. Key clinical specialties are expected to be permanent salaried positions, where this is required to meet standards of service provision. This will include emergency medicine, obstetrics, paediatrics and a range of procedural specialities. It may also include critical care. Specialist positions such as obstetricians and emergency physicians will be available to provide support and advice for local health services in the surrounding area. Where there is a teaching and training role the health services will have the specialist staff to provide for training and mentoring in accordance with professional college requirements. A range of other clinical and allied health professionals will be employed. In many cases, this team will include a support or outreach role for local health services within the region.

Clinical teaching and training Sub-regional health services provide clinical placements to support undergraduate education and training for medical, nursing and allied health staff and rotations for specialist nursing and medical education, including GP proceduralists. Sub-regional health services will continue to support postgraduate medical training, from postgraduate year 1 through to registrar level, in a range of specialty areas including GP proceduralists, emergency care and obstetrics. To support this role sub-regional health services will need to have the specialist staff to provide for training, in accordance with professional college requirements. Sub-regional health services may also provide direct education and training for nursing and allied health professionals within their areas, including provision of clinical placements. As with regional services, this training role supports the development of strong relationships and networks between services and clinicians that can support ongoing cooperation and sustainability. Education and training of nurses will include support for general nursing placements, midwifery and other speciality groups.

Regional relationships Sub-regional health services maintain relationships and referral pathways between the local services in their catchment area, regional and metropolitan health services. As with regional services, the coordinated system will support the vision of providing the right care in the right place. Sub-regional health services will take a leadership role and work collaboratively with their peers to develop and improve services for local communities. As with the regional services they will take a proactive leadership role in the quality of service provision throughout the area, ranging from support for developing and promulgating evidence-based clinical guidelines and practices, to support for improved coordination between agencies and advice on effective clinical governance. 42 Rural directions––for a stronger healthier Victoria

Sub-regional services will also assist local health services within the surrounding area with clinical advice and support for referrals. In some instances this will involve taking a lead role in coordinating collaborative service provision within an area. There are also opportunities to develop services as surrounding local services change service mix in response to changing circumstances or community needs. An example is providing intrapartum birthing support, where local health services have retained provision of antenatal and postnatal care. The changing nature of local health care provides increasing opportunities to develop this sub-regional role. As with regional health services, where sub-regional health services have developed relationships with surrounding health services there will be opportunities to share resources, including the specialist clinical workforce. Sub-regional health services should take a lead role in appointing specialists including area-based directors of medical services or allied health professionals who could also work across a number of services within a sub-regional area, providing the local health service can demonstrate service capability and all appropriate contractual arrangements are in place. This provides increased opportunity for long-term sustainability of specialist services. Sub-regional services also participate within their regional information technology (IT) alliances to support increasing cooperation and integration between health and community service providers. Meeting a population’s health care needs is broader than delivering hospital-based services and at times requires a whole-of-health approach. Sub-regional health services are expected to collaborate and partner with a wide range of local human service providers to facilitate comprehensive care planning and delivery.

Rural directions––for a stronger healthier Victoria 43

Local health services Local health services provide health care for rural communities The largest group of health services in rural Victoria are the local health services. These vary considerably in size and function, but in each case play an essential role in providing care to their communities and, in many cases, will be the first point of contact with the public health system. Local services range from those in small communities with catchment populations of less than 5,000 people to those in medium-size towns of up to 10,000 with total catchment communities of up to 20,000. Smaller campuses of regional and sub-regional health services are defined as local health services and should function as such. Local health services have a key role in facilitating access to an appropriate and seamless system of care for their community, so will have established relationships and partnerships with surrounding health services. Cooperative referral pathways between the local, sub-regional or regional health services for providing appropriate care in the right place will support high-quality care and recognise the important role of local health services within the coordinated rural health system. Rural directions 2005 described the changing nature of health care, with the need for flexibility in health care delivery. It noted that a contemporary health system would have less reliance on hospital beds and increasing focus on primary and community health. While the majority of local health services were traditionally hospitals many have now evolved into comprehensive health facilities providing a range of acute and primary care, with an increasing focus on health promotion and illness prevention. Local health services are also major providers of aged residential care within rural Victoria. Included with the local group are agencies such as BNC, which provide primarily nursing care to rural communities in more isolated areas and the seven multipurpose services (MPS), which are integrated health and aged care services. MPS are funded by the Commonwealth Government for aged care and the state government for health services and infrastructure. This brings a flexible mix and range of aged care and health services together under one management structure, and provides a more coordinated and cost-effective approach to service delivery for small rural and remote communities. Three local health services are located on the rural–metropolitan fringe, so are adjacent to major population growth corridors of metropolitan Melbourne. Their proximity to metropolitan health services provides both challenges and opportunities for future development. The majority of local health services, including BNCs and community health services, are funded through the small rural health services (SRHS) funding model. This model is applicable to those in towns of up to 5,000 people and provides the flexibility to reconfigure services in response to identified community needs, in line with local service planning. Local health services are defined within two sub-categories, differentiating those that provide acute inpatient treatment and care from those that are primarily community based. The categories are: • local health services––with acute inpatient care • local health services––community care. 44 Rural directions––for a stronger healthier Victoria

Role expectations Local health services––with acute inpatient care Local health services with acute inpatient care have changing and evolving roles. For some, retaining a level of acute medical and procedural services is important to meet community needs, for others, the future is in the increased provision of ambulatory community care and primary care. For many the future will be a combination of both, with the increased focus on a primary health care role and the improved management of chronic disease essential for all. The mix of clinical care provided varies depending on local circumstances, including population demographics and geography. In each case it is important that local health services provide high-quality and appropriate services in response to identified community need, cognisant of services provided in the broader geographic area, and with clear access and referral pathways and relationships in place where services are not provided on-site. As health care evolves, there will be opportunities for agencies to enhance services through business models that can add value to the local community and support sustainability. This includes support for GP practices on-site, employment of practice nurses and other initiatives that maintain a medical service.

Local health services––with acute inpatient care can be expected to provide: emergency stabilisation and care, with capacity for timely referral and transfer when required (local health services are either primary care services or urgent care services within the state trauma system) low to moderate complexity acute medical inpatient services, including definitive care for minor injuries and illnesses community and primary care services, including programs for enhanced management of chronic disease ambulatory care including care and support in people’s own homes residential aged care and community care for the aged and people with disabilities and complex conditions prevention, disease management and strategies to support improving health status. In addition, a range of other services could be provided, depending on identified capability and community need. There is an interdependence between many of these services, so comprehensive service planning will identify the appropriate service mix of: a level 1 acute stroke service level 1 or 2 procedural services a primary maternity care and birthing service up to level 3 (related to procedural service level) a level 1 neonatal service (related to maternity service level) chemotherapy, in conjunction with regional and sub-regional health services dental services––either directly or through referral arrangements renal dialysis as a satellite service level 1 palliative care for both inpatient and community, with specialist support from the regional palliative care consultancy service sub-acute services, both inpatient and ambulatory services mental health services, particularly community-based services but may also include psycho-geriatric services with support from regional mental health teams. Rural directions––for a stronger healthier Victoria 45

Local health services––community care Agencies described as community care include BNCs, independent community health centres and stand-alone residential aged care services. BNCs provide primary care for their local communities and have a major role to play in health promotion, illness prevention and community health support. They also work closely with Ambulance Victoria for management and treatment in emergency situations. The strategic directions for community health services were articulated in Community health services––creating a healthier Victoria.45 These services have become a major platform for delivering state-funded, population-focused and community-based health services.

