Rural Health Policy: Meeting the needs of rural communities

Wyatt Creech Health

Minister's Foreword

The rural sector is and will remain an essential part of the economic and social fabric of New Zealand. Rural health services are an essential part of New Zealand's overall health services. All health services are designed to meet a common goal - the Government's overarching health policy objective. This is set out in the Government's Medium-Term Strategy for Health and Disability Support Services.

Government health and disability policies are aimed at ensuring real gains in the health status of people so that all New Zealanders enjoy the benefits of good health and maximise their potential to live a full life.

To achieve this broad objective, the Government has twelve medium-term goals to focus the efforts of all agencies in the publicly funded health sector, designed to:

  • build certainty and confidence in the security and stability of the New Zealand health and disability support system amongst all participants
  • give equity of health status to all New Zealanders
  • maximise the benefits of early intervention, proper integration of services, health education, and involvement of communities in developing their own solutions to their health issues.

Improving rural health is a key part of this overarching health policy objective.

While a small country in terms of size and population, New Zealand still has a wide variety of different communities with different circumstances and needs. Rural communities are no exception; all rural communities have their own variations. For this reason, no one single blueprint of health services will fit all needs. Rural people, however, expect similar health and disability support results for their communities as for those in urban New Zealand.

Long distances, geography, smaller populations and dispersed health service providers combine to create a different set of challenges. Government health policy recognises that these challenges lead to specific issues that vary enormously throughout New Zealand. We are committed to backing rural communities as they develop solutions that best fit local circumstances.

A key commitment to rural communities is in the Hospital Services Plan which maintains the current distribution of health services for three years. There is also the recently released Roadside to Bedside which will ensure a safe backbone of acute and emergency services for people no matter where they live.

This Rural Health Policy highlights successful initiatives that have worked well for particular rural communities. It also describes how current policy gives communities, providers and health agencies the flexibility to innovate and tailor those local solutions to local needs.

Wyatt Creech
Minister of Health

Introduction - the place of rural health in overall health policy

The following goals are set out in the Government's Medium-Term Strategy for Health and Disability Support Services.

  1. Public certainty about access, quality and security of services
  2. Timely, equitable and nationally consistent access to elective services
  3. Acknowledging the special relationship between Maori and the Crown
  4. Decreased long-standing disparities in health status
  5. Improved mental health
  6. Improved child health
  7. Improved disability support services
  8. Greater emphasis on population health approaches
  9. Well co-ordinated, integrated services that contribute to better health and disability outcomes
  10. Intersectoral collaboration between public agencies - education, health and welfare - and various providers to achieve social policy objectives
  11. Improved capability and adaptability of the health and disability sector
  12. Sustainability of the publicly funded health system

A key goal is raising public confidence in the level, mix, quality and structures of health and disability services, including rural services, and making sure they are secure and appropriate to the needs of today and the future. This is achieved through:

  • the commitment to the current configuration of services via the Hospital Services Plan and subsequent developments of collaborative networks of secondary services indicated in the Roadside to Bedside policy
  • major investments in new public hospital facilities
  • making no further change to the current structures within the system (Health Funding Authority and the publicly owned Hospital and Health Services).

Rural health is specifically covered under Rural services in Goal 1 of the Medium Term Strategy for Health.

Services to people in rural New Zealand are specifically identified in the Strategy as a service area about which the Government wants people to enjoy greater security and confidence. The Government's policy for rural health and disability support services enables rural people to receive effective appropriate front-line care in their own community, and have timely access to acute emergency services of an agreed standard of care within acceptable modern standards. Decisions on the allocation of health resources must take into account the ongoing needs of rural communities.

The increasingly specialised nature of clinical services, coupled with higher levels of technology now employed in medicine, mean that some services are best delivered through regional or national centres of excellence. Used creatively, new technologies, such as telemedicine, telephone triage systems and better transport systems, can enable all New Zealanders to benefit from such services. The Government expects the sector to use technology creatively to facilitate access to health and disability support services for isolated communities.

The Government recognises there is diversity among rural communities and their needs and is keen to create opportunities for rural communities to develop local arrangements that suit their needs. They do not need to be the same everywhere - what works well can be used. The Government sees potential for effective alliances and networks to develop between providers at the primary level and between the primary and secondary levels. Provider competencies could be usefully expanded in rural areas, and Government would like to see improved recruitment and retention of rural health professionals.

In terms of hospital services, the Government's rural health policy proposes that people living at a distance from a hospital retain access to a full range of services. Access to public hospital services will be determined on the basis of reasonable need and ability to benefit and not by where a person lives. However, to maintain access to services that are safe, high quality, and operated by sufficiently experienced professionals, people will need to travel for some services, especially the more specialised services.

Proposals for new or changed services in rural areas, including those that service particular or at-risk groups, must be carefully assessed before they are launched and communities need to be properly informed of the proposals. Where that base work is done, the Government will encourage initiatives that address particular needs, for example a particular disease like diabetes, or a particular type of service like dental services. The list of proposals would be as short or as long as the community can identify.

There are many issues specific to rural health and support services. This document shows how they are being addressed. The Government's policy for rural health services aims to:

  • enable rural people to receive effective front-line care in their own community
  • organise services around people and their needs
  • recognise the diversity of New Zealand's rural communities and their differing needs
  • provide timely access to acute emergency services of an agreed standard of care
  • use technology where possible to reduce the impact of isolation
  • establish effective alliances and networks between providers (for example, integrated care organisations, regional referral patterns)
  • develop and maintain skills in rural services
  • offer greater certainty about access to services of a consistent agreed standard
  • create opportunities for rural communities to develop local arrangements that meet their needs.

The Government's priorities for the health and disability sector apply as much to rural communities as to the rest of New Zealand.The Government's rural health policy focuses on the commitment by Government and rural communities to maintaining and improving access to good-quality health and disability support services so that these priorities can be met for rural people.

Enabling people in rural communities to access a full range of services means ensuring the recruitment and retention of key health care providers for local communities. It also means carefully taking into account the specific needs of rural people when dividing up health funding.

The best solutions come from knowledgeable and committed participants. The submissions to the consultation draft of the Rural Health Policy confirmed that rural people are eager to work in partnership with Government agencies to maintain and improve their services. This document identifies opportunities for rural communities under current policy settings. The Government shares the commitment of rural people to better rural health care.

Rural People

Age structure

About one in four New Zealanders (23 percent) live in rural areas (including small towns of less than 10,000 people). The rural population has a higher proportion of children (aged 0-14 years) and older adults, while having a lower proportion of young people (aged 15-24). Graphs on the age structure of the rural population are included in Appendix 1.

Maori rural population

Around one in three Maori (32 percent) live in rural areas. One in five rural people (19 percent) are Maori. A map showing the distribution of the rural Maori population is provided in Appendix 2. The age structure of the rural Maori population is younger than that of the non-Maori rural population, with a significantly higher proportion of children and young people and significantly lower proportions of older adults (both the 45-64 years and the 65 years and older age groups).

Health status

Measures of health status indicate that the health of rural people overall compares favourably with urban people. This is especially so for non-Maori rural people, when measured by life expectancy at birth and at age 65. Of particular concern, however, is the relatively poor health status of rural Maori, compared with urban Maori and with rural non-Maori. Life expectancy tables are included in Appendix 3.

Rural people and people living in towns of less than 20,000 population have a significantly higher mortality rate from injuries than urban people but for other major causes of death their mortality rate is similar to or below that of urban people. Rural people have a lower hospital discharge rate than urban people except for neoplasms (cancers). (Refer to figures 6 and 7, Appendix 3.)

People with a disability requiring assistance

Fourteen percent of people with disabilities live in rural areas, which is significantly less than the 23 percent of the general population in rural areas. Around 10 percent of people with a disability living in rural and-urban areas report requiring some form of assistance on a daily or less frequent basis.

There is more of a rural-urban difference for different age groups. In contrast to the general population, children aged under 15 years and adults aged 65 and over who have disabilities make up a smaller proportion of the rural population than the urban population and this trend persists for children and adults who require assistance (refer to table 4 in Appendix 4). This could be because parents of children with disabilities prefer to live near specialist health and disability support services in cities. Older people with disabilities, especially those requiring assistance, also tend to shift to a city or town to be nearer to services.

Diversity including socioeconomic differences

Rural communities in New Zealand vary widely in their demographic, cultural and socioeconomic characteristics as well as in their geographic features. (Appendix 5 shows the most disadvantaged areas.) There is a close association between socioeconomic hardship and poor health.

