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Accessing Rural Health Services - rural realities


Rural Women New Zealand's Health Portfolio representative, Margaret Pittaway spoke at a seminar organised by the University of Otago's Wellington Medical School on Friday 21 July. Read the transcript of Margaret's speech below: 

Rural Women New Zealand has been working hard to strengthen rural communities for over 90 years. We have been a Leading Voice for rural Families and Communities since our beginning in 1925 in the areas of Health, Education, Social and Environment.

The issues in the 1920’s that affected the women, their families and their communities still exist today - isolation, lack of services and agency support. Their concerns were around health and education for themselves and their families, being connected to the outside world and being able to access the services they required.

In the time I have with you today, I want to talk about the difficulties rural New Zealanders face in their day to day lives in accessing health services, and to give you some of the reasons Rural Women New Zealand believe to be the main cause of our problems

The Organisation began 92 years ago when a group of very determined farmer’s wives took the opportunity to meet in Wellington while their husbands attended the Farmers Union Conference. These women recognised the need for representation and support for rural women in the areas affecting the welfare of women and children, and they were concerned at the stories they were hearing of loneliness, illness and lack of assistance.

One of the prime needs was to organise reliable help to step in when the women were ill, needed support when there was a new baby, or when they needed to leave home for a time. This was the beginning of the Women’s Division Emergency Housekeeping Scheme, and in April 1927 advertisements appeared for ‘House Keeper, willing to do anything’ and for’ Bush nurse with surgical skills and maternity certificate.’

These nurses were the beginning of the District Nursing Service and Community Midwives. Nurse’s wages were subsidised with donations from all over the country. The numbers employed were initially quite small, and then the Government of the day began to set up cottage hospitals and a District Nursing Service and the need for our Bush Nurses disappeared.

During this same era, homes were purchased throughout the country to enable members to have respite care when the need arose, or to take a family holiday for very little cost. When there was no longer the same need for this service, the homes were sold and the funds were used to set up a company, Access Home Help which operated throughout the country and continued to provide care to rural areas in spite of the time and travel costs involved – the only company to do so. Access was sold in 2014 and continues to operate in the same manner.

In 2000, the results of a Rural Health Survey undertaken by Rural Women New Zealand were released with the hope and idea that they would be used as a basis for planning for health services by DHB’s and other parties. Today I acknowledge this document as it remains relevant and was helpful to me as I was preparing this presentation.

In 2016, Rural Women New Zealand undertook to study rural communities in New Zealand so that we gained a better understanding of what and where the problem areas are. Other than this document, there is very little to find in the way of rural research, but we have found that this document is a valuable tool for us, particularly when we are preparing submissions. Rather than being a negative work, it gives examples of positive actions which have meant that the fortunes of communities have been turned around, both in New Zealand and in overseas communities.

The biggest disadvantage for rural New Zealand is that there is no accurate definition of rural. Government uses the NZ Statistics definition of rural which divides into four categories, Rural with high urban influence, Rural with moderate urban influence, Rural with low urban influence and highly rural remote. What these categories mean is that 40% of people who access rural health services are classified as urban, while a further 20% of people currently classified as rural, access their help from urban.

In response to a very recent request from our national office for information on statistics for cervical cancer and for the uptake of immunisation, with comparison between urban and rural settings, the reply from the Ministry of Health was;

‘Generally speaking, the Ministry doesn’t do much analysis looking at urban/rural discrepancies because there are some inherent biases in the way automated geo-coding copes with non-specific addresses. These addresses (which are more likely to be rural) tend to get re-coded at the nearest Post office. This means that a sizeable portion of rural people are recorded as urban making any attempt to draw meaningful conclusions impossible.’

This statement on its own underlines the absolute need for rural research. We currently have a rural population of some 620,000, making it effectively our second largest city, though widespread throughout the country, and yet we continually struggle to get the equivalent services that the rest of the New Zealand population expects.

We just do not have sufficient information to provide evidence based interventions to most effectively create better health outcomes.

What we and other key rural organisations would like to see is the system of rural proofing of Government Policies re- introduced. The system is used in the United Kingdom and ensures that the impact of changes in government to rural communities with low population density is taken into account as plans for change are developed.