Local health services––community care can be expected to provide the following. Depending on local circumstances and funding arrangements local health services (community) may provide some or all of the following services: allied health (physiotherapy, podiatry, dietetics, speech therapy, occupational therapy) community nursing counselling health promotion mental health drug treatment dental rehabilitation community and primary care and support in people’s own homes emergency stabilisation and care low to moderate complexity acute care for minor injuries and illnesses general practice residential aged care and community care for the aged and people with disabilities and complex conditions prevention, disease management and strategies to support improving health status.

Clinical support Local health services with acute inpatient care usually have access to pathology services through a contractual arrangement with a major private provider, so may not have services on-site. In many cases radiology services will be available on-site for plain X-rays and film reading. Where this is not available, there will be referral arrangements for patients requiring radiology assessment. Opportunities to employ digital radiology to allow support from sub-regional or regional health services should be pursued where this is feasible. As technology improves, opportunities to use telemedicine and other technological support to link to either the regional or sub-regional hospital will be enhanced.

45 Department of Human Services 2004, Community health services––creating a healthier Victoria, State Government of Victoria, Melbourne. 46 Rural directions––for a stronger healthier Victoria

Workforce A key characteristic of local health services is the integral role GPs play in providing timely medical care, including procedural services. Where inpatient services are provided it is essential that GPs are available to support safe and appropriate patient care, with the inter-dependency between rural general practice and rural health service provision critical to the ongoing sustainability of health services. Many local health services also engage specialist visiting medical officers (VMOs) to provide care, particularly surgical services. Local health services are encouraged to engage these VMOs in partnership with other local services, or through the sub-regional or regional health services. The benefits of this approach are: • improved coordination of medical workforce planning • efficient utilisation of a scarce resource • enhanced clinical governance and standards of practice • opportunities for shared process of medical credentialling • reduced professional isolation of individual practitioners. This may provide greater opportunity for the sub-regional or regional health service to attract and retain clinical staff, which then supports sustainability of specialist services across the area. With the challenges faced by rural health services in maintaining access to medical practitioners, services must ensure nurses are well trained and supported by guidelines so that, where appropriate, health care needs of people presenting in an emergency can be met without on-site medical support. A key strategy to enhance sustainability of services is to build on the capacity of the nursing workforce through skill maintenance and education, working collaboratively with other health services in the area, and encouraging innovation and flexibility in service delivery. In many cases allied health professionals are employed by local health services but, in some instances, these practitioners are accessed on a part-time basis from the sub-regional health service, or through shared services arrangements with other local health services.

Training and education At the local level, continuing development and maintenance of a competent and skilled workforce is essential to ensure ongoing, quality service provision and for individuals to meet duty-of-care responsibilities. Health services should actively support clinical staff to maintain skills by ensuring that appropriate education programs are accessible to all relevant staff, and that they have sufficient opportunities to maintain competence, including experience in other health services where appropriate. Where resources are available for training and education, opportunities to work with neighbouring health services to provide a critical mass for local training, to share other resources or to offer joint training programs should be explored. Some local health services are already involved in vocational training programs through appointing GP registrars. However, with the increasing emphasis on rural medical undergraduate training, such as the new Deakin Medical School, there will be a role for local health services to play in medical training through collaboration with local general practices and sub-regional and regional health services. Rural directions––for a stronger healthier Victoria 47

Regional relationships It is important that local, sub-regional and regional health services work together as a coordinated system within a geographical area, to support ongoing sustainability and increase effectiveness. This enhances patient pathways and referral, provision of expert advice, training and development, and increases the overall efficiency of each service. Collaborative arrangements can support complementary neighbouring services, where services are coordinated across sites, rather than each agency try to offer a wider range than is sustainable in the long term. This arrangement is particularly relevant to procedural services and maternity services or any service where throughput at each separate agency is comparatively low. Collaborative arrangements will also provide opportunities for local health services to work with sub-regional and/or regional health services within a geographical area. Where appropriate low-complexity procedures or treatments can safely be provided locally through a coordinated service, this will benefit: patients, by shortening waiting times; the local health service through maintenance of services; and the regional health service by freeing up capacity to provide more complex care. In the case of local health services located on the metropolitan fringe there are opportunities to partner with a nearby metropolitan health service. Some local health services have shared care arrangements in place, for example, working with nearby health services to provide emergency health care after hours. Typically shared arrangements involve local health services taking turns to provide care within their area. This arrangement can increase service sustainability by reducing the demand on GPs to be on call and to travel, but must be widely communicated to the community. Local health services will also participate within their regional IT alliances, to support increasing cooperation and integration between health and community service providers. 48 Rural directions––for a stronger healthier Victoria

Emergency ambulance and patient transport services The need to travel to access health services is a significant issue for some people in parts of rural Victoria. To support the integrated health system in rural Victoria it is essential that patients are able to access the right level of service at the right time to meet their needs. Progressively enhancing regional self-sufficiency for many clinical services and maximising appropriate use of home-based service delivery can reduce some unnecessary travel. In many other cases people will be able to make their own arrangements to get to necessary health services by either private vehicle or public transport. Where people have no option but to travel long distances to access specialist medical services, financial assistance may be provided through the Victorian Patient Transport Assistance Scheme (VPTAS). Where people are not able to make their own arrangements or where specific transport is required, there are three levels of patient transport: • emergency ambulance provided by Ambulance Victoria using paramedics, including airwing • non-emergency patient transport services (NEPT) (clinical) through licensed private providers, hospitals and the ambulance service • non-clinical transport (such as the Red Cross and Transport Connections initiatives).

Ambulance Victoria Ambulance Victoria is responsible for pre-hospital emergency medical care and patient transport and the majority of NEPT services for the Victorian population. In rural areas, services are provided by 124 ambulance branches (26 of which are ambulance community officer branches) and 26 community emergency response team locations, using both career paramedic staff and volunteer operational staff. The Ambulance Victoria rural service delivery planning process is currently underway. This will identify future service delivery requirements in rural Victoria and explore opportunities and alternative approaches to the role of the ambulance service and paramedics in rural communities. Developing alternative models of service provision could involve whole-of-health partnerships and examine how collaborative approaches might provide more clinically effective and efficient patient care. Adult Retrieval Victoria ARV is a business unit of Ambulance Victoria and provides an integrated, quality and timely adult retrieval and critical care coordination service 24-hours a day, seven days a week. ARV supports Victoria’s critical care system by: • providing telephone advice and assistance in the clinical care of critically ill patients • providing adult emergency retrieval services for critically ill patients across Victoria • coordinating access for critically ill adult patients to the required level of care (for example, intensive care or coronary care beds). ARV is now developing a service improvement program for the retrieval and critical care bed management and access system, in consultation with health services.

