Rural workforce focus

Around one in five New Zealanders live in rural areas. By virtue of our geography, ensuring that New Zealanders get excellent care wherever they live has unique challenges not always faced by other countries. Having a thriving rural workforce is essential to ensuring that care is consistent and high-quality.

On the whole our rural workforce faces larger gaps than our urban workforce – though this varies across the country. There are a few reasons for this:

• Most health training occurs in urban areas. Those who grow up rurally usually have to move to major urban centres to train for medicine and allied health professions. Evidence indicates that people are more likely to work within rural areas if they have lived in rural areas and/or had extended training in rural areas; so increasing training in rural areas will likely grow our numbers of rural health professionals.
• The culture of many health professions encourages specialisation as a source of prestige, progression and pay – particularly in medicine. Because rural areas typically require more generalist skills, with fewer specialist roles, these cultures can make rural practice less attractive; though rural generalism is itself a vital, specialist area of practice.
• New Zealand has a great many migrants in its health workforce. Because migrant communities more often settle in urban areas, our large, overseas-trained workforce are likewise less likely to live rurally.

Getting our rural health workforce sustainable is essential for the sustainability of our health system overall. Doing so requires both that we make our whole health system more responsive to rural communities and rural needs – and that we design specific interventions and approaches which work for the unique needs of rural communities. 

A more sustainable rural health workforce will rely on more health workers who want to work rurally. To make that happen:

• We need more training programmes based in rural areas or accessible rurally (such as through distance learning), so people can train close to home.
• We need to recruit more people to our tertiary training programmes from rural areas.
  We need to help address some of the barriers to people working rurally, like ensuring health professionals’ whānau can find fulfilling work.
• We need to rebalance pay and conditions across our services, so that urban areas don’t leverage economies of scale to lure workers out of vulnerable rural services – and so we have the right blend of incentives for people to live and work rurally.
• Specialising in rural practice often requires people to move around a lot, getting experience in a range of communities and settings – rather than staying in one or two large hospitals long-term. We can make these systems easier to navigate, so it’s more likely that our rural specialists thrive in training.

Alongside shifts to grow the rural workforce we need, we will also need to adapt models of care to get the right level of specialisation for rural settings – which won’t always mean using the same specialists who make sense in urban environments. For example:

• Services with high demands in rural settings – such as obstetrics (for pregnant people) and anaesthetics – can be supported by generalist doctors (whether GPs or general medics) who have some additional specialist skills. This model is already used on the West Coast; we could use it elsewhere to reduce the number of ‘traditional’ specialists we need in some rural settings, with the right support and networks.
• Urban general practice is usually oriented around physical premises; this doesn’t necessarily make sense in geographically disparate communities. In some rural areas, it might make more sense to have mobile GPs supported by paramedics and nurse practitioners who can bring care to people in their homes, or in a nearby community setting. This may require different funding settings to urban areas.

Short-term, the most pressing challenge for our rural workforce is simply sustainability: we need more people working rurally, growing sustainably over time to match rural population need (which, like our wider population, will grow as people get older on average). Sustainable rural staffing is a prerequisite to quality services for rural communities.

But we don’t want this growth to just be one-off – we need it to be enduring. This means our approach will require:

• Supporting tertiary education providers to establish new rural training programmes for professions where we have the greatest rural shortages – so we can train rural workforce close to home.
• Expanding training programmes and initiatives which support students from rural areas to train into health careers.
• Expanding initiatives which give students exposure to rural and provincial settings – making them more likely to eventually practice in those settings.
• Investing to grow workforces well-suited to support care in rural environments, such as rural hospital medicine specialists and paramedics.
• Smoothing rural training programmes, such as by employing rural hospital medicine specialists, to reduce attrition and average time to complete training.
• Working with rural communities on how we can make working in health in rural and provincial New Zealand a great experience, and recognise the contribution our health workers make to rural and provincial communities.
• Investing in mechanisms to share employment across settings, such as shared-employment contracts and workforce-sharing agreements between rural hospitals and community settings.

As we strengthen rural workforces, we will need to pivot to ensuring enduring sustainability and service improvement. The opportunity to do so is in moving to by-rural, for-rural models of care and service delivery.

This means:

• Establishing unique rural training pathways – which are based in and train for rural communities, and are grounded in local needs and interdisciplinary approaches to training. Our rural training hubs, established through this Plan, are the start of this approach.
• Adopting bespoke, rural ways of delivering care which make sense for rural communities – such as mobile general practice. This is both about reorienting hospital networks to provide the right blend of care close to home, with specialist services available in major centres (with better support for telehealth and travel); and about changing funding and incentives for the community sector to make rural models of primary and community care sustainable.
• Expanding generalist-specialist models which we already know work, drawing on rural generalists with specialist skill sets in specific areas. This ‘right level of specialism’ approach will allow us to more sustainably staff rural services into the future, without burdening clinicians or creating excessive cost to the health system.
• Supporting IMPBs to shape local workforce and care approaches for Māori, so community care can be adaptive to the specific needs of particular rural and remote communities.

Over the next three years we will start to make headway towards these more fundamental shifts, both through improved workforce planning, and by realising the opportunities of other work underway within Health NZ – such as national campus planning, and primary care change.