So, what are the concerns we have, and what are the realities in accessing health care that rural New Zealanders face?

Let’s start with Maternity Services, and some information shared with me by a young woman living in Te Anau, a major, but isolated tourist town with a growing younger population.

The nearest available mid wife lives in Tuatapere, 101K’s distant and her back up midwife has her home in Riverton, a distance of 147 K’s. Although there are two other midwives who do work in Te Anau they do not live in the area, and they both have a full case load. Further, there is no opportunity to access Ante-Natal classes in the area.

The nearest birthing unit is in Lumsden, 77Km distant, but as with a number of units throughout the country, it is in danger of being closed, and so young women are making the decision to go to Invercargill to have their babies as they feel safer there, and they want assurance that the unit will still be operating when they do go into Labour.

This is a trend that is happening throughout the country which is regrettable, but understandable, but if these units continue to close, it leaves no options to have extra time after the birth in a unit where there are staff to assist a new mum and baby in those all-important first few days. Most birthing units encourage their new mums to return home early, with no thought for a farming mum who will be quickly caught up in the day to day business of farming life, and with no support services close to hand. There is not much rest for a rural woman! And there is provision for a midwife to arrange for longer stay in the birthing unit or other facility on the grounds of geographical isolation.

During the first Trimester the midwife must discuss with her client the plans for managing her pregnancy and the six weeks following birth. An agreement of expectations about the number of post-natal visits must be reached. New mums are entitled to seven, but they may not be requested or required, or they agree to one home visit with the mother then undertaking to travel to a clinic for the other post-natal checks. There is no problem with that, but if a C-section was performed, the new mum is not permitted to drive for six weeks. If baby’s arrival coincided with a busy time on the farm, say lambing or harvesting, it is nigh impossible for a farmer to take his partner to an appointment, and other friends or neighbours are likely to be busy too. The value of regular checks in those first weeks cannot be understated as they provide the opportunities to ensure that there are no unrecognised signs of child or maternal problems, to say nothing of the reassurances that new mothers seek.

We haven’t touched on the birth yet, but if lengthy travel to the birthing unit is required, then careful planning is needed to ensure that the pregnant mum is resident in the area before labour begins. Get it wrong, and the stress and anxiety mount, to say nothing of enduring contractions on unsealed bumpy roads in adverse weather conditions.

Midwives have reported on the difficulties of using ambulance services to transport labouring women experiencing difficulties, to a primary birthing unit. The irony is, that if you break a leg on the ski field attempting something way beyond your capabilities, there are no questions about the need for a helicopter. What price the life and wellbeing of a mother and baby?

We don’t know whether our children are disadvantaged because they have poorer access to maternity and youth health services than urban children. There is no dataavailable.

The rural population is facing the reality of an ageing and burnt out GP workforce and a seemingly dwindling number of younger doctors who are willing to take up the challenges and rewards of working in rural areas, despite best efforts to promote and attract. The uncertainties around continued local medical services takes its own toll on our rural communities with reluctance for families to work in areas where the facilities are unreliable. Add the lack of ultra-fast broad band and poor cell phone coverage, still experienced in many areas and it becomes apparent why there is a reluctance to work in these areas.

The use of locums means that a relationship of knowledge and trust is difficult to build, and for our older patients in particular, this is a very real problem.

Currently, 25% of rural General Practices are seeking a full time GP and over a third of pharmacies are having difficulty with recruitment.

Consider the need for an Out Patient appointment for a family member. Urban dwellers would maybe allow two hours out of their day to get to the hospital, find parking attend their 15 minute appointment and be on their way home or back to work again soon afterwards.

For someone living in the country the reality is different where travel is a necessity. Hospitals are not always good at recognising that a patient has to make a real effort to attend an early morning appointment and that it may mean an overnight stay. Travel costs are prohibitive to many, as are accommodation costs.

For many, a specialist appointment can mean an eight to nine hour round trip and loss of a day’s wages or work. Yes, there are increasing opportunities for tele-health consultations, but generally speaking, the majority of patients will need to travel for their appointments.