The changing face of rural health and disability support services

Rural communities are affected by changing health-service delivery in New Zealand. Two pertinent examples are isolated communities with populations of less than 3000, and communities with small hospitals which are undergoing changes in service provision.

Very small communities have commonly had difficulty attracting and retaining health services. They can often support one doctor only who consequently has to face constantly being on-call, isolation and difficulty with relief arrangements. In recent years there has been a trend in urban practice towards larger groupings, better facilities, more teamwork, and less arduous on-call. This is difficult to achieve in the traditionally organised rural practice.

Hospital-based services in rural and provincial towns have had a strong influence on the work of primary health care workers in the area. Rural hospitals are changing as the result of quality, equity and cost considerations. They are increasingly focusing their service provision on stabilisation and referral services, some inpatient medical care, birthing-level maternity services, and community health services, such as mental health teams.

Disability support services and other home based services have traditionally been provided by district nurses employed by public hospitals (known as Hospital and Health Services or HHSs,) home-help workers, community-based support services such as IHC and WDFF, and family, friends and other informal sources of help. A wide range of providers are now contracted to provide home support and other disability support services. However, providing home-support services to rural areas, particularly more remote regions, remains a challenge.

Current access to services

Publicly funded service coverage

Each year, on behalf of New Zealand taxpayers, the Health Funding Authority (HFA) spends over $6 billion on health services and services to support people with disabilities. The booklet What Can I Expect? produced by the HFA sets out what services the Government funds. It is the job of the HFA to spend that money by funding the optimum mix of services to meet those twelve objectives set out in the Medium Term Strategy. In doing that, the HFA needs to assess health and disability support needs, consult with communities over priorities and decide where it will do the greatest good with the publicly provided health and disability dollars.

The HFA's Funding Agreement with the Minister of Health makes a commitment to ensuring access to services for rural people:

The HFA will ensure people have reasonable geographic access to services as close as possible to where they live, appropriate to the nature of the service.'

"When determining the availability of purchased services, the HFA will consider and accommodate the needs of people in remote areas in the most practical and efficient way.'

HFA 1998/99 Funding Agreement

Primary health care

Primary health care services are not only the first contact health services; ideally they should be where most of the action happens. Better primary services can reduce the cost and stress of higher level of intervention. Data comparing how rural and urban dwellers use primary health care are not available for the whole country, but research carried out in the Midland region of the North Island suggests that rural people use such services less frequently than urban dwellers. The availability of general practitioners (GPs) across the country varies, with the doctor-to-patient ratio in rural areas considerably lower than that of many urban areas.

Most people (at least 90 percent) are able to access primary health care services within 30 minutes' travel time from their homes. However, within these broad measures, there are communities which struggle to get and keep GPs and primary-care nurses.

Hospital services

Basic hospital services, such as low-risk general medical and surgical services, are generally available to 90 percent of people within 60 minutes' travel time.

Figures 1 and 2 show rural areas located further than 60 minutes' travel time from hospitals which offer 24-hour acute secondary services.

Disability support services

People with disabilities may require basic ongoing services such as home support, as well as provision of equipment and more specialised disability support services. By their nature, home-support services provided on a frequent and often ongoing basis create a challenge when delivered to widely dispersed people in sparsely populated rural areas.

Disability support services, especially those for people with complex/dual/multiple disabilities, have traditionally been in short supply in rural areas. Ongoing difficulties of access to these services cause some people with disabilities to shift to urban areas with better access.

Issues for rural health services

Community-based services and hospital services face similar issues in rural areas:

  • the recruitment and retention of appropriately skilled professionals
  • the maintenance of skills and service quality
  • ensuring that practitioners have a sustainable lifestyle for themselves and their families.

There are a number of issues in rural settings that have the potential to impact on safety. They are:

  • the effect of distance and isolation on services
  • solo practice
  • lack of peer support
  • limited training opportunities to maintain and enhance skills
  • challenges in obtaining and maintaining medical equipment
  • transport to medical services.
  • the appropriate balance between the inconvenience for the patient and family of travelling to an appropriate service and the risk of providing an inadequate or unsafe service locally.

In addition, particularly with the increasing specialisation of modern medicine, it is not possible to provide expensive new technologies in every health facility. Neither are the specialist and technical staff needed to operate these technologies widely distributed. Inevitably, some centralisation of services is necessary for both clinical safety and economic reasons.

Measures being taken to address issues affecting rural areas are outlined in the following sections.

Planning and funding better health and disability support services

Primary-care strategy

In order to meet the Government's health policy objectives, the HFA is currently working with the sector to develop its primary-care strategy. It builds on and responds to the consultation on The Next Five Years in General Practice, the draft strategy for general practice services released for consultation in 1998. The primary-care strategy has a broader focus and will include consideration of:

  • primary medical and nursing services
  • community and home nursing
  • primary mental health services
  • community health services
  • management of referred services, including laboratory tests, pharmaceuticals, imaging, physiotherapy and specialist medical services.

The strategy will also consider linkages between primary care and community mental health services, Maori health, well child services, palliative care, maternity and disability support services. It will allow increased flexibility about how services are best provided in rural and urban areas. Other key aspects of the HFA's primary-care strategy currently under development are:

  • recognition of primary care as the base of the health sector
  • a pragmatic focus on health outcomes, such as practice population programmes focused on prevention and early detection, management of chronic diseases and improvement of health status of those groups including Maori and Pacific people, who currently do not enjoy the same health outcomes as other New Zealanders
  • continued encouragement of Independent Practitioner Associations and outcome related contracting
  • encouraging the involvement in primary practice of a wider range of providers, consumers, and contracting that allows new alliances to form
  • increased collaboration between personal (primary and hospital), and public health providers
  • a focus on quality and on the right people providing the right care at the right place and in the right time
  • continuing analysis into the barriers to good care delivery (for example, access to accident and emergency services)
  • recognising good features of the rural environment (for example, linkages between GPs and home-based services that may be transferable to urban areas)
  • an enabling, flexible and innovative contracting framework that supports local solutions to local problems.

It is envisaged that the primary-care strategy will provide enhanced flexibility for practices to work with communities to respond to local needs with local, community-based solutions. As part of the primary-care strategy, the HFA is advancing workforce issues and health care provider development. This includes looking at the specific needs of rural communities.

Patea and District Medical Community Trust

The Patea community used to struggle to keep one GP. The Patea and District Medical Community Trust changed that, and now the town has a two-GP service plus access to the after-hours service at Hawera Emergency Department.

Chairman David Honeyfield says Patea had a long history of trying to retain solo doctors. "Doctors would usually stay 6 to 12 months and then move on. It was becoming increasingly hard to replace them . . . The main difficulty is that Patea is a doctor-and-a-half practice - for one doctor it is too much work; for two it is not quite enough.'

The community took the bull by the horns and worked towards solving the problem itself. It formed a community trust in 1991, rallied together public donations, and now, eight years later, its medical centre caters for 2733 patients. The practice is self-supporting and works in well with the health centre, which was built for the use of all community health groups in 1995 through a trust and Taranaki Health Ltd joint venture.

"Now the doctors work at the Hawera Emergency Department to make up the other part of their income, which means we have a good working relationship with the Taranaki Emergency Services. It also enables our doctors to have contact with other specialists and keep their skills in use,' says David. "It works well for the community because they have access to a GP in their own area and don't have to travel for half an hour for medical services, and it works well for the doctors because they are not working in isolation.'

"If the Trust had not been formed we would not have had GPs in Patea. It's working really well - a true success story.'

Rural GP premium and other support for rural general practice A General Practice Working Party in 1997 identified some key areas where rural general practice needed support. These related to improving:

  • the recruitment rate to rural practices
  • the retention rate of rural practitioners
  • the care given by rural practitioners.

Opportunities identified to improve the support of rural general practice included:

  • promoting rural practice as a positive career choice
  • easing the fear of a "rural entrapment'
  • targeting the rural bonus relative to a "rurality scale'
  • facilitating locum cover for rural practitioners
  • strengthening teamwork in rural practice
  • facilitating appropriate professional development for rural practitioners
  • formalising support for rural nurses working in isolation
  • ensuring high-quality co-ordinated emergency care.

Responses to the draft rural health policy suggested that there are still aspects of these issues that concern a wide range of rural practitioners.

The HFA currently pays a 10 percent premium on subsidised GP consultations and a 25 percent premium on travel payments for practitioners working in designated rural areas.