Non-emergency patient transport NEPT services provide specialised transport services involving clinical monitoring of patients in transit. In the metropolitan area Ambulance Victoria contracts out most of its non-emergency transport to private providers, but still provides most of the non-emergency transport in rural Victoria. Rural directions––for a stronger healthier Victoria 49

The Non-emergency patient transport regulations46 define the staffing and vehicle equipment required to transport patients based on patient illness acuity. Clinical practice protocols (referenced in the regulations) have been developed for NEPT providers to triage and care for patients during home-to-hospital transfer, inter-hospital transfer and hospital-to-home transfer. These protocols define an emergency patient who may not be transported by NEPT.47

Non-clinical patient transport Some community organisations and health services undertake patient transport where this does not involve a stretcher and the driver provides no clinical care, for example, Red Cross.

Patient travel Policy developments demonstrate a commitment to provide health services across rural Victoria so that patients can be treated as close to home as possible. However, there are frequently times when rural Victorians have to travel long distances, such as to Melbourne to access specialist or complex services. While this improves options for patient care, access can present a challenge for rural Victorians and can influence patient decisions about treatment options. VPTAS provides a financial subsidy to help address this through partial reimbursement for travel and accommodation costs incurred by eligible people living in rural regions. People are eligible where they need to travel at least 100 kilometres to access specialist medical or dental treatment. Current VPTAS developments include implementing initiatives to improve consumer awareness, ease of use and administration of the VPTAS. These include redesigning application forms and promotional material and developing a single integrated IT system to improve processing of VPTAS claims. Rural communities also require a range of travel options to enable them to access distant services. Availability of accessible public and community transport is necessary to complement use of private motor vehicles.

Transport connections Transport is consistently rated by rural and regional communities as one of the most significant barriers to accessing services, employment and social networks. Transport Connections is a whole-of-government project about communities working together to improve local transport. Through local partnerships and using existing assets and services such as taxis, school buses, community buses and volunteers, communities are able to develop innovative approaches that can make participation in community life easier for people with limited access to transport. The Transport Connections Flexible Fund helps to deliver small-scale localised initiatives across the state. These include extensions to existing services or implementing new trial services. The Department of Transport is the lead agency for this initiative. Reference: www.ambulance.vic.gov.au www.health.vic.gov.au/ambulance

46 Department of Human Services 2005, Regulatory impact statement––Non-emergency patient transport services regulations, State Government of Victoria, Melbourne 47 Department of Human Services 2006, Non-emergency patient transport––Clinical practice protocols, State Government of Victoria, Melbourne. Available online at . Direction 3: Strengthening and sustaining rural health services Rural directions––for a stronger healthier Victoria 51

Direction 3: Strengthening and sustaining rural health services To strengthen and sustain rural health services, Rural directions 2005 outlined a program of enabling work with a combination of specific projects such as sustaining the health workforce, enhancing governance structures and processes, and improving reporting requirements, together with an ongoing commitment to build capacity and enhance agency fabric and equipment. Since that time initiatives and programs have continued to support the rural clinical workforce, and this will remain an ongoing commitment. The growth of rural clinical schools is one way of supporting workforce growth, but shortages across all clinical areas will take time to address. Some shared care models have been supported, particularly for clinical staff; area networks are being developed and strengthened. Governance has been strengthened, with health service boards now supported through an ongoing rigorous training program. The Victorian Government has provided significant investment in system change, service growth and capital infrastructure, and this commitment to build capacity is continuing, so enablers related to supporting organisations are still applicable. This update provides the opportunity to re-examine the enablers and refine them as required to continue development. The service development priorities or goals for each enabler are identified, and these will be progressively developed over the next five years. In addition to the clinical program-specific developments outlined in direction 1, the service enablers for continued development in rural Victoria now include: • continuing service enhancement • growing workforce capacity • improving governance and performance. 52 Rural directions––for a stronger healthier Victoria

Continuing service enhancement

Health care will evolve as demand and capability changes, with services enhanced to meet current standards of care As community needs and models of care constantly evolve, the priorities and capability of services to respond to change will vary. As has been repeated throughout this document, coordination, collaboration and partnerships are essential to continued sustainability of the health system in rural Victoria. This enabler targets area-based planning and the support required for strengthening roles at all levels. For regional and sub-regional services this means enhancing their leadership and specialist referral role and for small local health services fully embracing opportunities provided through flexible funding to tailor services towards primary and community care. Capital investment is also essential to maintain quality services and ensure facilities are fit-for-purpose, with infrastructure that supports new and innovative models of care. Details of capital allocations are outside the scope of this document, but the drivers and priorities for rural areas are defined. Continuing development in ICT provides opportunities to improve patient care, improve access to care and reduce travel demands for rural Victorians.

Planning for geographic areas Service planning provides the opportunity to examine current practices and identify developments and innovation in service delivery. It includes a critical analysis of community needs and expectations for the future, and provides the opportunity to recognise the changing role of health services in response to the evolving demographic and health profile of the area. Service planning will generally be undertaken on an area basis, with planning at individual agency or program area only in limited circumstances. The service development priority is to: ensure health service planning area-based and includes a sub-regional and/or regional health service within its boundaries. This will provide a system-wide approach to planning the delivery of health services for a broader geographic area. Geographical areas will not be prescribed but will be defined cognisant of roles and functions of agencies, local context, program and local planning and government policy.

Enhancing regional and sub-regional service capacity Regional health services must meet the needs of their own growing communities and also provide a secondary support role for the total population within their regional areas. Regional and sub-regional services are also experiencing increasing demand as smaller health services within their regional areas change service models and roles. This has led to an increase in demand for more complex services including procedural and maternity services. As the provision of health care in rural areas changes in response to changing demographic, safety, quality and workforce drivers, more is expected of regional and sub-regional health services. Service development priorities are to: enhance regional self-sufficiency through building both the specialist workforce and technological capacity at regional and sub-regional services foster leadership at regional and sub-regional services to support local services, provide clinical and workforce expertise, education and training, mentoring and coordinated service approaches. Rural directions––for a stronger healthier Victoria 53

Supporting local health services The SRHS funding approach was introduced in 2003 to give local health services in towns with fewer than 5,000 people flexibility in service delivery. The intention was to remove requirements for eligible health services to meet acute bed-based service targets and support flexibility in determining service type and volume in response to local community need. This approach aimed to increase the proportion of community-based primary-care-type services provided, where this represents the most appropriate care in response to local community needs. The department is now working to improve understanding of the achievements that have occurred since the policy’s inception, while also identifying opportunities and challenges for further development and improvement. The key objective is to support ongoing improvement in service delivery in small rural communities. The key objectives of the project are to: • better define and clarify the role and activity of local health services providing services to small rural communities • develop tools to assist and facilitate service transition and continuing service development • develop a service planning framework for future directions. Service development priorities are to: strengthen accountability through reviewing agency annual service profiles and activity and reporting arrangements, within the context of a flexible service model develop a planning framework for local health services in line with role expectations examine options to extend the flexible funding approach to other health services. Enhancing regional partnerships Planning and developing relationships across and within regions is essential. This is best achieved through shared arrangements and collaborative projects. All health services, both public and private, need to work collaboratively to sustain services in rural areas, reduce unnecessary duplication and ensure services remain at a high quality to meet community needs. The service development priority is to: continue to promote and support partnerships and innovation through opportunities such as shared service models and collaborative practice models with neighbouring health services.

