Perhaps it is time to require an equity impact statement on new policies so that the people who most need services have a hope of obtaining them.
Recently, I’ve started working in a rural community, and I am reminded yet again how beautifully our system is designed to maximise disadvantage.
Despite my GP superpower of duct-taping the system together, and plugging the holes with bloody-minded enthusiasm, systemic disadvantage seems as relentless as black mould. The cycle goes something like this.
You live in the country, so this means there are less health professionals. There is also more disease, so the competition to see said health professionals is high. People are older, sicker and have fewer services, so the GPs are under the pump.
The response in Canberra is to “unleash the power of the health workforce”, undertaking a series of initiatives to improve “access” by opening up algorithmic prescribing in the local pharmacy.
In rural communities, there are less pharmacists per 100,000 people, and those 100,000 people are spread over a wide area. Even if a pharmacist prescriber happened to be within cooee of your town, the 20 conditions they are trained to treat are unlikely to be yours, because anything simple like conjunctivitis has probably already been managed by the highly competent rural person and their family.
This is without taking into account the pharmacy prescribing algorithms, which are based on RCTs conducted in (mostly) urban environments, meaning they are less relevant, and potentially more harmful, to rural people.
This is particularly the case for Aboriginal communities. I doubt pharmacy training in dermatology, brief as it is, ever considers how different a rash looks on black skin, let alone how prescribing needs to be adjusted.
Not only are there less services, and less health professionals, sick people are more likely to be poor.
Being poor increases your risk of becoming sick, for a variety of reasons, and being sick can certainly cause poverty. Poverty reduces access, especially when there is no public transport and the cost of services and medications are high. Given rural people are, in general, sicker and tend to avoid GPs unless absolutely necessary, there is a greater need for longer consultations for complex care, which (of course) are disincentivised by Medicare.
Related
Digital poverty
The “solution” to the access problem is often to put processes and options online.
There are a few problems with this, of course. Literacy is lower in rural areas. Of the adults with only secondary education, 60% have literacy too low to manage the requirements of everyday life. Sixty percent of people with fair or poor health have literacy too low to manage the requirements of everyday life. Sixty percent of those whose first language is not English have literacy too low to manage the requirements of everyday life.
Even if these people can read the words, they may well be unable to understand what the words mean.
Take the NDIS application form (please). The literacy level required to read the application guide is around that required to read Hamlet, and the language is just as obscure.
For instance, step one requires you to “connect with an NDIS partner”. How can such a short sentence be so confusing?
The form itself is worse. Try this statement, and see if you can make sense of it.
Parental responsibility means all of the duties and powers that parents have in relation to a child under 18 years of age. To have parental responsibility, you must not have ceased to have parental responsibility due to an order made under the Family Law Act 1975 or a law of a State or Territory.
Of course, in order to access care under NDIS, there must be options for care available, and you must have the health literacy to know the NDIS exists. You also need a computer. And wifi. And the ability to manage digital processes, tasks and digital problem-solving.
You guessed it, there is substantial digital poverty associated with being sick, poor and rural.
Solutions
I’m told in Scandinavia there is a program of travelling social workers who tour around in bureaucratic buses, solving issues for people who are unable to access social services.
There is no reason we can’t have travelling Centrelink workers, or add a social worker to our Flying Doctor network.
I do know that cumulative disadvantage is cumulatively wrong. With all the enthusiasm around how digital innovation will drive change, it is easy to miss how none of it will reach Mrs Jones, Lot 34245 (the one with the sheep on the mailbox) who needs help to get out of bed.
Professor Trish Greenhalgh describes a category of health service that she calls “strategically traditional”.
Such a service recognises that there are people who cannot access digital gateways, services and forms, and should be supported to manage their needs with human help. Unfortunately, such help has disappeared from rural communities, as digital services overtake face-to-face.
Privileged people have multiple resources above and beyond money and education. They have the social connections to reach out for help, the privilege to be persistent advocating for the services they need, and have ready access to all the paperwork they need to complete lengthy application forms. They also have a series of new services, squabbling for scope like seagulls on a chip.
People living with marginalisations need a person not an app.
The only person likely to be available to them is the GP, but the GP who does long consultations is disappearing from the healthcare landscape. These GPs are reputationally targeted if they don’t bulk bill and financially disadvantaged if they do.
The cumulative health inequities for rural people are unacceptable. Perhaps it is time to require an equity impact statement on new policies so that the people who most need services have a hope of obtaining them.
Professor Louise Stone is a GP in Canberra and an academic at Adelaide University. A collection of her research, policy and teaching materials can be found at drlouisestone.com.