However, the designation of a rural area has become outdated and the HFA has been working with the Rural GP Network and other interested groups to develop a better way of recognising the increased costs associated with providing rural general practice.

Factors that may be taken into account include: the degree of isolation of the practice; the proximity of other practitioners; after-hours cover; proximity of centres for continuing medical education; and the amount of travel required to reach patients within the rural area. The changes to the rural GP premium are expected to be finalised shortly.

Other components of the support package for rural general practice include GP training, training of GPs and practice nurses to participate in the PRIME scheme (refer page 19) and indirect support for locum services.

Rural pharmacy allowance

The HFA has introduced a rural pharmacy allowance in recognition of the need to ensure that rural people continue to have access to pharmacists and pharmaceuticals. The rural pharmacy allowance is paid to pharmacies that meet a number of criteria, including distance (at least 30 minutes) from the nearest other pharmacy, more than one hour from a major city where continuing education occurs regularly, and the number of pharmaceutical scripts processed each year.

Rural nursing services

A considerable amount of rural primary care is performed by nurses who are multi-skilled and are frequently required to function across a broader range of nursing domains than their urban counterparts. The domains that nurses in rural areas cover include district nursing, practice nursing, child health and, in some cases, midwifery. They also provide the link between primary and secondary services, providing hospital-at-home care to enable safe early discharge from hospital. There has been a recent increase in funding to nursing and other health worker provision to rural areas as part of the implementation of the child health strategy.

Rural nurse led services offering primary care, health promotion and referral services perform a valuable role in some localities where the nearest GP may be some distance away.

The HFA is keen to encourage the development of innovative solutions to rural problems and to contract with new provider organisations. Within this framework, there is a very important role for nurses and nurse led organisations. The key criteria for the HFA will be the ability of any new organisation to improve health outcomes and give better overall value for the health resources involved. This implies a need to view the patient in a holistic way rather than services as individual silos of service. This concept drives the development of "integrated health care'.

ACC is also contracting with rural nursing services in isolated communities (50 kilometres or 30 minutes travel from the nearest GP clinic or hospital) to provide primary care assessment and treatment for accident and injury conditions.

Rural nurse led services at Takapau

The Takapau Health Centre was nurse Anne Lloyd's dream.

Sadly, Mrs Lloyd passed away a few months after the centre was opened. Her dream has developed into a valuable community asset providing a range of nurse-led health services,' says nurse practitioner, Ingrid Cheer.

Today there are approximately 4000 contacts made each year via telephone, face-to-face consultations and group activities.

Our focus is on picking up health problems early, maintenance of health, and health promotion and screening. We also work towards empowering patients and helping them get access to other services. Working in closely with other health providers is crucial to the centre's overall functions.'

The centre, managed by the Takapau Community Health Charitable Trust, now has one full-time and one part-time multi-skilled registered nurse working, as well as a voluntary administrator. There is also an outreach clinic in Norsewood.

Operating in a large, rural, isolated community where there are few other locally based health services and limited public transport, the centre co-ordinates visiting health professional clinics, provides regular clinics such as hearing, asthma, podiatry, cervical screening and CPR classes, and uses internet services to ensure ready access to information. The service has a licence to sell a small range of pharmaceuticals, and has equipment such a blood glucose meters, wheelchairs and crutches available. There is also transport assistance to GPs and other health services via the Friends of the Health Centre (a voluntary group).

"The community's support never ceases to amaze me and at times it is most humbling,' says Ingrid. "I believe it's been a success because the community feels it owns the centre. Local control and local solutions to local problems in a depressed area are huge attributes to community morale.'

Primary health services in areas of high health need

In November 1998, new Government funding was announced to provide start-up capital and ongoing support for up to seven new primary health services in areas of high health need. Healthcare Aotearoa, a national network of primary health providers which are not-for-profit and community controlled, has been contracted to administer the fund. A quality improvement programme and administration is also included within the two-year contract. The new primary health services, which must be not-for-profit, will provide services to low-income populations with high health needs in either rural or urban areas.

The Hospital Services Plan

A dependable, secure and certain public hospital sector remains at the heart of the Government's health strategy. This is made clear in the Hospital Services Plan which was released in September 1998.

The plan responds to the need for greater certainty about the ongoing provision of hospital services, and places special emphasis on the needs of rural and provincial communities. It is part of the Government's general health strategy, which is motivated by the ideal of timely access to good-quality, cost-effective health care for all New Zealanders.

The plan sets out a framework that describes five kinds of hospital facilities. These range from health centres that offer diverse services in a wide number of places up and down New Zealand to high level tertiary facilities where the most complex and highly technical health services take place. The range of facilities together provide an integrated network of expert health coverage. The plan outlines where services are currently provided and will continue to be provided until at least September 2001. The Government has made a firm commitment to maintaining the current distribution of services for that period.

This does not mean that all changes to hospital services are being put on hold. Clearly, the aim of the Hospital Services Plan is to stop the loss of services to regions; the plan will not be used to block changes that result in improved outcomes for the local communities.

The Government is committed to providing rural hospital services and already pays a significant premium to recognise the extra costs involved.

Opotiki Health Facility

The Opotiki Health Facility was opened by Health Minister Wyatt Creech in March 1999. The health facility is owned by the community, Pacific Health Ltd and the Whakatohea Trust Board. Replacing the old Opotiki hospital, it provides health services for the Opotiki District - around 10,000 people.

"A vision that was created five years ago has at last become a reality. It is a pleasure to see this valuable community asset up and running,' says Ron Dunham, Chief Executive Office of Pacific Health Limited.

"It is an important community asset, allowing people access to health services in an area where those services are quite hard to access,' Heather Thompson, health facility co-ordinator says. "While the old hospital was a beautiful site and was loved and revered by the community, it was just not economical.

"The community wanted to retain the old hospital, but there has been a shift of emphasis to retaining services within the community. To do this we needed a facility which provides all the same services, but as a more economic unit.'

The new health facility provides GP services, physiotherapy, midwifery and maternity services and a range of specialist outpatient services. The facility has five beds for maternity and hospital care.

Rural hospital premium

A rural premium of $15 million has gone into small publicly owned hospitals through the contracting process in 1998/99.

This was the first time that there had been an attempt to develop a consistent and fair approach to a rural premium across the country. While it is not yet perfect, it is a step in the right direction towards a transparent and equitable rural premium.

Of this premium, $6 million was allocated to hospitals that provide 24-hour acute cover but have a workload less than what is financially sustainable for that level of service. The remaining money was negotiated on a case-by-case basis, recognising each region's unique characteristics.

In future years this payment will be refined. It is aimed at making support for health services in the regions more transparent, so that everyone knows what is being paid for and why.

Child health

At the end of 1998, new funding was announced for child health to be directed to the following service areas:

  • well child care, with a particular emphasis on tamariki Maori, Pacific children, children with high health and disability needs or suffering socioeconomic disadvantage
  • services for children with disabilities living in rural areas
  • school health nurses for the most disadvantaged schools
  • preschool dental services.

Mental health care

Mental health services available in rural areas tend to be general, with access to more specialised services requiring referral to the main centres. Rapid response to mental health crises is more difficult in rural areas.

Hospitals serving rural areas have in recent times established crisis teams or psychiatric emergency services that are mobile and can cover rural areas. As crisis teams develop, emergency service coverage is extending into more rural areas.

The Government is seeking to increase the mental health workforce via "Mason funding'. This is the extra funding made available by the Government for mental health services subsequent to the 1996 Mason Inquiry into mental health services. The range of community-based mental health services is being expanded with what is known as the Mason money, and should result in better rural mental health services.

East Coast Mental Health Services

"Enthusiasm and passion are the main fuels for the East Coast Mental Health Service, which strives to provide East Coast people with a service that is moulded to their needs,' says team leader Rose Kahaki.

The Mental Health Service serves a population of 6000 from the vast area running between Potikirua in the north to Anaura Bay in the south of the East Coast, an area where there is no public transport and high levels of poverty and unemployment.

"When the service first started we did not know much about mental health at all. Mental health issues had been dealt with at GP level and then transferred out to other areas like Porirua and Tokanui. We were pretty new on the block. So the service was born out of the needs of the community, from the bottom up,' says Rose.

It began with one nurse in the community one day a week. Then that grew to five days a week. Nowadays the majority of care is community based and includes home visits to clients and their families by a mobile multi-disciplinary team including key workers, a doctor, psychiatrist and an activities co-ordinator. The service also offers social work, family support for clients with dual diagnosis alcohol and drug / social service counselling and advocacy. A 24-hour service is available for crisis and early intervention and for families in need of intensive home-based support and for respite, sub-acute and crisis admission.