Redesigning services and systems As services change, with greater focus on ambulatory care models, facilities need to adapt to these changing models of care. Similarly, new models of care within previously bed-based services have changed the critical functional relationships between clinical areas. Old and outdated infrastructure can impact on the ability of health services to embrace changing models of care and to operate efficiently. Many smaller rural services have been responding to the need to change models of care by increasing provision of primary and community care. This then has a flow-on effect to the larger services. Service development priorities are to: enhance coordination and referral pathways across the service system to provide more options for care provision (this includes between health services, general practice and other primary and community care providers) improve system integration and clinician engagement in policy and services planning through establishing and strengthening clinical networks in major clinical streams create stronger networks of service providers who can take shared responsibility for services within an area, such as PCPs or other integrated health planning. 54 Rural directions––for a stronger healthier Victoria

Investing in infrastructure and facilities Health facilities are among the most intensively used public assets and, even with changing service provision and more flexible models of care, are still in constant use. Continual investment is required to ensure that facilities are able to sustain operation at an optimal level, respond to changing medical technologies and evolve to support modern practice. Capital funding is allocated on an annual basis, in accordance with government objectives and priorities, so is not within the scope of this document. This annual funding of government priorities ensures a combination of projects, both large and small and metropolitan and rural. The key drivers of capital investment are to either: expand capacity to cater for population growth and development of new services; redevelop fit-for-purpose facilities to reflect changing service delivery and models of care; or renew or replace obsolete infrastructure to mitigate critical risk. Capital investments in rural Victoria over the coming years will be targeted towards projects that clearly respond to one or more of these drivers. As service development opportunities are defined, opportunities for infrastructure redevelopment will also be identified. Where more than one public health service exists within a rural town, opportunities for these to be collocated to the one shared site will be fostered. This may include acute, aged care services, community health and ambulance. In some instances GP clinics and other private providers can also be included, where this supports their long-term viability. Collocation supports the development of coordinated health services that provide a single point of contact for the community, make best use of scarce health resources and increase operational efficiency. Service development priorities are to: invest in strategic asset replacement based on expanding capacity, designing facilities fit-for-purpose given changing service profiles and renew or replace obsolete infrastructure, within budgetary capacity improve local access and regional self-sufficiency through capital developments targeted towards increasing capacity (this will be where population growth and changing demographic profile is most evident, which are predominantly the regional and sub-regional services) support capital redevelopments where changing models of care are driving changing infrastructure needs (this is applicable to all levels of health service, with reconfiguration to embrace changing health care needs and to support service sustainability particularly relevant to local health services) support innovative infrastructure development such as collocating public health services to support service integration and increase efficiency (examples include developing and extending service centres or hubs (superclinics) and placing core specialist services in regional centres) continue to develop bush nursing hospitals (BNH), BNCs and SRHS infrastructure by allocating minor capital funds and other service development activity. Rural directions––for a stronger healthier Victoria 55

Information and communication technology Continuing to develop ICT provides opportunities to improve patient care, improve access to care and reduce travel demands for rural Victorians. There is already significant investment in ICT infrastructure to support telehealth, with most rural health services having teleconferencing and telemedicine facilities, and applications that enable some data sharing across services. The true potential of this technology to support patient care, care coordination and to reduce the need for patients to have to travel for assessment or pre-and post-operative care is still relatively undeveloped. This has been identified as an area for development by both the Commonwealth and Victorian governments, with Victoria’s plans outlined in the Whole-of-health ICT strategy.48 The greatest benefit of developing telemedicine will be realised in rural areas, where opportunities exist to use enhanced telemedicine and telehealth to support: • clinical advice and support for enhanced management of emergency and unplanned presentations • direct patient care for assessment, outpatient presentations and pre- and post-operative care • clinical education and skills improvement • statewide collaboration between clinicians. These require developing a service delivery framework for telemedicine services including protocols, standards, funding models and clinical governance. Service development priorities are to: implement a whole-of-health ICT strategy further develop the digital regions initiative, which is a four-year Commonwealth Government initiative to co-fund innovative digital technology projects with state governments in a collaborative approach develop a service delivery framework to support mainstreaming of telemedicine and telehealth into service provision models.

48 Details available online at . 56 Rural directions––for a stronger healthier Victoria

Growing workforce capacity Rural health services will be supported to maintain a sustainable workforce Workforce remains one of the predominant enablers of rural health service provision. Service and Workforce Planning Branch and Nurse Policy Branch lead the department’s key initiatives to improve recruitment and retention of health professionals across Victoria. Key enablers of growing workforce capacity in rural areas are in workforce planning, succession planning, change management practices and innovative initiatives that enable workforce redesign to better reflect changing service delivery models. Workforce development policies and priorities will consider the key areas of people, place, environment and performance in all program developments.

Improving recruitment and retention in rural and regional areas Some of the specific programs and initiatives currently underway to recruit and retain a health workforce include: • Health Careers for a Healthy Future49 to attract highly qualified international medical graduates (IMGs) to the Victorian workforce • overseas/interstate allied health professional incentive packages • Region of Choice to improve the recruitment and retention of allied health professionals in rural Victoria • Rural Workforce Agency of Victoria to recruit, support and advocate for the health workforce throughout rural and regional Victoria • Rural Medical Family Network to support doctors and their families to establish and maintain social networks in rural areas. While recruitment and retention of an appropriate clinical workforce presents challenges in all areas, the current workforce shortages are most keenly felt in local health services where continuation of a clinical specialty may rely on a very limited number of practitioners. The need to work collaboratively with other health services in the area, examine opportunities to upskill the available workforce and encourage innovation and flexibility in service delivery is critical for many of these services. An example of innovation in recruitment is sharing of clinical resources between health services within geographical areas. In many cases allied health professionals are employed by local health services but, in some instances, these practitioners are accessed on a part-time basis from the sub-regional health service or through shared services arrangements with other local health services. A valuable opportunity exists with the distribution of rural clinical schools in rural Victoria to address the rural workforce shortage. Although the focus is on medical training, rural clinical schools create a network of quality to support all health professions in rural Victoria. The development is intended to support clinicians to train in rural areas, therefore, be introduced to the rural lifestyle and hopefully choose to continue to work in rural areas. Workforce shortages may also be felt in non-clinical areas such as administration, finance and health information. In addition to training support, opportunities for shared service arrangements in these areas should also be explored and supported. The Rural Management Residency Program is a partnership between the Australian College of Health Service Executives and the department. This is a two-year program that provides university graduates with a commitment to working in rural Victoria placements of up to six months. These placements are either in rural health services, peak agencies or the department and are offered to those completing a graduate diploma in business management. The program aims to increase the supply of health service management and executive personnel in rural Victoria.

