COMMUNITY
PARTICIPATION IN RURAL HEALTH SERVICES
Sue Grimwood and Martin London
Centre for Rural Health
2003
© Centre for Rural Health August 2003
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means electronic, mechanical, photocopying, recording or otherwise without the prior permission of the publishers.
PUBLISHER
Centre for Rural Health
Department of Public Health and General Practice
ChristchurchSchool of Medicine and Health Sciences
University ofOtago
New Zealand
ABOUT THE CENTRE
The Centre for Rural Health was established late 1994. It was funded (initially by the Southern Regional Health Authority, then the Health Funding Authority and finally by the Ministry of Health) for a series of projects to support rural health services and community involvement. The Centre was under the directorship of Martin London and Jean Ross from, respectively, rural general practitioner and rural nurse backgrounds. It was also known as the National Centre for Rural Health. The Centre closed in late 2002, with final publications being completed in 2003. The resources and reports created under the auspices of the Centre were uploaded mid 2003 to be available indefinitely.
AUTHORS
Sue Grimwood RGON PGDipHSc (Primary Rural Health Care)
Staff Nurse, AkaroaCommunityHospital
Coordinator, Community Akaroa Resource Centre
Coordinator, Safer Community Council, Akaroa/Wairewa
Martin London MB, ChB, Dip Obst, FRNZCGP
Director, Centre for Rural Health
Senior Lecturer in Primary Rural Health, Department of Public Health and General Practice, Christchurch School of Medicine and Health Sciences, University of Otago
General Practitioner, Main North Road Medical Centre, Papanui, Christchurch
CITATION DETAILS
Please cite this work as follows:
GRIMWOOD Sue and LONDON Martin (2003) Community Participation in Rural Health Services Centre for Rural Health : Christchurch, New Zealand
Accessible from
ISBN 0-9582475-3-6 (Internet)
page i
ACKNOWLEDGEMENTS
The authors wish to acknowledge the contribution made by all rural communities who have, by their endeavours, retained their healthcare professionals and improved the future delivery of primary healthcare services within their areas.
We are indebted to those who shared their stories in this booklet for the benefit of those who may decide to play an active role in their own communities.
We are also gratefulto Shelley Jones for her editorial advice and assistance in formatting this booklet.
Sue Grimwood and Martin London 2003
© Centre for Rural Health
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CONTENTS
Acknowledgementsi
Contentsii
Using the Bookletiii
SECTION ONE : Introduction1
Lessons Learned in this Study2
Lessons Learned Internationally5
Key Points for New Zealand6
SECTION TWO : Communities and their Achievements7
Fox Glacier8
Hanmer Springs14
Great Barrier Island 19
Amuri 24
Roxburgh30
Opotiki36
Lawrence40
Takapau49
Kaitaia56
References62
Appendices
- Synopsis of International Literature Review
- Rural Teamwork
Sue Grimwood and Martin London 2003
© Centre for Rural Health
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USING THE BOOKLET
Small endeavours can have significant benefits in ensuring the retention and security of rural primary healthcare providers and rural health services. This booklet shares a number of communities’ experiences in providing and preserving primary health care services.The communities are presented in the order of their base-population size rather than the extent of community action.
Each community is described in its own chapter, which includes success factors and cautionary tales. The chapters are essentially ‘snapshots’ of the results of partnership and involvement when health professionals and communities have chosen to proactively secure their primary health services. We hope that readers find these chapters a ‘recipe book’ of activities and processes that they can adapt to their own situation. There is space inside the cover of each chapter for you to note ‘relevant points for my community/service’.
Any community considering moving towards achieving secure rural health services and wishing to learn more details of the experiences of others are encouraged to make contact with some or all of the contributors. Contact names and addresses are provided for each community.
“No one was more mistaken than he who did nothing because he thought he could only do a little”
Edmund Burke (1729 –97)
DON’T DO NOTHING!
Sue Grimwood and Martin London 2003
© Centre for Rural Health
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SECTION ONE
INTRODUCTION
LESSONS LEARNED IN THIS STUDY
LESSONS LEARNED INTERNATIONALLY
KEY POINTS FOR NEW ZEALAND
Sue Grimwood and Martin London 2003
© Centre for Rural Health
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INTRODUCTION
Many rural communities’ primary health care services, including local hospitals, can be threatened with change, restructuring or closure. Some have been struggling for years just to maintain the status quo. Although it may be considered the responsibility of central and regional government to provide primary health care services, many communities decide to play an active role to fend off or deal with threats to their services.
There are various ways in which communities may help to achieve secure rural health services. Lessons from within New Zealand are set out on the following pages, along with lessons from the rural communities internationally.
Possibilities that have been tried successfully in New Zealand rural communities include:
- things which cost nothing beyond time and enthusiasm
- things that cost money as well as time and commitment.
