Wonca World Rural Health Conference Gramado April 2014

The WONCA WORKING PARTY on RURAL PRACTICE is the rural working group of the world organisation of academic associations and national colleges.
Amongst other work it runs regular conferences and Gramado in Brazil was host to the 12 th WWPRP conference.

The picture above is of Carlos Grossman and his wife Doris, he was heralded during the conference as the father of family medicine in Brazil, I spoke to him about why as a cardiologist in the 1970s he had decided to set up a family medicine programme.

His response was both simple and profound : ” We need to be close to the people.”

Is there a better explanation ?

Rural people are disadvantaged from the outset because of distance, Carlos Grossman recognised it is essential to have health care that is provided close to the people, by a professional trained to engage closely with them in their work and family life, a professional who shares the closeness of the community. This shared experience, also identified by McWhinney as a essential part of family practice, brings with it opportunities for fantastic work in supporting people to live happier and healthier lives.

It is a phenomenal thing to come to a realisation that the culture you work in as a GP is substantially different from that of other GPs, and the question of what it means to be a “rural” GP is worth a later exploration, suffice to say being able to spend time with like minded but different people, with a richly diverse way of dealing with a common set of challenges was not only interesting but I suspect will prove useful in the New Zealand context.

My task now is to share some of the ideas that were shared with me during the event.

For those of you who “twitter” searching through my recent tweets using #nzrgpn you will be able to find slides and comments from the main speakers.

Consider following me @opotikigp and @ruralwonca for future links and conversations about rural health.

Rural Resilience

“He taru kahika” – Walk on, it is only summer rain falling – (Maori Proverb about resilience.) 

Resilience and sustainability are going to be the “buzz words” of 2014 I suspect. 

Rural communities in the 21st Century need to build resilience and as rural health providers can be powerful contributors to that work. 

They need resilience because they are facing the challenge of climate change.

They need resilience because they are facing economic pressure. 

They need resilience because they are getting smaller.

They need resilience because they are politically marginalised. 

They need resilience because no-one else is going to be there when push comes to shove. 

 

The New Zealand primary system in rural areas particularly depends on small businesses owned and operated by GPs – this competitive model of providing care is prone to inefficiency and reduces resilience as what is right for a business is often not what is right for a community. Competition between providers may result in “lean” businesses, but people’s needs are often sacrificed and long term planning and development takes second place to profit and short term gain.

PHOs and DHBs mainly show little or no regard for the long term future of primary care services, and time and time again we hear of practices closing, amalgamating, or struggling from locum to locum with little or no help or support from the system that is supposed to be responsible for the care of the community. 

As a profession we take responsibility for the whole person, we walk the talk when we adopt the bio-psychosocial model of care – we approach the individual and their family in a holistic way and address their physical, emotional, and spiritual needs to enhance their sense of wellness. Increasingly we need to do this for communities as well – people need communities to live and work in, and an unhealthy community makes life worse for everyone. 

It may seem too hard to begin to embrace the task of developing sustainable, well connected communities in which our patients can live – the good news is that it starts with ourselves as a community of rural providers. 

Small towns and communities may have rosy reputations as “rural idylls” but those of us that live in them know the truth that many small communities are exclusive, self absorbed, toxic to change and intolerant of difference. Financial sustainability of small business in small communities is marginal and a competitive business model adds stress into an already stressed work environment. Rivalries are not diluted by the sense of anonymity and distance that can be achieved in larger places, individual and generational grudges can develop and tend to be sustained. 

Health workers are not immune to these failings, we can develop professional jealousies and anxieties that make us inaccessible to others, and cut us off from our fellow health team members. 

However there are great examples of how we can do better.

In preparation for the upcoming conference in Gramado (http://www.woncarural2014.com.br/ingles/index.php) the Wonca Working Party for Rural Practice has been discussing the role of rural hospitals in communities and disaster preparedness. It is heartening to see initiatives like Arran Resilience (http://www.arranresilience.org.uk) showing how it can be done – if you have “the spark!” (http://www.globalfamilydoctor.com/News/RuralRoundupItsallaboutthepeople.aspx) 

It is also important that rural providers, despite being intensely busy day to day, become involved in national networks.  We bring a unique perspective to these tables and without our involvement our communities will be less visible, by being involved we can help make the people who have power focus on the resilience of our communities. This is what the New Zealand Rural General Practice Network (http://www.rgpn.org.nz/) is all about, linking together rural providers nationally and in combination with the Rural Health Alliance Aotearoa (http://www.youtube.com/watch?v=qHBcZV6Lzdg) bringing communities of interest together to keep rural health and wellness on the agenda. 

It doesn’t have to be so hard. Ask yourself – how often do you sit down with the other health providers that work in your area and share a cup of tea? There is a wealth of expertise in your neighbours that can be learnt from and built on, and you have a shared experience of care and can support each other in your work. Make 2014 the year to take advantage of your networks, put aside past grievances, pull up your big boy / girl  pants and get together for a chat.