"Because the service has been community led, this means prevention mechanisms were put in place early,' says Rose. "We challenge the concept of the health professional remaining aloof to the struggles and realities of consumers and acknowledge that we as a team are very much part of the East Coast community.'

Improving access to disability support services

The HFA has encouraged a variety of solutions to the problems of access to disability support services for rural people. In some areas, home support and other providers have been asked to ensure that their service covers people living in rural and urban areas of a defined sector. In other areas, the emphasis has been on using existing services, such as the rural health centre, as the basis for delivering disability support services. In some instances the same professional or community worker may deliver disability support services as well as other services.

One of the problems in the past has been that rural people have not had access to information on available disability support services, nor known how to access them. New Zealand Disabilities Resource Centre, Palmerston North, now has an 0800 number which provides information (0800 ENABLE) or refers people to their nearest regional disability information centre.

Since 1 July 1997, all people with disabilities wanting to access services, regardless of location, first have their needs assessed. Information on services is also provided as part of the needs assessment and service co-ordination or planning processes. Needs assessors and service co-ordinators travel to clients' homes in rural areas. Accredited assessors for equipment and other more specialised assessors or providers also travel to homes where possible. The uptake of disability support services by people in rural areas has increased as a result of putting these systems in place. Even so, rural people use services less frequently than those living in urban areas.

The recent allocation of funding for services for children with disabilities living in rural areas demonstrates Government recognition of the need to improve services.

Meeting the challenge of providing disability support services in rural areas

"Care workers have to be excellent problem solvers and communicators,' says Jill Kersey, unit manager of Nelmar, a private agency which provides home support to people around the top of the South Island.

Nelmar is based in Nelson and has offices in Blenheim, Motueka and Wellington (Wellcare Home Support). Co-ordinators are based in Golden Bay and Picton areas to ensure the service is as close as possible to its rural clients.

"We cover a wide geographic area. We have one client who lives at the base of the Heaphy Track. Because our Nelmar careworkers have to work in such isolated conditions it is important they have the right competencies and knowledge,' says Jill.

For this reason every Nelmar careworker has orientation training to ensure they know the basics, such as lifting and legal requirements. Nelmar also runs ongoing seminars (last year there were 99) for its staff and is currently working with the New Zealand Qualifications Authority to provide training for careworkers who want to study towards its National Certificate in Support of Older Persons.

"Many of our clients are older people who may not have very much contact or family support, and sometimes Nelmar careworkers are the only people who go into their homes so it is so important to match the right careworker with the client. This is even more difficult when you are providing a service to rural areas because it can be hard to recruit people who live nearby,' she says.

There is no doubt rural-based careworkers face different challenges to their city counterparts.

"Some of our careworkers have to cross a multitude of obstacles to even get to the client's house. The careworker has to drive for miles in the country up unsealed roads and tracks and in some cases even climb fences and cross paddocks,' Jill says.

Travel and accommodation assistance

The HFA provides travel and accommodation assistance to patients who have to travel for treatment. At present this varies regionally but generally focuses on Community Service Card holders or those younger than 16 years. Assistance is financial contributions to travel and accommodation costs for those having to travel long distances or frequently for hospital treatment.

People with disabilities also have access to travel assistance. Having services available locally is particularly important to people with disabilities who find it difficult to travel and often need to get services regularly.

As part of meeting the Crown Statement of Objectives' goals for 1999/2000, the HFA will consult on and develop a fair, transparent and nationally consistent patient travel and accommodation policy by 30 June 2000.

Improving acute and emergency services

The Government is committed to ensuring a safe backbone of acute and emergency services throughout the country. It is an essential requirement of our publicly funded system. To achieve this a significant amount of work is in progress.

Acute management system

The aim of the 24-hour clinically integrated acute management system is to ensure that people get "the right care, at the right time, in the right place, from the right person'. The framework for the acute management system is outlined in Roadside to Bedside, released by the Minister of Health in March 1999. Roadside to Bedside was developed by the Ministry of Health in conjunction with the HFA, the Accident Rehabilitation and Compensation Insurance Corporation (ACC) and the Council of Medical Colleges in New Zealand.

The key elements of the 24-hour clinically integrated acute management system are:

  • establishing five regional collaborative networks covering all hospitals and providers involved in emergency work
  • transferring patients with acute health needs to the nearest hospital capable of providing definitive care
  • ensuring appropriate and timely access to resuscitation and stabilisation services for all emergency patients
  • integrating all services involved in the management of acute health needs
  • ensuring an appropriate emergency transport system
  • using nationally consistent and agreed guidelines, protocols and standards
  • developing the workforce to maximise the current expertise and skill mix of health professionals
  • providing hospitals and health professionals with access to opportunities involving telecommunications.

The acute management framework is not about centralising the provision of emergency services, but rather aims at ensuring rural health professionals are supported and well linked into a network of providers. The network, once developed, will also provide rural populations with certainty about their ability to access the most appropriate place of care within the optimal timeframe.

The HFA is leading the implementation of the framework, supported and guided by a National Advisory Committee comprising health professionals, ACC and the Ministry of Health. The HFA will also be establishing regional teams to develop the backbone of the first networks and a number of clinical teams that will focus on development areas such as pre-hospital care, Emergency Department care and obstetric emergency care.

The HFA and ACC is planning to implement the backbone of the first two networks, improve the integration of ambulance contracting and commence the national roll-out of the PRIME scheme by 1 July 1999.

The PRIME scheme

The PRIME (Primary Response In Medical Emergencies) scheme aims to ensure high-quality access to medical emergency treatment. GPs and practice nurses will be available to attend emergencies and will be provided with extra training and equipment.

This scheme is a good example of different agencies working together to provide better services, as it has had the support of ACC, the HFA, the New Zealand Rural GP network, and the Order of St John, which has done much of the training and orientation.

The PRIME scheme is being implemented progressively, New Zealand-wide. The scheme, once fully implemented, will give rural people more security about the immediacy, quality and co-ordination of their emergency services.

Ambulance services

One of the highest priority areas that will be addressed as part of the implementation of Roadside to Bedside is ensuring better co-ordination of ambulance services. The HFA and ACC, with the New Zealand Ambulance Board and the Ministry of Health, will be looking at ways of working together to achieve a more nationally consistent and co-ordinated approach to contracting for emergency ambulance services. Changes will be required from 1 July 1999 in response to the Accident Insurance Act 1998. Special consideration will be given to how the needs of rural populations and those ambulance providers covering rural populations can be addressed through this process. The national implementation of PRIME will also assist in ensuring that volunteer ambulance officers are supported by specially trained health professionals when attending an accident or emergency.


The Government has provided the HFA with the funding necessary to run a pilot 24-hour telephone advice and triage helpline in Northland, the East Coast of the North Island, and the West Coast of the South Island, from the year 2000. The Healthline will provide timely health care advice to callers of all ages about the most appropriate treatment they should seek, or if they can self care at home. The telephone service will be staffed by experienced nurses who are fully supported by computer based algorithms (decision support for triage) which will help ensure consistent, safe and high quality advice is provided. Overseas evidence shows that this type of service has a number of benefits, including guiding patients to the right care, at the right time in the right place. Evidence also shows that this type of service is safe, popular and effective.

Nurses would provide triage advice, including assessment of a patient's condition and directing the patient to the most appropriate level of care, advice on self-care if appropriate, advice on the prevention of illnesses, information about diseases and pharmaceuticals, and information about available services, entitlements and user charges.

Community-based initiatives

Government health agencies will continue to work in partnership with local communities to find solutions to the problems they face. These solutions are likely to focus on organising services around patients, better relationships between providers, local solutions to local problems, and having decisions about resources made as close as possible to need.

The HFA Localities Teams approach rural health issues by looking at community needs and identifying gaps in service provision. The HFA wants to work with communities in making decisions on how best to meet these needs with available resources. Rural community consumers, groups or health care providers wanting to discuss health and disability support services for their community should contact the HFA Locality Manager. (Contact addresses are provided on page 35.)

Health centres

The health centre (or health clinic) model is becoming more common in rural areas. Health centres range from the very small to those that cover a significant range of services. Some go to the extent of having inpatient facilities. Typically, this type of facility provides an integrated range of services including primary and community health services. Health centres usually have a community service base (for example, providing public health nursing, district nursing, home help and mental health teams) with facilities for visiting specialists, and for treatment (for example, physiotherapy, public health and pharmacy services). Sometimes it will also have general practice and/or maternity beds.