LESSONS LEARNED IN THIS STUDY
THINGS WHICH COST NOTHING BEYOND TIME AND ENTHUSIASM / 1.Using the service
It is far easier to justify moving extra resources towards a service if it is seen to be actively used by the whole community. Most after hours services are heavily cross-subsidised by daytime services. The service is harder to sustain if it is only used asemergency back-up.
2.Ensuring regular communication between community and service providers
Formal communication between the community and the doctors, nurses and other practice staff (e.g. through community health committees) helps the practitioners to appreciate community health concerns and the community to appreciate the limitations on the practitioners’ capacity to respond. Regular dialogue is an exercise in matching realistic expectations of the community with reasonable demands on the service.
Sue Grimwood and Martin London 2003
© Centre for Rural Health
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- Accepting the need for time-off for the practitioners
THINGS WHICH COST NOTHING
BEYOND TIME AND ENTHUSIASM /
- Supporting rural clinical education
Welcoming students into the community and ensuring they have a chance to meet people and participate in events will make their attachment more enjoyable and build for them a positive image of a career in rural health (e.g. ask them in for a meal, take them hunting, include them in a muster!).
Student accommodation can be a problem in rural areas. Perhaps the community can find affordable solutions.
Some communities have proposed scholarships for local students to study in health care in return for service back in the community when fully trained.
Raising the vision of rural high school students to study for health care professions can increase the pool of those more likely to choose a career in rural practice.
- Making locums welcome
- Interacting with the politicians
THINGS WHICH COST MONEY
AS WELL AS TIME AND COMMITMENT / 7.Purchasing equipment and/or resources
Service clubs, raffles, fund-raising drives, donations, bequests, are a few of the ways in which expensive medical equipment can be bought for the community and used by the service; x-rays, defibrillators, physio equipment are some examples. Others include meeting education costs to upskill practitioners, e.g. nurses taking on advanced roles.
8.Providing accommodation
Houses for doctors or rural nurses, flats for students, registrars or locums – it’s all been done before. Would it make a difference in your community?
9.Providing premises
Ownership of medical premises threatens to lock practitioners into a community, and may put them off rural practice. Many communities have provided facilities in order to smooth the entry of doctors to rural practices.
10.Forming a community trust to run the service and employ the staff
This is a bigger commitment but is an opportunity for a community to really take charge and negotiate contracts with providers. Increasing numbers of communities are taking this course.
IN GENERAL /
- Using or creating the chance to get to know other people in the community
Sue Grimwood and Martin London 2003
© Centre for Rural Health
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LESSONS LEARNED INTERNATIONALLY
A literature review undertaken in 2001 by Simon Bidwell for the Centre for Rural Health identified problems for delivery of rural health services including rurality, socio-economic disadvantage, occupational related health problems and maldistribution of healthcare professionals. He also established success indicators as those providing an improvement in health outcomes, sustainability, security and local integration of primary health services and providers.
Bidwell found that factors influencing the successful development of models in rural primary healthcare were dependent on the multi-skilled roles of health professionals and the commitment to rural nurse training and support. Retention and recruitment of physicians was enhanced by having appropriate facilities, a supportive, professional environment, sustainable resources, decentralisation of healthcare training and community strengths.
However challenges influencing successful models included funding limitations, inadequate resources, lack of community experience and community knowledge, overworked service providers and the lack of integration and cooperation from health service providers.
Bidwell explored models from Australia, America and New Zealand, which are summarised in the Appendix. Key points from New Zealand models are outlined overleaf.
Sue Grimwood and Martin London 2003
© Centre for Rural Health
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KEY POINTS FOR NEW ZEALAND
Bidwell (2001) found success for New Zealand models incorporated the following factors:
- local leadership
- local commitment
- involvement of the GPs
- operational flexibility.
He also acknowledged that community involvement and empowerment were factors in contributing to the successful retention and recruitment of health professionals.
In consideration of these points, some rural communities may wish to increase their level of participation in securing a sustainable primary healthcare service for their locality.
Some communities’ actions have been to support their local GP to ensure the retention of primary healthcare services, which has required nothing more than time and enthusiasm. Others have invested financial resources, often establishing community trusts, purchasing buildings and providing accommodation for health professionals.
The communities contributing to the booklet have indicated that collectively they managed to bring about positive changes for themselves with:
- strong leadership,
- community buy-in,
- commitment,
- and, above all else, belief in themselves and the process.
Sue Grimwood and Martin London 2003
© Centre for Rural Health
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SECTION TWO
COMMUNITIES AND THEIR ACHIEVEMENTS
This section provides examples of models developed by New Zealand communities to retain and secure their primary healthcare services.
1. FOX GLACIER Population 250
2. HANMER SPRINGS Population 850
3. GREAT BARRIER ISLAND Population 1146
4. AMURI Population 1568
5. ROXBURGH Population 2200
6. OPOTIKI Population 2400
7. LAWRENCE Population 3400
8. TAKAPAU Population 4000
9. KAITAIA Population 30,000
Sue Grimwood and Martin London 2003
© Centre for Rural Health
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FOX GLACIER
“Local solutions for local circumstances. Secure a house, ensure primary health services.”