49 For more information, see . Rural directions––for a stronger healthier Victoria 57

Service development priorities are to: provide ongoing support for targeted recruitment packages and incentives for rural training posts extend skills training for GPs establish the Strengthening Medical Specialist Training program, to better target specialist training expand the Medical Clinical Educator program to support health services to improve assessment, upskilling and support of IMGs develop regional training partnerships to support medical education and training for both junior doctors and IMGs develop the rural Allied Health Undergraduate Scholarship program complete the statewide Best practice clinical learning environment framework, which will have the potential to improve recruitment and retention. Initiatives designed to improve retention rates among the existing workforce are aimed at improving employee satisfaction, reducing the risk of burn-out and dislocation/disorientation within the workplace, and better supporting career pathways for health professionals through enhanced opportunities for further training and upskilling.

Redesigning the workforce to meet changing local needs The workforce of today has different expectations than those of previous generations. Reduced working hours and expectation of more work–life balance presents a challenge for agencies to maintain services as older workers retire or relocate. This can lead to developing alternative service models that require more flexibility in service delivery. Nurses are the major workforce that supports ongoing service provision in local health services. These staff require ongoing education and support to be able to maintain the services to the appropriate level of quality care. With the challenges faced by rural health services in maintaining access to medical practitioners, services must ensure nurses are well trained and supported by guidelines so that, where appropriate, health care needs of people presenting in an emergency can be met without additional medical support and doctors only called in when necessary. Service development priorities are to: provide ongoing support for nurse practitioners and other projects that support shared service models for nurses and other staff encourage relationship building between health services and Ambulance Victoria paramedics enhance training options at regional and sub-regional health services to support clinical staff in local health services to maintain skills, as defined within service roles in direction 2 explore flexible models and other options for professional groups develop a comprehensive strategy that provides an appropriate emergency response in small rural communities (the strategy will include support for local health services to: develop and adopt a collaborative practice model to advance nursing clinical practice; embed policies and protocols that support collaborative practice; and deliver training and ongoing clinical competency assessment to ensure quality care). The Better Skills Best Care strategy is exploring new and re-designed work roles in health services. The aim is to ensure the most appropriate combined set of skills are available and used effectively to provide the best level of care to meet community health care needs. 58 Rural directions––for a stronger healthier Victoria

Preparing for future workforce growth While workforce challenges are being faced now, the number of medical students has increased substantially in recent years as Victoria grows its medical workforce. The number of medical intern positions required by domestic graduates of Victorian medical schools is predicted to rise from 346 in 2009 to as many as 690 in 2012. Demand for postgraduate year two and specialist training places will also increase. In addition to funding to support growth in student numbers, increased funding will also support medical educators, IMGs and organisational capacity-building. The growth in rural clinical schools and targeted recruitment of medical students from rural areas will see a significant proportion of these students seeking placements in rural health services. It is essential that placements are well supported with adequate supervision and support for trainees, so this will present a challenge to some rural health services. The department has formed the Postgraduate Medical Reference Group to assist in planning for growth in the prevocational medical workforce. Service development priorities are to: fund medical educators in a number of health services expand clinical placements to settings such as community health, general practice and specialty areas within health services provide project funds to assist health services to expand their capacity to provide more medical education and supervision support affiliations of health services through the Medical Workforce Partnership Model to facilitate the prevocational education and training of Australian medical graduates and the assessment, upskilling and support of international graduates continue to develop capital infrastructure to support rural teaching and training (this includes developing new facilities in regional centres and service enhancements at some sub-regional health services). Further information: www.health.vic.gov.au/workforce/medical Rural directions––for a stronger healthier Victoria 59

Improving governance and performance Clinical governance is about being accountable for providing good safe care, and is fundamental to continuing to improve patient safety within Victoria’s health care system50 Boards of directors and boards of management are responsible to the Minister for Health for setting the strategic directions of public health care agencies within the framework of government policy. The government is committed to ensuring there is strong governance and accountability of these governing bodies for the performance of organisations and delivery of health services. Governing bodies must have a clear understanding of their responsibilities to govern well, and must ensure there is a structured and systematic approach to identifying and controlling risks. Governing bodies are accountable for ensuring that public health care agencies are: • effectively and efficiently managed • provide high-quality care and service delivery • meet the needs of the community • meet financial and non-financial performance targets. Health service management is then responsible for the actual operation of the health service. The governance role therefore includes overseeing maintenance of care standards, financial and corporate functions, setting strategic directions, managing risk, improving performance and ensuring compliance with statutory requirements. Identifying and responding to staff training and development needs is another important component of health services’ governance responsibilities, and to maintain an adequate workforce. Within the responsibility for setting strategic directions should be consideration of policy directions and initiatives at both the Commonwealth and state levels. Developing networks within areas to support collaborative practice and changing models of care, and the increasing focus on primary care as the optimal means of managing chronic disease and other related strategies, have changed the role and function of many rural health services. While these can present a challenge to rural communities, responding to the opportunities presented to develop alternative services is another responsibility of the governing board.

Enabling robust governance structures and processes The department funds a comprehensive board development program, the Victorian Health Boards Governance Program, to develop the governance capacity of metropolitan and rural health service board members. The program focuses on governance and legal frameworks, stakeholder engagement, strategy setting, clinical and financial governance, risk, group dynamics and current health policy issues. Training is tailored to meet the requirements of different audiences, according to the knowledge and experience of participants and the type of organisation they represent.

50 Department of Human Services 2008, Victorian clinical governance policy framework, State Government of Victoria, Melbourne. 60 Rural directions––for a stronger healthier Victoria

Service development priorities are to: enhance board effectiveness and understanding of responsibilities and accountabilities through continuing access to board development activities expand the strategic leadership of board directors through the Council of Board Chairs and by board participation on the Health Service Management Innovation Council develop more tailored and flexible service delivery options to assist board members of smaller health services and those in rural and remote areas.