There is a wide range of ownership structures. A number of health centres are run by public hospitals. In some places, local community groups or groups of health providers have developed health centres to replace small hospitals that were once run by the public health system. Some have been developed using the Community Trust Assistance Scheme (CTAS). There are also partnerships between the public hospital and the local community. Despite initial community concern regarding this development, experience is increasing widespread support for these new health centres.

A good example of a higher level health centre in action is the new community hospital that opened in Dannevirke in 1997. While the hospital itself is owned largely by local health providers, the services are publicly funded by the HFA. The new hospital works with the town's GPs to provide medical inpatient care and includes x-ray and ultrasound facilities, physiotherapy and a medical laboratory. MidCentral Health also provides a range of services from the facility.

Dannevirke's solution

"The best advertisement for the Dannevirke Community Hospital is that staff are happy in their work', says manager Sharon Wards. "My philosophy is, if you keep your staff happy, then your patients will be happy too.

"Originally Dannevirke wanted its hospital on the hill come hell or high water but that was not happening. We rallied for the new service through constant public relations, talking to the public and working through the issues that arose. Dannevirke Community Hospital opened its door in September 1997 and now the community is right behind us.

"It's worked well with all services being utilised.

"We had the opportunity to make this place work, and everyone's attitude and time has made it the success it is. It was a huge change in thinking for many of the staff from big hospital bureaucracy to a small, patient-focused environment. But it did not take long for staff to make this their own baby.

"What we have is a purpose-built facility with no wasted space. Administration costs are kept to a bare minimum and most resources are going towards staff and patients. We have tried to design services that are focused on the needs of the community.'

For example, Dannevirke Community Hospital has GP-managed beds to provide convalescence following surgery and for medical problems which don't require specialist intervention.

The hospital houses eight GP beds, three maternity beds, x-ray facilities, Medlab and Homecare 2000. MidCentral Health also operates public health, district nurses, specialist outpatients, and mental health and occupational therapy in the building.

Over time, more health centres will develop as community initiatives come forward. The HFA is continually looking at developments in this area including, where appropriate, trials of new services with associated evaluations.

Integrated care

Many integrated care initiatives are now developing up and down this country. There are a range of initiatives that come within the understanding of what is meant by integrated care. At one end of the spectrum is the emphasis on improved co-ordination between services; at the other end it means taking the available budget and using it to purchase a whole range of services for a whole population so as to get the best outcome overall.

Integrated care in its various forms seeks to deliver health services to people and to communities in a co-ordinated way. It looks at the bigger picture when providing health care, so that the community's need for preventative and educational services are worked on as part of a constructive overall package.

Integrated care aims to give both better co-ordinated and more health and disability support services with existing resources. Integrated care services may have the following features:

  • coverage of a particular population
  • a range of services
  • more than one provider
  • well developed, effective collaboration between providers
  • the use of a single pool of funding.

The Government is encouraging communities and local providers to consider a variety of integrated care arrangements, thus allowing local people to take the initiative in developing their own local services by working out the solutions that serve them best. Such approaches are expected to help communities to resolve some of the issues in maintaining effective health services experienced by rural communities.

Because rural communities tend to be small, they often already have some important ingredients for successful integration, such as existing relationships between key groups. Unfortunately, sometimes strong parochialism and existing health provider relationships can run counter to regional attempts to develop integrated solutions. In small communities where the community and health professionals are able to work co-operatively, initiatives seem to have moved forward faster than in cities.

Kaitaia Maternity Service

The Kaitaia Maternity Service incorporates all the maternity services in the region spreading from Mangamuka to North Cape. The majority of the region's roads are unsealed and access to some areas is difficult during the winter months. The service has to deal with these problems, as well as significant population factors like having a high percentage of Maori women (45% of the women aged 15-44 years) and a high proportion of young families, many of them on low incomes.

"We didn't want to create competition in this area,' says Donna Mayes, Kaitaia Maternity Services manager. "GPs and practice nurses have a long history of working together and we wanted to continue that relationship, ensuring that our service met the needs of rural women. We wanted to make a service where the midwives and GPs had security of income, collegial support working as a team, and flexibility in how the services were delivered.'

The midwives provide antenatal care, and do home deliveries as well as look after the maternity service at the hospital. GPs provide the medical backup throughout the pregnancy as need and choice demands. The maternity service provides senior midwife cover at the Kaitaia hospital maternity unit and Northland Health provides support staff. The service also works in closely with community groups such as Plunket, Ringa Atawhai and iwi-based health groups.

"We are too isolated to operate in a competitive environment. Our drive was to get focused on how to meet the needs of women and we made a decision to leave the politics behind. Our satisfaction is in seeing women in the region receiving good care,' says Donna.

The formation of Independent Practitioner Associations and other groups interested in integrated care, such as Healthcare Aotearoa and Maori Integrated Care groups, have also encouraged the development of integrated care.

The earliest rural integrated care initiative was in Hokianga. This is not a typical initiative because Hokianga has a special area status but it has been accepted as a very successful development for the local community.

Developments have also moved quite rapidly in some small community towns with outdated existing facilities that were confronted with change. Examples are Balclutha, Ranfurly and Gore in the south, and Dargaville and Kaeo in the north.

Balclutha looks to the future

Balclutha's integrated Healthcare Facility opened its doors to the community in December 1998. Brian Dodds, the chairman of the board of Clutha Health Incorporated, says it has been a challenging task bringing the community around to accepting the new facility as the key health service.

In December 1991 a campaign to fight for the retention of surgical services at Balclutha hospital started. Three years later these remaining surgical services closed down and the Hospital Support Committee rallied to find alternatives which would secure sustainable health services in the Balclutha.

"In the beginning we were all fighting for what we had; then we stepped back and thought, shouldn't we be looking to the future? There was divided opinion on it. Concern about whether or not, as a community, we should be taking on the responsibility for the provision of health services,' says Brian.

In August 1997 the group presented a business plan, centred on a new facility in Balclutha, to the community and members of the committee spoke to as many community organisations as possible to gain the support they needed to get the project under way.

"It's been a big change for the community to accept but we are confident that the quality and range of services which the new facility offers will do much to overcome the remaining opposition.'

Now the focus is on ensuring the continuing provision of the best health services by drawing together local health personnel and through better co-ordination and co-operation improving the services to the community.

Clutha Health Incorporated has been formed to own the facility on behalf of the community. It is an incorporated society with a board membership of 10 (five of whom are elected, while three are appointed by the people who work in the facility, one by the Clutha District Council and one by the Minister of Health). The incorporated society, in turn, has appointed a board of five directors to the Clutha Community Health Company Limited, which holds the contract to provide health services.

The facility includes seven general inpatient beds, two observation beds, four inpatient beds with specialist geriatric supervision, a maternity facility ward, two postnatal beds and two more beds to cope with overflow, five suites for general practices, x-ray services, a laboratory, physiotherapy, and an outpatients department where visiting clinicians and speciality nurses will conduct clinics. District nurses, occupational therapists and a medical social worker will also work from the facility.

There are a number of other rural-based integrated-care projects under way. One of these is with Kaipara Care in Dargaville for the multi-disciplinary management of diabetes, child asthma and frail elderly in a rural bicultural environment. There is also interest from communities such as West Coast, Gisborne, Eastern Bays and Southland to find ways for community-based providers, the hospital and local government to work together.

The Government is keen to foster a variety of different approaches that may serve to integrate care in rural communities. Some of these arrangements could mean changes to people's choice of service providers. Generally this will have community and provider support. However, that may not always be so. Because of this, care will be taken to ensure the following:

  • if an arrangement will cover everyone living in an area, then very careful and responsive consultation will be needed
  • if people will have to make a choice of which arrangement to use, it will be crucial they know what they are signing up to and are able to make free choices
  • people must be protected against organisations refusing to enrol individuals purely because of their need for services
  • the aspirations of Maori for more control over their health services need to be addressed
  • accountability and monitoring of access will be needed
  • provision needs to be made for ensuring that national policies are complied with
  • any extra costs for an integrated approach must be evaluated against the benefits.

Family health teams

Family health teams are currently being piloted in Waitakere, Eastbay and Otago. The pilots aim to provide a comprehensive family health team concerned not only with specific health problems, but also with broader social and cultural factors. This would involve, for example, assisting parents to get help from the appropriate services. It would also involve supporting and speaking for families, and co-ordinating different services for them if necessary. This concept, once evaluated, could be a useful model for application in rural areas.