A model of commitment and some financial contribution from a community to provide accommodation for a district nurse (later a rural nurse specialist) in the absence of a resident General Practitioner.
Population : 250
FOR FURTHER INFORMATIONSue and Colin Peterson
Phone03 751 0818
/ Carrol Browne
Phone03 751 0825 (work)
03 7510891 (home)
Sue Grimwood and Martin London 2003
© Centre for Rural Health
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Relevant points for my community/service:
Sue Grimwood and Martin London 2003
© Centre for Rural Health
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FOX GLACIER
A small town close to the Fox Glacier servicing a tourism industry, located on the West Coast of the South Island, 171km south of Greymouth (430km from Christchurch). That Fox Glacier is extremely remote and a major tourist thoroughfare impacts significantly on its health services.
PRECIPITATING FACTORS FOR CHANGE
The community risked losing nursing services 8-9 years ago. With the closest GP based at Whataroa (60km or 40 minutes north) there was some security in having a nurse based at Fox Glacier. The Area Health Board told the community that if there was no house available for a nurse, services would be discontinued and there would be, therefore, no locally based primary health care. (Accommodation at Fox is at a premium with a shortage of rental houses).
EXISTING COMMUNITY ORGANISATIONS
- No health organisation existed.
Leadership and Community Mobilisation
Initially:
- Locals formed a committee to explore options and to investigate purchasing a house for a nurse.
Latterly:
- Exploring options for refurbishment or replacement of the community owned house provided for a nurse.
New Entity Formation
- Fox Glacier Community Trust.
Sue Grimwood and Martin London 2003
© Centre for Rural Health
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Goals of the New Entity
- To obtain a house to accommodate a nurse, retaining and preserving primary healthcare services for the future.
- Latterly: to refurbish or replace the original house for the nurse.
- To preserve accommodation for a health professional within the area ensuring the retention of a nurse, primary healthcare services and the ‘special area’ designation – long-term.
Government Agency Involvement
- Westland Health Board, then West Coast District Health Board.
- Westland District Council.
Fundraising
- Initially the community raised funds to purchase a Ministry of Works house that was moved onto a local site. An affordable rental helped to service the mortgage.
- Latterly the rental was insufficient/inadequate to meet ongoing maintenance requirements. The District Council has agreed to meet the refurbishment costs of (approximately) $70,000.00, with the community relinquishing their equity ($60,000.00), to the Council.
- Community and philanthropic trusts have funded the purchase equipment (e.g. defibrillator) for the volunteer ambulance service.
Critical Success Factors
- A community working together.
- The Trust’s provision of a house has enabled nursing services to be retained within the Fox Glacier area.
- Working with the District Council to secure long-term accommodation for a nurse.
- Transferring the house to the Council on the understanding that they would carry out the refurbishment, bringing it up to standard, and taking on the responsibility for ongoing maintenance. (The Trust saw this as being a major drain on scarce resources in the future due to the type of construction of the house).
- The Council agreeing to clear the remaining mortgage as part of the arrangement.
- Changing the rental agreement so that the nurse and Health Board negotiate this within the nurse’s salary package. The Health Board now has the responsibility of reimbursing the Council. Previously, the commercial nature of the Trust’s ownership of the house prevented the Trust from negotiating rental with the Health Board or for inclusion within any employment package.
- The volunteer ambulance service is an integral part of primary healthcare provision. The nurse and ambulance volunteers provide complementary services, support for each other and ‘teamwork’.
Cautionary Tales
- At times a committee needs to make decisions that may be seen as the best solution for the retention of their services, but may not have unanimous approval from all within the community.
- Be prepared, negotiations may be difficult and may take time.
- Always be vigilant. Decisions may be made from outside your immediate area, particularly when employment of service providers and the provision of services are made from a distance.
Salient Challenges
- Ensuring that the West Coast retains its special area status in the foreseeable future.
- Although the committee has secured the right to purchase back the house at a favourable price if Council decides to relinquish this role/involvement/ support for the provision of primary healthcare, the community is no longer the landlord for the house. This may prove to be a challenge for the community in the future.
- Retaining trained volunteers for the ambulance service – in small communities ensuring adequate volunteer staff coverage (particularly during daytime hours where it can no longer be expected that workers will be able to automatically respond to call-outs) – may be a challenge. This is, in part, due to the socio-economic circumstances of rural businesses, employers and employees.
- As there is no dedicated St John’s ambulance station at Fox, volunteers are not eligible for any remuneration.
- The Fox Glacier ambulance service has found an innovative solution which goes some way towards ensuring the service will be covered. The ambulance service is assigned a volunteer alpine guide for a 24-hour duty every ten days. This assignment negates the requirement for alpine guides to revalidate their first-aid certificates every two years – a reciprocal benefit.
- Lack of health resources continues to be a challenge for rural areas. Resource allocation tends to under-estimate the costs to the rural communities incurred by visitors and seasonal workforce changes in rural areas.
Achievements in Community health SERVICES