Improving clinical governance The governance of clinical care occurs within the context of the broader governance role of boards. An effective system of clinical governance at all levels of the health system is essential to ensure continuous improvement in the safety and quality of care. The Victorian clinical governance policy framework51 describes the system and strategies that health services are expected to have in place to ensure they are accountable for providing safe, effective care. Consumer participation, clinical effectiveness, an effective workforce and risk management are the four domains of quality and safety that provide a conceptual framework for strategies to enhance the delivery of clinical care. All public health services are expected to review their local clinical governance policies against the framework. The means to measure and monitor compliance with the framework, and report on this in the annual quality of care reports developed by the department. Capability-based planning frameworks have been developed for clinical areas including maternity and newborn, and rural procedural services and stroke; other program areas are in development. An important component of effective clinical governance is to ensure agency capability is measured in accordance with these frameworks and action taken to ensure appropriate staffing levels, guidelines and infrastructure are provided, or service levels modified accordingly. An important related element of appropriate clinical governance is maintaining a robust credentialling and defining scope of practice policy for all medical staff. This provides a means of assuring the community that a competent clinical workforce is in place in rural Victoria. All public health services have responsibility for maintaining this process, in accordance with the departmental policy handbook.52 This policy sets out clear expectations regarding the commitment required from health services to support and maintain high-quality medical services and the need to strengthen the existing role of the director of medical services or medical manager to ensure this occurs. Clinical networks are also a key reform for the Victorian health sector. Clinical networks have the broad aims of improving the quality of care through engaging clinicians in the health policy and planning process, and in providing a platform for improved system integration and access to high standards of health care for all Victorians. The following objectives were agreed to by government for establishing clinical networks: • increase clinician participation in decision making and policy development • increase dissemination of evidence-based practice • decrease variations in clinical practice • improve system monitoring and performance benchmarking • improve effectiveness of service delivery.

51 Department of Human Services, Victorian clinical governance policy framework. Department of Human Services, Victoria 2008. Available online at . 52 Department of Human Services 2009, Credentialling and defining the scope of clinical practice for medical practitioners in Victorian health services––a policy handbook. State Government of Victoria, Melbourne. Rural directions––for a stronger healthier Victoria 61

Service development priorities are to: enhance clinical involvement and engagement in health policy and standard-setting support credentialling and scope of practice decision making by boards through developing core capability and training expectations for GP proceduralists develop a process for complying with the Victorian clinical governance policy framework a single national regulation and accreditation scheme for the health workforce is due to be operational by 1 July 2010. This is being established as a result of an Intergovernmental Agreement, signed by COAG.

Strengthening accountability and performance The accountability and performance of regional public health services is measured against the statement of priorities (SoP) agreed annually between each of the board chairs and the Minister for Health. The indicators are reported through the Integrated performance report on a monthly and quarterly basis. The SoP outlines the key strategic directions for each health service for the coming financial year directly linked to their strategic plans, a set of financial, service performance and access targets and agreed funding across all health and human services programs. Each regional health service is to account for its performance in the annual report. All rural and regional health services report their financial results monthly. The regional and central offices of the department then work closely with each health service to understand the reasons for the financial position and monitor progress against financial and key performance indicators. Service development priorities are to: expand benchmarking information available to boards to enhance accountability continue to improve and strengthen performance indicators, particularly for sub-regional and local health services. 62 Rural directions––for a stronger healthier Victoria

Improving funding models As outlined in Rural directions 2005, funding policy will continue to be reviewed to create an environment in which health service managers may allocate resources as required across the suite of services that they deliver. Funding policies will acknowledge the unique role of many rural and regional health services in meeting a broad range of community care needs, and improve and streamline the provision and administration of funding. Flexible funding models are also integral to meeting policy directions and supporting service changes, particularly where funding flexibility can contribute to reconfiguration of service mix. The SRHS funding model has been in place since 2003. When compared with the casemix approach applicable in larger health services, the SRHS model provides potential for more flexible and appropriate use of funding, linked to local service planning and identifying community needs. It is possible that some of the larger local health services currently ineligible for this funding approach might be better serviced by full or partial movement towards the SRHS model, particularly those with stable or declining populations. Any adjustments to funding models needs to take place within the context of the national COAG work relating to activity-based funding. Service development priorities are to: review and update the SRHS funding policy in 2009–10 to complement the development of the planning framework for local health services consider the best funding model for local health services in larger communities, previously identified as Group Cs, with the objective of enhancing funding flexibility to reflect changing service delivery models. Rural directions––for a stronger healthier Victoria 63

Rural directions––for a stronger healthier Victoria 65

Appendix 1: Minimum emergency care

All rural public health services providing acute care should ensure they have the capacity to perform emergency resuscitation and stabilisation for adults and children that includes the following.

Assessment triage including mental health triage comprehensive patient assessment to accurately detect any immediate threat to life or limb Airway management airway management techniques including laryngeal mask airway cervical spine immobilisation with rigid collar Breathing support administration of oxygen bag valve mask ventilation decompression of a tension pneumothorax using needle decompression or ‘pneumocath’ management of a sucking chest wound Circulation support automated external defibrillation peripheral intravenous cannulation and therapy including intravenous fluid replacement intraosseous needle insertion provision of first-line emergency medications including thrombolysis Ongoing management management of mental health emergencies* initial management of a patient while awaiting further assistance or transfer providing relief for severe pain accessing ongoing advice and support as needed Initiating transfer initiating the appropriate transfer protocol preparing patient and patient information for transfer

* with established links with area mental health services and a directory of local community services and practitioners, including general practitioners, able to provide support to people with mental health or psychosocial problems

Health services must ensure that clinicians with appropriate qualifications, training and competence to meet the minimum requirements are available at all times. This will require: • mechanisms for continuing professional development and maintaining skills • clinicians to be credentialled and have their scope of practice determined in accordance with guidelines53 • treatment based on evidence-based clinical guidelines that reflect current best practice and are consistent with state and national guidelines where available.

53 Department of Human Services 2007, Credentialling and defining the scope of clinical practice for medical practitioners in Victorian health services––a policy handbook, State Government of Victoria, Melbourne. 66 Rural directions––for a stronger healthier Victoria

Appendix 2: Regional profiles

Barwon-South Western region

Barwon-South Western is the smallest but most populous rural region. The region covers an area of 29,637 square kilometres extending approximately 380 km from St Leonards in the east to the South Australian border. The region includes Geelong, the largest city in Victoria outside Melbourne. Barwon Health (Geelong) is the regional health service and the two sub-regional health services are South West Healthcare (Warrnambool) and Western District Health Service (Hamilton). There are 15 local health services including two stand-alone aged care services, one independent community health centre and two BNCs. The region has three PCPs and nine local government areas (LGAs): Borough of Queenscliffe, City of Greater Geelong, City of Warrnambool, Colac-Otway Shire, Corangamite Shire, Glenelg Shire, Moyne Shire, Southern Grampians Shire and Surf Coast Shire. Forecasts indicate the population centres in the east of the region, including both Geelong and the Surf Coast will continue to grow significantly. The south-west area is also demonstrating population growth, but the southern Grampians and Glenelg areas are more stable and show a slight decline in total population to 2019. Rural directions––for a stronger healthier Victoria 67

Total estimated resident population (ABS 2008)

Primary Care Partnership 2008 2018

Barwon 260,987 299,150

South West 66,387 70,669

Southern Grampians-Glenelg 38,322 39,083

Region Total 365,696 408,902

Actual and forecast inpatient activity 2008–09 2018–19 for public health services in the region 106,268 141,583