Developing and maintaining skills in rural areas

Appropriate and well-maintained local skills for front-line care are critical to rural health.

Rural health and disability support service providers must be innovative and flexible in their efforts to develop and maintain skills.

This requires, firstly, that health professionals with the right training are recruited and retained in rural areas. Practitioners in rural and provincial areas need to have a wider range of skills than their city counterparts. This is a large part of the enjoyment and the challenge of rural practice. They need to have, for example, an understanding of community health systems, skills in initial assessment and emergency care and understanding of chronic disease management and disability support.

Once health professionals have been recruited to rural areas, it is important that they be able to continue their professional development. Ongoing professional development is needed for the safety of their practice, and also helps overcome any sense of professional isolation. Isolation raises other issues, such as the need for locum support, and whether the lifestyle is attractive for the rest of their family members.

The recruitment, retention and ongoing education of rural health professionals have all been difficult issues for many years, and they are being faced directly and positively. There are a variety of ways the current situation can be improved, and the Government is keen for these improvements to happen. There are already a number of local and national initiatives aimed at supporting the needs of local communities, including improvements in rural practices and the development of nurse prescribing. These generally involve improving training available for GPs and nurses in rural health centres, giving more attention to ways of retaining health professionals in rural locations, and making sure locums are available for them.

Clinical education, training and ongoing support

Undergraduate medical and nursing education includes attention to the basic knowledge and skills required in rural practice. This level of education imparts a general experience. More specific training for practice in rural areas is a focus for postgraduate study.

Universities and polytechnics vary in the extent to which they take account of the needs of rural communities when they select medical and nursing students. Health care funders, providers and communities need to express their requirements to these education providers. However, it should be noted that rural health is already an area of increasing focus in medical and nursing education.

Ongoing support and training of rural practitioners is also vital. A variety of initiatives are being developed to increase the support available to rural practitioners. Examples of developments in clinical education, training and ongoing support are presented below.

  • In early 1999 the HFA approved support for a Director of Rural Health based in the South Island. The director will work with South Island rural GPs to promote rural practice and liaise with training providers. Consideration is being given to supporting a similar post for the North Island.
  • The General Practitioners' Vocational Training Programme (GPVTP), purchased by the HFA through the Clinical Training Agency, is being re-oriented to be better at meeting rural health needs. From the year 2000, the programme will place more emphasis on the rural GP's role as part of a multi-disciplinary team delivering care to individual patients, and in carrying out proactive health programmes to improve the health and wellbeing of the people of that practice. The GPVTP will also investigate ways to enhance the recruitment and retention of trainees in rural practices.
  • The Dunedin School of Medicine is establishing a rural health network. The Dunedin School of Medicine will provide administrative support to the network as well as supplying visiting specialists to rural areas for teaching purposes. Part of the School's new approach to rural training includes undergraduate fieldwork in rural areas. It is proposed that through their training, students will be attached to practices in rural areas for periods of up to seven weeks in the fifth year of the course and for four weeks in the sixth year.
  • A new multi-disciplinary Diploma of Health Sciences (Primary Rural Health Care) is being offered by the University of Otago. The Diploma aims to enhance the skills of nurses and doctors in rural areas. The Clinical Training Agency aims to fund approximately 30 training places each year.
  • The Goodfellow Unit (Department of General Practice, Auckland Medical School) is contracted to provide education and peer support to rural GPs and practice nurses in the midland region of the North Island.
  • The Christchurch School of Medicine Department of Public Health and General Practice has a locum support service for practitioners in rural areas. A similar scheme is provided by Southlink Health Independent Practitioner Association network. Both of these schemes offer relief for rural practitioners to make it easier for them to get away for study and annual leave. It is anticipated that more programmes such as these will be developed.
  • Wider GP networks can offer more opportunities for fostering professional development. For example, the Northern Rural General Practice Consortium Inc (which has a membership of 54 GPs and 53 practice nurses, comprising 95 percent of all rural general practices north of Wellsford) employs a professional development facilitator to provide continuing medical education programmes and other ongoing training and development for its GP members. It also employs a practice nurse facilitator to provide continuing education, peer review and support services to its practice nurse members.
  • The Paediatric Specialist Services review is currently developing a network which will permit isolated paediatric specialists to have more regular contact with peers in order to reduce professional isolation and improve quality of care for rural children.
  • A further proposal under development by the Dunedin School of Medicine is the provision of a nationally recognised qualification for medical practitioners who staff rural hospitals. Learning aims would include the management of medical emergencies, resuscitation and stabilisation, and the transfer of patients to base hospitals.
Multidisciplinary Diploma of Health Sciences (Primary Rural Health Care)

Jean Ross and Dr Martin London, directors of Christchurch's Centre for Rural Health established in 1994, are adding another string to their bow of rural specialist services. With a good knowledge of rural practice issues and a broad rural health practitioner database, the rural health centre, urged on by the Clinical Training Agency, is introducing a Diploma of Health Sciences (Primary Rural Health Care) for GPs and nurses as part of its integrated rural health support package.

"We were aware of the challenges experienced by rural health professionals and their families in Canterbury and Westland. Research showed they were isolated and the consequent impact this had on the delivery of health services to rural communities,' says Jean.

The centre was initially set up to improve the quality of patient care in rural practices, but it has moved forward to emphasise the team approach for effective health delivery.

"The basis of the diploma is to advance the skills of the practitioners so they are clinically able to take on the diverse roles encountered in a rural environment and adapt their work practice to fit in with the community. On completing the diploma, GPs and nurses will either be in a better position to stay in the rural environment or have the ability to decide it is not for them.'

Three papers have been developed to date as part of the Diploma course. Advanced Rural Primary Care, initially run for rural nurses, has been broadened to include GPs. It covers clinical assessment and procedural skills to manage rural patient pre-hospital emergency care, develops advanced health assessment skills for nurses, and extends clinical skills relevant to rural practitioners.

The Rural Communities and Team Function paper develops an understanding of rural communities and skills to optimise the experience of life in a small community. The emphasis is on effective team function and integration in rural communities.

The third paper, Applied Clinical Rural Practice, begins in 2000 and is based on placement in rural practices with supervision and mentor input.

Nurse prescribing

Currently, the Medicines Act 1981 limits the prescribing of prescription medicines to medical practitioners, dentists and midwives. In May 1998 the Minister of Health announced that Cabinet had agreed to amend the Medicines Act to enable the formulation of regulations to:

  • extend prescribing rights to nurses and other defined groups of health professionals
  • designate health professionals who are able to select and administer specific prescription medicines, for particular classes of patients, when acting in accordance with standing orders.

Nurse prescribing is being introduced with considerable caution to make sure it is safe and works well. Initially it will be limited to certain paediatric and geriatric applications. There is considerable concern being expressed by GPs at this development. The Ministry of Health is working with all parties involved to make sure the implementation goes well and that people benefit overall. If the initial implementation of nurse prescribing is successful, nurses in rural practices could be one group for which granting limited prescribing rights may be a useful and cost-effective complement to the services provided by rural GPs. In many rural areas there are excellent working relationships between health professionals who support each other's work in the community. Extending prescribing rights in such an environment can strengthen the team and increase people's access to timely services.

As to the implementation of nurse prescribing, the Ministry of Health has established working groups comprising nurses, medical practitioners and pharmacists. These groups will define the scopes of practice and the generic classes of medicines that it may be appropriate for nurses to prescribe in the areas of child health (in the context of the family) and care of the elderly. The information provided by the working groups and wider consultation will form a basis for evaluating the benefits of safely extending prescribing rights.

Maori provider development

The increased number and diversity of Maori providers has been a feature of health changes since 1993.

Maori providers have an important role to play in rural service delivery. One example of how the Government is encouraging workforce development of Maori health professionals to meet the needs of Maori is through the Maori Provider Development Scheme.

The Government has committed funding over three years for Maori provider development to support the sustained growth of quality Maori providers of health services and to enhance the ability of Maori providers to deliver effective health services. A key element of the Maori Provider Development Scheme is to improve integration and co-ordination of health and disability support services for Maori, so that services are easier for Maori to use and are provided in ways that minimise the financial barriers to health care access. The establishment of mobile service delivery units - particularly for dental, primary care, child and youth health, and mental health services - which move within rural communities at specified intervals, aims to decrease the access and cost barriers that many rural communities face. For example, a caravan is being used to improve young people's access to dental care in Northland.

