In conversation with National Rural Health Commissioner Ruth Stewart

Professor Ruth Stewart

New National Rural Health Commissioner Ruth Stewart is committed to tackling the health inequities faced by people living in rural and remote Australia and ensuring they get access to quality healthcare.

“The major challenge for rural and remote Australia is that health outcomes are far poorer than they are for urban populations,” Associate Professor Stewart says.

“Our access to healthcare is restricted and the health literacy in rural and remote regions is reduced.”

Associate Professor Stewart was appointed Australia’s new National Rural Health Commissioner in July, replacing inaugural Rural Health Commissioner Professor Paul Worley, who held the position from November 2017.

The role, established to help reform rural health in Australia, provides policy and strategic advice to the Federal Minister responsible for rural health, Mark Coulton, and the Commonwealth Department of Health.

The independent Commissioner’s Office works with rural and remote communities, the health sector, universities and across all levels of government to improve rural health policies.

“I see the role as engaging with rural and remote communities and the key stakeholders in rural and remote health,” Associate Professor Stewart explains.

“Engaging with them to find out what their issues are, what their suggestions are, what their problems are and formulating, from that engagement, advice for the Minister and Department of Health.”

Associate Professor Stewart grew up in country Victoria and studied medicine at Melbourne University.

Together with her husband, Dr Anthony Brown, also a GP obstetrician, she lived and worked in Camperdown for more than two decades, running a rural practice.

Her advocacy to reform rural health in Australia traces back even further, to when she moved from her hometown of Tatura to boarding school in Melbourne and was struck by people’s lack of knowledge about rural and remote communities.

“I was also struck by their condescension towards rural people, as if rural people, just by being rural, were somehow less clever and less deserving of attention and autonomy.”

Associate Professor Stewart moved to Queensland in 2012 to take up the position of Director of Rural Clinical Training and Support at James Cook University’s School of Medicine.

She worked clinically as a GP obstetrician in Mareeba and on Thursday Island, where she has lived for the past five years. She has held Board positions with the Australian College of Rural and Remote Medicine (ACRRM), the Torres and Cape Hospital and Health Service, the Rural Doctors Association of Australia and the Tropical Australian Academic Health Centre.

Associate Professor Stewart says her longstanding rural health advocacy is underpinned by her clinical work in rural and remote Australia and informed by engaging with residents and communities.

“It’s the people of rural and remote Australia,” she says when asked what continues to drive her to improve healthcare for people living out bush.

“The people I know. The people I haven’t yet met whose stories I know. I’ve seen a great deal of Australia, and I love the land. I feel a deep sense of connection with the land and I just really enjoy the people who I meet in rural and remote communities. I’m a rural person. I get the way people think and when you’re a GP you don’t have superficial conversations with people; you talk to them about those things that matter the most to them, what’s closest to their hearts. “

Disappointingly, Associate Professor Stewart says the health inequities facing rural and remote Australia endure.

“As a rural resident, I don’t see why my tax dollar earns me less access to care than my brother’s tax dollar in Melbourne and I really am appalled that we have allowed rural and remote communities to languish in poor health for so long.”

She says Australia’s health system is designed for urban environments and focuses on large hospitals backed by specialised teams.

The health system has failed rural and remote Australia and its unique needs, she argues.

“There aren’t the numbers of people for rural hospitals to support specialised teams and putting an intensive care unit in every little town is absolutely uneconomic; that’s never going to happen. But we don’t have a health system that is engaged with rural realities. Australia needs to begin allowing local communities to co-design health services that are provided to them.”

Historically, Associate Professor Stewart says rural and remote people have often been wrongly described as stoic. They solider on with ill health until they can’t go on any longer.

When she first started working in general practice in Camperdown, a doctor in a neighbouring town died, drastically reducing access to healthcare.

“We had people coming in with advanced cancers and when we said ‘why didn’t you come in when you first noticed this lump?’ the response was ‘I didn’t want to bother the doctors because I knew how busy they were’. So it wasn’t that those people were being stoic, they just had a very practical response to the level of work of their healthcare team in their town. They knew that they were really overworked. I think if we improve access this mystical stoicism of rural and remote people might be found to be baloney.”

The opportunity to feed into the highest level of policy and strategy concerning rural and remote health convinced Associate Professor Stewart she was the right person to take on the role of National Rural Health Commissioner.

She believes her broad combination of expertise, led by clinical roles across rural and remote Australia, can take the voices of rural and remote communities to Canberra, and hopefully, drive solutions and long overdue reform that delivers quality healthcare that residents want and need.

The Federal government recently extended and expanded the Office of the National Rural Health Commissioner to have a broader focus. The Commissioner will now be supported by two Deputy Commissioners that will provide expertise across a range of health disciplines including nursing, allied health and Indigenous health.

Looking ahead, Associate Professor Stewart says key objectives for the Office include advising the government on the impact of COVID-19 on the rural health workforce, working with the Department of Health to formulate the government’s response to review of the Rural Health Multidisciplinary Training Program (RHMT) and investigating and supporting innovative models of care fit for purpose for rural and remote communities.

Working together with a Deputy Commissioner with expertise in nursing will further help drive innovation and on the ground improvements.

“My vision for rural and remote healthcare is that we’ll develop multidisciplinary teams that are local and engaged and that is with integrated care and continuity of care,” Associate Professor Stewart says.

“The greatest part of the Australian health workforce is nursing and the further remote you go, the greater the prevalence in the workforce nursing is. Nurses are absolutely vital to rural and remote healthcare and vital to healthcare in Australia.”

Other big ticket projects include the ongoing rollout of the National Rural Generalist Pathway, which aims to attract, develop and retain more students and trainees to rural medical training pathways and rural generalist practice.

Between 2008 and 2012, Associate Professor Stewart worked with Deakin University, developing and implementing the Integrated Model for Medical Education in Rural Settings for the university, which facilitated integrated clinical placements in small towns for students.

Nowadays, she says universities such as James Cook are making inroads in this space by giving enrolment preference to rural students, particularly from North Queensland.

The push has contributed to 67% of its graduates working outside urban centres.

“It gives them early and well supported clinical experience in a rural and remote context and repeats that throughout the years. By the time a James Cook University student graduated they’ve had a minimum of a year and a half in a small rural town. There’s an explicit rural curriculum and there’s also encouragement and support for Aboriginal and Torres Strait Islander students,” she says.

“It’s choosing the right people, giving them the right support and encouraging them to have the vision to work in rural and remote.”

The Australian government recently announced a $1.2 million investment to boost healthcare in the bush in its 2020-21 Federal Budget, saying its suite of reforms will address the distribution challenge and invest in new approaches and localised solutions, including an emphasis on new models of primary care and expanded rural training opportunities to build the rural workforce of the future.

Associate Professor Stewart says funding is important but stresses there is no silver bullet to fix issues.

“If you’ve got a broken system, throwing more money at the broken system isn’t going to fix the system. Yes, there are things that require more money, but it doesn’t mean that we should keep on doing the same thing that hasn’t been working for the last 50 years.”

Associate Professor Stewart remains acutely aware of the challenges that lie ahead and committed to finding real solutions.

She regards the position of National Rural Health Commissioner as a privilege and one which carries great responsibility and perhaps, more importantly, hope.

“This government is really trying hard to tackle that inequity, engaging deeply with the evidence and the organisations who are wanting to see a change. I think now is a time of great possibility for the health of rural and remote communities,” she says.

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