Regional health service Private hospitals Barwon Health (Geelong) Cobden District Health Services Geelong Private Hospital Sub-regional health services Monash IVF––Geelong South West Healthcare (Warrnambool) Specialist Surgicentre Geelong Western District Health Service (Hamilton) St John of God Health Care––Geelong St John of God Health Care––Warrnambool Local health services The Geelong Clinic Beaufort & Skipton Health Service (Skipton) (Beaufort campus is in Grampians region) Casterton Memorial Hospital Colac Area Health Hesse Rural Health Service (Winchelsea) Heywood Rural Health Lorne Community Hospital Moyne Health Services (Port Fairy) Otway Health & Community Services (Apollo Bay MPS) Portland District Health South West Healthcare (Camperdown) Terang & Mortlake Health Service (Terang) Timboon & District Healthcare Service (MPS) Western District Health Service (Coleraine and Penshurst) Dartmoor and District Bush Nursing Centre Balmoral Bush Nursing Centre Koroit Health Services Lyndoch Warrnambool Bellarine Community Health 68 Rural directions––for a stronger healthier Victoria

Gippsland region

The region covers an area of 41,539 square kilometres extending approximately 515 km from Cowes on Phillip Island to Mallacoota in the far east of the state. The far east of the region includes some of the most sparsely populated areas in Victoria. Latrobe Regional Hospital (Traralgon) is the regional health service and the sub-regional health services are Central Gippsland Health Service (Sale), Bairnsdale Regional Health Service and West Gippsland Healthcare Group (Warragul). There are 16 local health services, including four independent community health centres and six BNCs. The region has four PCPs and six LGAs: Bass Coast Shire, Baw Baw Shire, East Gippsland Shire, Latrobe City, South Gippsland Shire and Wellington Shire. Significant population centres have grown through the region along the Princes Highway, including Traralgon, Moe, Morwell, Sale and Bairnsdale. As each of these towns is significant in size, the region has more sub-regional health services than any other. The three sub-regional services have developed over time to offer a similar range and mix of services. West Gippsland Healthcare Group (Warragul) is also a health service on the metropolitan fringe. While it is in the same PCP as the regional service, it provides services to the growing population at the western end of the PCP. This area abuts the rapidly growing metropolitan area of Cardinia. Gippsland region is forecast to grow by 2018–19, primarily in the south coast and east Gippsland areas. Bass Coast Regional Health (Wonthaggi) is currently a local health service but is located in one of the most rapidly growing areas of the state. Over time Bass Coast Regional Health will be transformed into a sub-regional health service, which will necessitate service growth in all areas. Rural directions––for a stronger healthier Victoria 69

Total estimated resident population (ABS 2008)

Primary Care Partnership 2008 2018

Central West Gippsland 114,106 123,733

Wellington 42,576 45,921

East Gippsland 42,742 48,004

South Coast Health Service Consortium 56,061 64,293

Region Total 255,485 281,951

Actual and forecast inpatient activity 2008–09 2018–19 for public health services in the region 91,871 100,963

Regional health service Private hospitals Latrobe Regional Hospital (Traralgon) Heyfield Hospital (BNH) Maryvale Private Hospital (Morwell) Sub-regional health services Neerim District Soldiers Memorial Hospital (BNH) Central Gippsland Health Service (Sale) Bairnsdale Regional Health Service Bass Coast Regional Health (Wonthaggi)(1) West Gippsland Healthcare Group (Warragul)

Local health services Central Gippsland Health Service (Maffra) Gippsland Southern Health Service (Korumburra and Leongatha) Omeo District Health Orbost Regional Health (MPS) South Gippsland Hospital (Foster) Yarram & District Health Service Kooweerup Regional Health Service(2) Gelantipy District Bush Nursing Centre Buchan Bush Nursing Centre Cann Valley Bush Nursing Centre Dargo Bush Nursing Centre Ensay Bush Nursing Centre Swifts Creek Bush Nursing Centre Bass Coast Community Health Service (San Remo) Gippsland Lakes Community Health (Lakes Entrance) Latrobe Community Health Service Nowa Nowa Community Health Centre (1) To be developed into a sub-regional health service over time (2) Hospital is located within the metropolitan area, but functions as a rural local health service 70 Rural directions––for a stronger healthier Victoria

Grampians region

Grampians region has the smallest population base of all rural regions, but the region is large with some of the most sparsely populated areas of Victoria where providing health services provides a significant challenge. The region covers an area of 47,980 square kilometres and extends approximately 360 km from Bacchus Marsh in the east to the South Australian border in the west, and from Woomelang in the north to Inverleigh in the south. Ballarat Health Services is the regional health service and the sub-regional health service is Wimmera Health Care Group (Horsham). There are 16 local health services, including two independent community health centres and four BNCs. The region has three PCPs and 11 LGAs: Ararat City, Ballarat City, Golden Plains Shire, Hepburn Shire, Hindmarsh Shire, Horsham Rural City, Moorabool Shire, Northern Grampians Shire, Pyrenees Shire, West Wimmera Shire and Yarriambiack Shire. The City of Ballarat is the single dominate population centre in the region. The far west of the region, bordering South Australia, includes some of the most sparsely populated areas in Victoria. Due to this dominant population at the eastern end of the region around Ballarat, this region has only one sub-regional service in Horsham. Many small rural centres surround the City of Horsham, which are the traditional broad acre farming areas most affected by changing patterns of farming and drought. A major challenge for Grampians region is the ability to provide services over such a large area to an ageing population while retaining clinical staff and services. The region needs to continue to transform service provision and develop flexible service models to meet community needs. Within the eastern area, Djerriwarrh Health Service in Bacchus Marsh is identified as a local metropolitan fringe health service. This health service is close to the growing metropolitan LGA of Melton and has strong links to Western Health. Rural directions––for a stronger healthier Victoria 71

Total estimated resident population (ABS 2008)

Primary Care Partnership 2008 2018

Central Highlands 151,204 175,133

Grampians Pyrenees 30,874 31,419

Wimmera 38,082 36,316

Region Total 220,160 242,869

Actual and forecast inpatient activity 2008–09 2018–19 for public health services in the region 67,482 86,811