Te Puke Karanga Hauora Trust

As part of Pipiriki Marae, Te Puke Karanga Hauora Trust provides nursing services and health education services to isolated communities on the Whanganui River. These communities have populations which are predominantly Maori. Te Puke Karanga Hauora Trust also co-ordinates services provided by other health professionals.

The centre considers kaumatua wisdom and support to be a big bonus. Management has a monthly meeting with the community to discuss proposals and receive input. Manager Pet McDonnell says the service is a major asset for the community, taking in Tieke to the north and Jerusalem (Hiruharama) in the south, and all surrounding areas.

"We've been going for two years and I think we can now say the local community views the service as its own service; as a community-owned service.'

The centre services about 200 people, "depending on who's home,' and a number of tourists in the summer. Flexibility is the name of the game, she says; whanau may come home for a weekend and stay for a month.

"The old people now have access to a nurse at their doorstep, day or night. Someone is always on hand 24 hours a day. We have a vehicle for when people need to get to Wanganui Hospital's accident and emergency service quickly or to take them to the doctor at Raetihi. We also have a helicopter arrangement with the local Department of Conservation office and through them we have radio access to Tieke Marae, which we also service.

"We are currently devising an emergency plan for Tieke with Department of Conservation staff, and local people with boats who know the Whanganui River like the backs of their hands. The area is very isolated - you couldn't expect an outsider in a helicopter to necessarily find Tieke quickly in an emergency.'

Pet believes the service has given local people more of a sense of security than they had before. "In the past, if you had a heart attack you'd get to hospital, but if you had an asthma attack, you'd probably just cope as best you could. Now, we can get people to hospital quickly and safely.'

Networking, partnership and technology

New technologies are supporting big advances in many areas - health is no exception. Likewise, different agencies working together can make the sum significantly greater than the parts.

There are many ways we can use our health resources more effectively through networking and partnership between providers and between welfare agencies. Modern technology is an especially useful tool for people to work together. It means that networking can now occur at a distance, greatly reducing isolation for all who use it.

The Strengthening Families programme

The Government supports intersectoral initiatives that recognise the range of causes behind poor health and disability. This is goal 10 of the Government's Medium-Term Strategy for Health and Disability Support Services. The Strengthening Families strategy arose from Government's concern about the ongoing inter-generational cycles of disadvantage and their impact on children and families. There was also recognition by the health, education and welfare sectors that there were many common areas of concern - for example, the same clients in the same localities of New Zealand.

Service co-ordination at the local level

At the local level, service co-ordination has been developed to help people at the front line work more closely together. This is achieved through inter-agency case management, identifying gaps and overlaps in services, and joint initiatives to use resources more effectively. The initiative first involved health, education and welfare agencies and has now expanded to include other government agencies and community groups.

Local level co-ordination began with a pilot in 1996 and there are currently 54 local co-ordination groups covering the whole country, including rural areas such as the Bay of Islands, Central Hawke's Bay and Buller/Westland. Client feedback confirms that the collaborative approach is beneficial. In addition, the sectors have developed greater understanding of each other's services, and this provides opportunities to develop other intersectoral initiatives.

As part of the Strengthening Families strategy, a more preventative approach is being explored in three priority areas (Northland, East Cape and Porirua / Hutt Valley). The number of priority areas is likely to increase.

Family Start programme

Family Start is an intensive home-visiting programme for at-risk families which starts at birth. The Family Start service aims to build the strength and capacity of families and to ensure their children have the best possible start in life. Family Start is currently being run and evaluated in Whangarei, West Auckland and Rotorua. Additional funding for Family Start announced in the 1999 Budget will expand the programme to another 13 localities, including Kaitaia, Kawerau and Horowhenua.


Telemedicine is being trialled and increasingly used to allow specialist expertise to be more widely accessible. An early example was the Waikato teledermatology service, which involved communication between Health Waikato and one of its satellite hospitals, Taumarunui. This has now been extended to involve GPs and is part of an international trial. As well as diagnosis, telemedicine can include distance prescribing, and nurse field workers supported by telecommunication links with doctors.

The Starship Hospital has developed a telemedicine proposal to link paediatric specialists around New Zealand. This is being supported by HFA funding and the first task will be the formation of a national paediatric tumour board, to improve services to children with cancer. It is anticipated that telemedicine will increase rural practitioners' access to specialist paediatric advice.


The use of telephone and computer technology to gain access to radiology services provides significant opportunities to rural hospitals and health centres. Reading x-rays and CT scans remotely can be of particular value in determining whether or not a patient must be transported to another centre or not. It can also be of assistance where it is not feasible to have an onsite radiologist.

Difficulty in recruiting a radiologist led Coast Health Care to contract with a Christchurch-based radiology service allowing urgent x-rays to be scanned through to Christchurch and a consultation provided within 20 minutes. A radiologist and a sonographer visit Greymouth Hospital weekly. This initiative has increased the quality of radiology services and reduced the need to refer West Coast people to Christchurch.

Roadside to Bedside, the acute management system described earlier, will rely heavily on effective communication links and provider networks.

Visiting specialists and service networks

The different levels of health and disability support services need to be connected and to support each other through service networks. A good example of this in operation is the increasing use of visiting specialists in rural areas. This means that services are received by patients in their communities, and that the service is provided by a health professional who is experienced and has access to wider support networks. The visiting specialist services are particularly well received by disability support services consumers, who need to use these services often.

Hospital in the home

Provision of hospital-level care in the home may be an option for rural people in the future. A pilot project in Taranaki has commenced, which provides highly skilled nursing services to patients in their homes. Home-based care is being provided to patients who would normally be admitted to a hospital. This initiative is being trialled with patients relatively close to a base hospital. If it is successful, consideration could be given to whether this type of service could be used by rural people as long as skilled nursing, medical oversight and allied services are available.

Information sharing

Rural Health Network
Local solutions to local problems

"If you have seen one rural community, you have seen one rural community.'

Dannevirke Community Hospital manager Sharon Wards says local solutions to local problems are the way to go as no rural community is the same as another. But that doesn't mean communities shouldn't learn from each other, and with that in mind Sharon set about establishing the Rural Health Network.

"The future is for rural health initiatives to solve their own health problems for their own communities, but those communities need support. We bit the bullet and did it ourselves - no one else was going to do it for us.'

The network's inaugural conference was held at Dannevirke in August 1998. Delegates included managers, nurses, GPs and allied health professionals from both public and private sectors of rural health facilities. The conference developed a forum for sharing information about rural health services and best practice in the changing health environment. Sharon says common issues were the centralisation of health services and the different models of service provision. "It was great, we learned heaps. And the biggest plus was that we now have a list of contacts, and in each area there is someone to talk to about the issues surrounding rural health initiatives.'

A newsletter, with a detailed list of contacts, is being published as a resource kit for all those involved.

Innovations in Health and Disability Services in New Zealand

The Ministry of Health has developed a Web site focusing on innovative ways of delivering health and disability support services. This is called Innovations in Health and Disability Services in New Zealand ( The three areas on the Web site are Action and Innovation, Integrated Care and Best Practice. Initially only the Integrated Care site is expected to have an interactive component. Provider interest will be assessed before establishing this component.

This Web site could have the potential to enhance communications between rural health initiatives. If there is sufficient interest among rural practitioners, a specific rural site could be included either through incorporating rural care with one of these sections, or establishing a separate area for rural services. This could have an interactive component to facilitate the active exchange of ideas and information.

 Rural public health

There are a number of public health issues of particular importance in rural areas:

  • sewage disposal
  • water supplies (sufficiency and quality)
  • exposure to unsafe levels of agrichemical spraydrift
  • injuries and injury-related fatalities (people in rural areas experience a high rate of motor vehicle injuries and fatalities, and farm injuries)
  • the health consequences of serious rural housing need (particularly affecting Maori)
  • emergency management (particularly floods)
  • exposure to zoonotic diseases.

There will always be challenges associated with maintaining public health services in rural areas. Nonetheless, every effort must be made to retain viability of these services.

Government at the local, regional and national levels is working to protect and enhance public health by improving water quality monitoring and providing information, for example, on food safety.


The rural sector is and will remain an essential part of the economic and social fabric of New Zealand. Rural health and disability service requirements must continue to be met - they are an essential part of New Zealand's overall health services policy framework. This framework is designed to meet a common goal - ensuring real gains in the health status of all people so that all New Zealanders enjoy good health and maximise their potential to live life to the full.