The distance that cancer patients have to travel for treatment are significantly further for those living in rural areas Often women with breast cancer will choose a more aggressive treatment in order to get home to their families, and any patient undergoing prolonged treatment will struggle with the travelling and the distance, particularly if they have no one else to drive them.

Difficulty is often experienced in accessing drug and alcohol services and counselling services.

Accidents in rural areas pose more problems. We are reliant on a largely volunteer ambulance service which means that the crew need to be called into the station before the ambulance can leave. Time lost. In most rural areas, stabilising the patients for transport to a base hospital is the main aim. In severe cases, helicopters can be called in to transport, but that takes time too, and adverse winter conditions may mean that the choppers can’t fly. Time lost. Winter road conditions for ambulance transfer may well mean a slower than normal trip. More time lost, and the reality for many of us is that the base hospital is three hours by road in good driving conditions.

Consider also that many of our high density tourist traffic areas have very poor cell phone coverage which can mean more time delays to get urgent help.

Let me touch briefly on the volunteer system that is the reality for the rural population. Don’t get me wrong. The people who volunteer in any service to their community are fabulous, but it comes at a cost to both them and to their families. On call means just that – the need to abandon all plans and activities to answer an urgent call out, sometimes in the middle of the night. Depending on the reason for a call out, realistically it could involve hours with the initial need for assessment, stabilisation, transfer, hand over, return journey home and then clean up and re-stocking time so that the ambulance is ready for the next call.

Many of our volunteers also have day jobs and responsibilities which they have to consider, as well as the fact that training is undertaken in their own time without full recompense. Volunteer ambulance staff is being put under increasing pressure as they are filling gaps being left behind by 24 hour services that have been centralised. Not only do our volunteers need our recognition and continual support, but also their families who miss out on family time.

We are all aware of the state of our mental health services in this country. Ponder for a moment on what this means for rural communities where we have a high suicide rate in our farming communities and particularly in the male 20 – 25 year age group. Rural Support trustees report that when they have a suicidal client, they have little problem accessing GP assistance, but when it comes to getting further help in the form of an urgent appointment from Brief Intervention services, the wait can be from 10 days to three weeks. Not good enough. Can you just imagine the anxiety and stress that the family will experience during this time?

Consider those who patients in hospital who are sometimes discharged at short notice, to make way for another patient, at times in the middle of the night. If they live in a rural area and have been brought in by ambulance or a friend or family member- how do to they get home? Or where do they go if they have no family in the area? - very distressing, especially for the elderly.

There is unlikely to be any available public transport, many are not permitted to drive after surgery, and so are reliant on someone yet again being able to take time out to collect them. And home could be a good distance away.

Often when patients are discharged from hospital they require on going care – maybe wound care, maybe drug administration or assistance with the usually simple tasks of showering and dressing. In an urban situation it is simple as the District Nursing Service is able to administer those treatments. Not so for rural patients, and we have had a number of our members approach us for help and advice when treatment at home has been refused for a family member. I do not use the word refuse lightly, as I have been told by nurses, that the service and the extra costs of travel to rural areas is just not within the budget allowances of the District Nursing Service, and even worse, that if people choose to live in remote areas it’s their own fault.

So how do we get around the problem of getting continuing treatment once a patient is discharged? Some elderly people may qualify for respite care for a short time, but for the majority, it means frequent travel to a medical centre for the cares that are needed, involving not only time and travel costs, but fees incurred at the Medical Centre.

I have briefly touched on connectivity, but I want to return to the topic as it is in fact a major issue in rural areas for a number of reasons.

Firstly for Safety and access to emergency services.

When an accident occurs in a rural area, there is often no cell phone coverage because of black spots, and so it requires someone to find access to a landline, or find somewhere where there is cell phone coverage to ring for help. Not always easy if those seeking help are visitors to the country, or are unsure of the area they are in. And if those involved are injured themselves, they may not be able to send for help. Unfortunately much of the vital “Golden Hour” can be taken up finding help.

As an example, a farmer who had an accident with a digger and badly injured his hand was fortunate that he had satellite internet, so he was able to call for help. Phone service had been out for weeks and there was no coverage for cell phones.