Regional health service Elmhurst Bush Nursing Centre Harrow Bush Nursing Centre Ballarat Health Services Lake Bolac Bush Nursing Centre Sub-regional health services Woomelang & District Bush Nursing Centre Wimmera Health Care Group (Horsham) Ballarat Community Health Centre Grampians Community Health Local health services (1) Local health service on rural/metropolitan fringe Beaufort & Skipton Health Service (Beaufort) Private hospitals (Skipton campus in Barwon-South Western region) Djerriwarrh Health Services (Bacchus Marsh)(1) Ballan and District Soldiers Memorial Bush Dunmunkle Health Services (Rupanyup, Minyip Nursing Hospital & Hostel and Murtoa) Ballarat Day Procedure Centre East Grampians Health Service (Ararat and Willaura) St John of God Health Care––Ballarat East Wimmera Health Service (St Arnaud) (Charlton, Donald, Wycheproof and Birchip campuses in Loddon Mallee Region) Edenhope & District Memorial Hospital Hepburn Health Service (Daylesford, Creswick and Trentham) Maryborough District Health Service (Avoca) (Maryborough and Dunolly campuses in Loddon Mallee Region) Rural Northwest Health (Warracknabeal, Hopetoun and Beulah) Stawell Regional Health West Wimmera Health Service (Nhill, Jeparit, Kaniva, Rainbow, Natimuk and Goroke) Wimmera Health Care Group (Dimboola) 72 Rural directions––for a stronger healthier Victoria

Hume region

The region covers 40,427 square kilometres extending approximately 263 km from Wallan in the south to Wodonga on the New South Wales border. Hume region has two regional health services, Goulburn Valley Health (Shepparton) and the recently integrated Albury Wodonga Health, which will develop more fully into this role over time. The sub-regional health service is Northeast Health Wangaratta. There are 21 local health services, including four independent community health centres and two stand-alone aged care residential services. The region has four PCPs and 12 LGAs: Alpine Shire, Benalla Rural City, Greater Shepparton City, Indigo Shire, Mansfield Shire, Mitchell Shire, Moira Shire, Murrindindi Shire, Strathbogie Shire, Towong Shire, Wangaratta Rural City and Wodonga City. Much of the population is spread throughout the region in the larger centres of Shepparton, Wangaratta and Wodonga, all of which are located in the northern half of the region. The region shares the border with NSW so is impacted on by residents of towns across the border, including the large regional centre of Albury. The rest of the region includes small townships spread across many relatively isolated farming and agricultural areas. The geography of the region includes mountainous areas, making travel between services a challenge in some instances. Rural directions––for a stronger healthier Victoria 73

The southern half of the region includes areas of rural amenity where the population is growing, particularly southern Mitchell Shire. In these areas service trends indicate that the population is more likely to travel to metropolitan health services for care rather than the regional or sub-regional health services in the north. Within this southern area Kilmore and District Hospital is identified as a local metropolitan fringe health service and is close to the growing metropolitan LGA of Whittlesea.

Total estimated resident population (ABS 2008)

Primary Care Partnership 2008 2018

Goulburn Valley 99,621 107,974

Central Hume 63,185 68,280

Upper Hume 57,047 63,520

Lower Hume 47,743 60,254

Region Total 267,596 300,028

Actual and forecast inpatient activity 2008–09 2018–19 for public health services in the region 82,230 109,281

Regional health services Darlingford Upper Goulburn Nursing Home (Eildon) Indigo North Health (Rutherglen) Albury Wodonga Health Goulburn Valley Health (Shepparton) Goulburn Valley Community Health Service (Shepparton) Mitchell Community Health Service (Broadford, Seymour Sub-regional health services & Wallan) Northeast Health Wangaratta Ovens and King Community Health Service (Wangaratta) Upper Hume Community Health Service (Wodonga) Local health services (1) Local health service on rural/metropolitan fringe Alexandra District Hospital Private hospitals Alpine Health (MPS––Myrtleford, Bright and Mt Beauty) Beechworth Health Service Euroa Health (BNH) Benalla & District Memorial Hospital Murray Valley Private Hospital (Wodonga) Cobram District Health Nagambie Hospital (BNH) Goulburn Valley Health (Tatura) Shepparton Private Hospital Kilmore & District Hospital(1) Wangaratta Private Hospital Mansfield District Hospital Yackandandah Bush Nursing Hospital Nathalia District Hospital Numurkah District Health Service Seymour District Memorial Hospital Tallangatta Health Service Upper Murray Health & Community Services (MPS Corryong) Yarrawonga District Health Service Yea & District Memorial Hospital Walwa Bush Nursing Centre 74 Rural directions––for a stronger healthier Victoria

Loddon Mallee region

 Loddon Mallee region is the largest geographic region and covers an area of 59,149 square kilometres extending approximately 492 km from Gisborne in the south to Mildura on the NSW border. Bendigo Health is the regional health service, with three sub-regional health services being Mildura Base Hospital, Echuca Regional Health and Swan Hill District Health. There are 21 local health services, including five independent community health centres and two BNCs. The region has five PCPs and 10 LGAs: Buloke Shire, Campaspe Shire, Central Goldfields Shire, Gannawarra Shire, Greater Bendigo City, Loddon Shire, Macedon Ranges Shire, Mildura Rural City, Mount Alexander Shire and Swan Hill Rural City. The far west of the region, bordering South Australia, includes some of the most sparsely populated areas in Victoria. Bendigo is the most densely populated community in the region. The northern Mallee area includes some traditional broad acre farming areas but also the large rural City of Mildura, which is one of the three sub-regional services. All three sub-regional services are along the Murray River. The agencies in this region also provide services to residents of NSW towns across the river and to parts of South Australia. At the southern end of the region Kyneton is a local metropolitan fringe health service and is close to the growing metropolitan LGA of Hume. Rural directions––for a stronger healthier Victoria 75

Total estimated resident population (ABS 2008)

Primary Care Partnership 2008 2018

Bendigo-Loddon 108,127 126,315

Central Victorian Health Alliance 71,821 82,899

Northern Mallee 53,122 54,253

Campaspe 38,339 40,844

Southern Mallee 40,446 39,704

Region Total 311,855 344,014

Actual and forecast inpatient activity 2008–09 2018–19 for public health services in the region 99,371 121,113

Regional health service Dingee Bush Nursing Centre Lockington & District Bush Nursing Centre Bendigo Health Red Cliffs and Community Aged Care Services Sub-regional health services Bendigo Community Health Services Echuca Regional Health Castlemaine District Community Health Mildura Base Hospital Cobaw Community Health Services (Kyneton) Swan Hill District Health Northern Districts Community Health Service (Kerang) Sunraysia Community Health Services (Mildura) Local health services (1) Local health service on rural/metropolitan fringe Boort District Health Castlemaine Health Private hospitals Cohuna District Hospital Appearance Medical Centre––Bendigo East Wimmera Health Service (Donald, Charlton, Bendigo Day Surgery Birchip and Wycheproof) (St Arnaud campus in Mildura Private Hospital Grampians Region) Sea Lake and District Health Service (BNH) Goulburn Valley Health––Waranga (Rushworth) St John of God Health Care––Bendigo Inglewood & Districts Health Service Kerang District Health Kyabram & District Health Services Kyneton District Health Service(1) Maldon Hospital Mallee Track Health & Community Service (MPS Ouyen) Maryborough District Health Service (Maryborough and Dunolly) (Avoca campus in Grampians Region) McIvor Health & Community Services (Heathcote) Robinvale District Health Services (MPS–– Robinvale and Manangatang) Rochester & Elmore District Health Service Swan Hill District Health (Nyah)