Delivering services to the dispersed rural New Zealand population has always presented particular challenges. The Hospital Services Plan builds certainty and security into rural hospital services. The progressive implementation of the PRIME scheme and the new framework for acute and emergency services set out in Roadside to Bedside will ensure continued access to high quality emergency services for the years ahead. The Government already pays more to ensure this continued availability of rural hospital and rural GP services. Recently a rural pharmacy allowance was introduced. New funding for child health services announced at the end of 1998 covers new preventative services. There is an emphasis in funding arrangements on better health outcomes for young Maori and others who have not fared so well in health for sometime. Services for children with disabilities living in rural areas are also included.

New service initiatives, from small health centres led by nurses through to state of the art facilities for new community hospitals, are springing up all over New Zealand. Integration of health services offers ways to achieve the ultimate win/win situation - better, less-stressful outcomes for the patient and better use of the taxpayers' health dollar. The Government wants to encourage community and provider partnerships with various government agencies in developing innovative quality integrated care proposals. The approach adopted by the Government incorporates the flexibility needed for local solutions to local issues to come forward. The Government is also conscious of the needs of the rural health services workforce.

The use of modern technology, including telemedicine and teleradiology, to enhance health outcomes for rural people is also to be encouraged. This can reduce the impact of distance and geographical barriers as well as allow more specialist expertise to be available to rural people. A Web site being developed by the Ministry of Health has the potential to enhance communications and spread knowledge of best practice solutions around rural New Zealand.

This Rural Health Policy paper explains its approach with examples of innovative new developments actually happening now in the rural sector. Building on initiatives like these, the Government seeks to create the environment that encourages the best health and disability support outcomes for rural New Zealanders wherever they live. /P>

If you want to discuss health and disability support services for your community, please contact:


Senior Locality Manager
Health Funding Authority
Private Bag 92-522
Phone (09) 357 4300
Fax (09) 357 4301

Hawkes Bay/Tairawhiti,

Senior Locality Manager
Health Funding Authority
PO Box 10-097
Phone (04) 472 7633
Fax (04) 472 7639

Waikato/Bay of Plenty/ Taranaki

Senior Locality Manager
Health Funding Authority
PO Box 1031
Phone (07) 834 4500
Fax (07) 834 3355

Canterbury/West Coast

Senior Locality Manager
Health Funding Authority
PO Box 3877
Phone (03) 372 1000
Fax (03) 372 1015

There is a senior locality manager for each of the following service areas: disability support, mental health, personal health, and public health. If you wish to discuss a range of services for your community, contact the Senior Locality Manager, Personal Health Services in the first instance.

Measures of health status

Table 1: Comparison of life expectancy of total urban and total rural populations

  Urban Rural
   Male Female Male Female
At Birth 74.4 79.6 74.3 79.9
At 65 years 15.4 19.0 16.1 19.5

Table 2: Comparison of life expectancy of urban Maori and rural Maori populations

   Urban Rural
   Male Female Male Female
At Birth 67.6 72.5 66.4 71.0
At 65 years 12.5 15.4 12.4 14.0

Table 3: Comparison of life expectancy of urban non-Maori and rural non-Maori populations

   Urban Rural
   Male Female Male Female
At Birth 75.0 80.2 75.8 81.5
At 65 years 15.6 19.2 16.4 20.1

Source: Abridged Life tables, 1995 - 97, Department of Statistics.

Note: The rural population includes small towns of less than 10,000 population.

Organisations and individuals who made submissions on consultation draft Rural Health Policy

Sue Grimwood and Pam Richardson, Akaroa Health Focus Group

Florence Annison

Joe Bell

J Geoff Carleton, Carleton's Pharmacy

Russell J Checketts, Chairperson, Central Advisory Committee on Health

Kevin Roche, Committee Secretary, Christchurch City Council

Dr Martin London, Dr Cheryl Brunton and Professor Les Toop, Department of Public Health and General Practice, Christchurch School of Medicine

Jim Johnstone, Clutha Agricultural Development Board

Juno Hayes, Mayor, Clutha District Council

Robyn Steed, General Manager, Community Services Health Waikato Ltd

Dr Derek Gibbons, Chairman, Dargaville Medical Centre

Matthew Preston, Medical Advisor, Eastbay Health

Dr Gill Boddy, Executive Director, Family Planning Association

Graeme Hight, Taranaki Province, Federated Farmers of New Zealand Inc

Cr Johnson Davis, Health Policy Co-ordinator, Far North District Council

Ross Haldane, President, Golden Bay Province, Federated Farmers of New Zealand Inc

Iris Marshall, Southland, Women's Division Federated Farmers of New Zealand Inc

Alistair Polson, Vice President, Federated Farmers of New Zealand Inc

Ellen Ramsay, Health Convenor, Women's Division Federated Farmers of New Zealand Inc

Nancy Robertson, Social Policy Committee Chairperson, Southland, Federated Farmers of New Zealand Inc

M Appleton, President, Franklin Community Care Committee Inc

Ngawai Webber, Chairperson, French Pass Community Health Group

John Lee, Golden Bay Community Health Group

Jacqueline Goyen, Secretary/Treasurer, Grey Power Central Otago Association Inc.

Don Guadagni, Guadagni Surgical Ltd

Clem Hall

Robyn Stent, Health and Disability Commissioner

Dr Don Quick, Clinical Director, Community Mental Health Service, Healthlink South

Fiona Robertson, Rural Mental Health Team, Healthlink South Ltd

Bridget Allan, Chief Executive Officer, Hokianga Health Enterprise

John Chaffey, Mayor, Hurunui District Council

Wayne McLean, Chair, Maori Health Commission

Dr Cliff Mason

W ten Hove, Chief Executive Officer, Masterton District Council

Ministry of Agriculture and Forestry

Miriam Clark, Manager, Nelson Community Health Council

Karen Guilliland, Director, New Zealand College of Midwives

Liz Hicks, Executive Officer, National Council of Women of New Zealand

Judy Cole, Chairperson, New Zealand Federation of Country Women's Institutes

Eileen Austin, Secretary, New Zealand Nurses Organisation

Helen Kingston, Chair, New Zealand Rural GP Network

Dr Graeme Fenton and Adrienne Harris, Treasurer and General Manager, Northern Rural General Practice Consortium Inc.

Ingrid Cheer, Norsewood and Districts Health Centre

Dr Bruce Phillips, Otorohanga Medical Centre

S Lyn Reardon, Secretary, Patea and District Community Medical Trust

Public Health Association

Helen Axtens, Chairman, Reporoa Community Health

Jean Ross, Rural Nurse Co-ordinator

Cr Steve Chadwick, Chair, Community and Social Policy Committee, Rotorua District Council

John Burton, Rural Representative to Council, Royal New Zealand College of General Practitioners

Cath Webber, Royal New Zealand College of General Practitioners

John Thompson, Chief Executive Officer, Royal New Zealand Plunket Society Inc.

F J Jeffrey, Roxburgh Medical Services Trust Board

Ruapehu District Council

Weston Kirton, Mayor, Ruapehu District Council

G.E and L F Sharland

Rachel Broomfield, Policy and Development Planner, Southland District Council

Kate Motion, Membership Services Co-ordinator, South Link Health Inc

Anne Hilson, Strategic Planner, Tararua District Council

J.J O'Halloran, Chairperson, Te Kuiti 4H Community Trust Board

Paora Howe, Branch Manager, Social Policy, Te Puni Kokiri

PJ Tauroa, Te Runanga O Whaingaroa

Kamiria Gosman, Managing Director, Tuwharetoa Health Services Ltd

Allen Hair, Chair, Wairarapa Community Health Council

Denise Udy, Hospital Services Manager, Wairarapa Health

Chris Clarke, Manager, Mental Health Services, Wairarapa Health

Paul Davey, Chief Executive, Waitomo District Council

M W Jeffries, Chairman, Waverley Maternity Home Services Inc


Senior Locality Manager
Health Funding Authority
Private Bag 92-522
Phone (09) 357 4300
Fax (09) 357 4301

Hawkes Bay/Tairawhiti,

Senior Locality Manager
Health Funding Authority
PO Box 10-097
Phone (04) 472 7633
Fax (04) 472 7639


Senior Locality Manager
Health Funding Authority
PO Box 5849
Phone (03) 477 4222
Fax (03) 474 0080

Waikato/Bay of Plenty/ Taranaki

Senior Locality Manager
Health Funding Authority
PO Box 1031
Phone (07) 834 4500
Fax (07) 834 3355

Canterbury/West Coast

Senior Locality Manager
Health Funding Authority
PO Box 3877
Phone (03) 372 1000
Fax (03) 372 1015