A further example – In a small settlement where the phones were out of order, a motorcyclist on an event was injured. In this instance, a helper had to drive 20 minutes to the nearest town, then drive another 20 minutes to find a phone that worked, while the injured person lay in pain until help arrived. The nearest ambulance was over an hour away. Even with a first response team on site it was an unpleasant wait- if cell phone coverage had been available, that wait time would have been considerably less.

In an emergency where there is only a landline already in use for contacting emergency services, there is then no opportunity to call for extra assistance from close neighbours or friends. It can be a traumatic and distressing time for everyone involved.

I spoke earlier about the pending closure of maternity hospitals, and I wish to make further comment, and this time, include some of the smaller general hospitals.

The downgrading and closure of rural hospitals has left a gap in rural health and emergency services in communities throughout the country, for they provided an essential focus and service to the communities they served. The effects are variable but the increased separation between patients and vital services is creating barriers to access to health services.

Kurow is a small service town in North Otago. Its Medical Centre is open four days a week and an afterhours service is provided by volunteers. The town pharmacy closed some time ago, and until recently, prescriptions were brought down by car daily form Twizel, and delivered to a local shop owner who was licensed to give the prescriptions to the locals when they called in. Regrettably, the owner has decided not to renew her license and so now a car drives from Twizel each day and parks on the street for one hour so that prescriptions can be collected, and then returns to Twizel with any unclaimed prescriptions – a round trip of 158 K’s and a service that is not convenient for the local population. Has anyone given consideration to the safety of the person in the car if it becomes known more widely of the contents?

Bill, aged 82 and a long-time resident of Kurow has a number of health issues including prostate problems and blindness in one eye. He has been waiting at great length for eye surgery with no operation date on the horizon yet. He is unable to do much at all in his daily living. Bill’s comment on the situation, apart from his disillusionment with the state of the health system, is that he has had enough and is ready to die.

This brings me to my final point. Evidence from a number of countries states that those who live rurally have poorer health than their urban counterparts.

“There is little information about the prevalence of of illness or disease among our rural populations, but it is reasonable to assume that its rates of illness or disease are similar to those of New Zealand’s total population. However, once diagnosed, rural people unquestionably face greater challenges and costs of access to health services and specialist treatments. It is also reasonable to assume that there is a greater impact of disease or illness on rural people and their families. It is also a reasonable assumption that this results in poorer health outcomes.”

I acknowledge the help and support from my peers, our National Office staff and the health organisations who we work with in partnership.

I hope today that Rural Women New Zealand has successfully brought our concerns to you and that the word will be spread that our rural population deserves better treatment and consideration.

 

Read All NewsRecent news

The Rural Women New Zealand National Office has relocated to Technology One House, Level 5, 86-96 Victoria Street, Wellington.

RWNZ National Office would like to advise members that since the relocation on 10 July 2017, postal delivery to the new office location has been disrupted.

We have already mailed out Membership invoices to members. We expect that you may be sending your payment and invoice slip back to National Office. We are aware that some mail posted to RWNZ has been returned to senders. Sincere apologies for any inconvenience. We are working with New Zealand Post to resolve the situation as soon as possible.

If you have any concerns about invoices, please email: [email protected] or phone the National Office: 04 473 5524.

As at Tuesday 18 July, the reception phone line is connected, phone 04 4735524. 

If you have an email enquiry, please email [email protected]

We will keep you updated with progress on the relocation, phone and email services, through the RWNZ website and social media: Facebook (www.facebook.com/ruralwomennz/) and Twitter (www.twitter.com/RuralWomenNZ).

 

 

RWNZ National Office has moved

Thursday, July 06, 2017

The Rural Women New Zealand National Office has relocated to Technology One House, Level 5, 86-96 Victoria Street, Wellington. Read More

Entries are now open for the Rural Women New Zealand Journalism Award 2017, which will be presented at the NZ Guild of Agricultural Journalists annual awards dinner in Wellington on 13 October.

The Rural Women New Zealand award encourages journalists to report on the achievements of women living and working in rural communities.

Entries in the RWNZ Journalism Award 2017 must be of two articles, radio broadcasts or television programmes broadly based on the theme of “rural women making a difference.” This could be in the sense of community involvement, on farm, or in another rural-based business or activity.

“RWNZ is proud to sponsor this Award for journalism features celebrating the achievements of rural women, through enterprise or volunteering in roles that support their rural community,” says Fiona Gower, National President of Rural Women New Zealand.

Nadine Porter was the winner of the 2016 Rural Women New Zealand Journalism Award. Nadine's winning articles featured research on rural women and isolation, and the role of social media and were published in the Ashburton Guardian Farming.

Entries close Wednesday 6 September 2017. Any New Zealand-based journalist or communicator is eligible to enter the award. The winner will receive $750 in prize money.

Click here to download an entry form.

 

Entries open for the Rural Women New Zealand Journalism Award 2017

Thursday, August 10, 2017

Entries are now open for the Rural Women New Zealand Journalism Award 2017, which will be presented at the NZ Guild of Agricultural Journalists annual awards dinner in Wellington on 13 October. Read More

Rural Support Trust representatives are working closely with farmers to monitor well-being and directing them to relief assistance for flooding and other adverse events.

The Rural Support Trust advise farmers to ensure stock and domestic animals have food, water, and shelter where necessary, and are secure. Ensure that all stock injuries are promptly attended too, after human needs are met.

If your farm or rural property or stock has been affected by an adverse event and you need assistance, contact your local Rural Support Trust on 0800 787 254 (0800 RURAL HELP) with information on the impacts on your farm, or requests for help.

The Rural Women New Zealand Adverse Events and Relief Fund is available to individuals, communities and groups, with a particular emphasis on rural women and children. The fund provides financial assistance to persons or groups, where there is an identified urgent need due to recent adverse events such as drought, fires, floods or earthquakes.

Click here to read more about applying for the fund.

Contact details for support agencies:
The Rural Support Trust (RST organise community events and one-on-one mentoring, as well as targeted support services in emergency situations)  
http://www.rural-support.org.nz Ph: 0800 787 254.

DairyNZ: Sharemilkers support http://www.dairynz.co.nz/farm/tactics/support-for-sharemilkers/

Federated Farmers http://www.fedfarm.org.nz/ Ph: 0800 327 646 or drought feedline 0800 376 844.

Doug Avery’s Resilient Farmer http://www.resilientfarmer.co.nz/

Farmstrong http://www.farmstrong.co.nz


If you just want to talk, or know someone who is at risk, there are a range of support options available, including counselling services:

Lifeline: 0800 543 354 - Provides 24 hour telephone counselling

Youthline: 0800 376 633 or free text 234 - Provides 24 hour telephone and text counselling services for young people

Samaritans: 0800 726 666 - Provides 24 hour telephone counselling.

Women's Refuge: 0800 REFUGE (733 843) a 24/7 crisis and support line provide advice and information.

Shakti New Zealand 0800SHAKTI (0800 742 584) If you are in a situation of domestic violence call our 24-hour crisis line, and multi-lingual staff will provide information.

Tautoko: 0508 828 865 - provides support, information and resources to people at risk of suicide, and their family, whānau and friends.

What'sup: 0800 942 8787 (0800 What’s Up) is a counselling helpline for children and young people, aged 5-18. Phone Mon-Fri 1-10pm, Sat-Sun 3-10pm.

Kidsline: 0800 543 754, it is a 24/7 helpline for children and teens, run by specially trained youth volunteers.

Thelowdown.co.nz - Free Text 5626, watch videos or contact for support. 

depression.org.nz National Depression Initiative (for adults), 0800 111 757 - 24 hour service 

Ministry for Vulnerable Children Oranga Tamariki If you're worried about a child or family that you know, there are ways you can help, contact Child, Youth and Family.

For information about suicide prevention, see http://www.spinz.org.nz .

If it is an emergency, or you feel yourself, or someone you know is at risk, please call 111.

Rural community support services

Thursday, April 06, 2017

Rural Support Trust representatives are working closely with farmers to monitor well-being and directing them to relief assistance for flooding and other adverse events. Read More

The Ministry of Health has proposed a new framework for suicide prevention and is seeking feedback. Rural Women New Zealand’s (RWNZ) submission supports the general framework.

Although expresses concern regarding the lack of concrete targets and detailed methods for how any of the initiatives will be implemented. We are especially concerned about the lack of a strategic plan to lead and fund these activities.

The proposed framework aims to address the devastating impact that suicide has on New Zealand’s communities and the unfortunate reality that over 500 people in New Zealand die by suicide every year. RWNZ supports the framework’s focus on supporting positive wellbeing for all ages, increasing awareness of suicidal behaviour and mental health, strengthening systems already in place to support communities, and improving collaboration among those working to prevent suicidal behaviour.

In our submission, we have addressed the fact that the suicide rate is higher in rural areas than in urban areas, as well as the various factors that place rural communities at an increased risk of mental illness. These factors include vulnerability to economic fluctuations and social isolation, which are compounded by the lack of access to services and support, substandard or no access to reliable and affordable internet and mobile coverage, and the history of inequalities that rural communities face often being overlooked.

RWNZ has suggested that in order to improve mental wellbeing in rural areas, rural health research must become a priority to understand and address the needs of rural communities. We have also urged the Ministry of Health to refrain from relying on technological health services, recognising that not all rural communities have access to reliable and affordable internet and mobile coverage.

Rural Women New Zealand strongly supports the framework’s proposal to involve, train and educate community members on suicide prevention. Rural Women New Zealand has expressed that it is essential for rural communities to be provided with the right tools to improve mental wellbeing within the community and reduce social stigma associated with mental illness.

As further information becomes available, this will be distributed to the members.

 

Click here to download the Submission: June 2017 Suicide Prevention Strategy Submission


 

 

Suicide Prevention Strategy Submission

Wednesday, July 26, 2017

The Ministry of Health has proposed a new framework for suicide prevention and is seeking feedback. Rural Women New Zealand’s (RWNZ) submission supports the general framework. Read More

Associated Country Women of the World (ACWW) is RWNZ's topic of study for 2017. We have included an overview of the purpose of ACWW below, along with some links to further information.

RWNZ was one of the founding members of ACWW. It is one of the largest international development organisations for rural women.

The ACWW network allows it to engage at the local, national, and international level with the aim of achieving these goals:

- To raise the standard of living for rural women and their families through education, training and community development programmes.

- To provide practical support to our members and help them set up income-generating schemes.

- To support educational opportunities for women and girls, and help eliminate gender discrimination.

- To give rural women a voice at an international level through our links with UN agencies and bodies.

Caption: Delegates from the South Pacific Area Conference in New Plymouth complete the ACWW Walk the World event in April 2017. 

Click here to download an information booklet about ACWW (8MB PDF)

Click here to go to the ACWW website

 

ACWW Study Topic 2017

Friday, June 16, 2017

Associated Country Women of the World (ACWW) is RWNZ's topic of study for 2017. We have included an overview of the purpose of ACWW below, along with some links to further information.  Read More

The Justice and Electoral Committee is seeking feedback on the Marriage (Court Consent to Marriage of Minors) Amendment Bill. RWNZ's submission fully supports the Bill and its intent to prevent forced marriages from occurring in New Zealand by requiring minors aged 16 and 17 to gain approval by the Family Court in order to marry.

In our submission, RWNZ cited various international conventions and declarations of which New Zealand is a signatory or party to that do not condone forced marriage. These include the United Nations Convention on the Rights of the Child (CRC), the Universal Declaration of Human Rights (UDHR), and the United Nations Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW). RWNZ expressed that the proposed amendment to New Zealand’s marriage law upholds New Zealand’s commitment to these documents.

RWNZ also noted that the law as it currently stands, which allows minors aged 16 and 17 to marry with parental consent, is insufficient in preventing forced marriage. The proposed amendment serves as a precaution to prevent parental guardians from attempting to facilitate a forced marriage.

As further information becomes available, this will be distributed to the members.

Click here to download the RWNZ submission.

Marriage Amendment Bill

Tuesday, July 25, 2017

The Justice and Electoral Committee is seeking feedback on the Marriage (Court Consent to Marriage of Minors) Amendment Bill. RWNZ's submission fully supports the Bill and its intent to prevent forced marriages from occurring in New Zealand by requiring minors aged 16 and 17 to gain approval by the Family Court in order to marry. Read More