On July 1 2009, the Federal Government will change the geographical classification system that is used to target funding to health programs in rural and remote areas. The current, predominant classification system is the Rural, Remote and Metropolitan Area (RRMA) system. The new geographical classification system has not been decided, although the Australian Standard Geographic Classification (ASGC) is heavily favoured by the Australian Bureau of Statistics (ABS). The ASGC is based on the second version of the Accessibility/Remoteness Index of Australia (ARIA+). The uncertainty this raises for future funding of rural health workforce retention programs is a concern for the rural VHA members.
RRMA has been under review for some time, as there are doubts about the accuracy of this data-set to fully inform the Department of Health and Ageing (DoHA) in regards to its policy advising and program management responsibilities. RRMA was developed in 1994 using 1991 census data and 1991 Statistical Local Areas (SLAs). The index score was calculated by combining a personal distance index (relating to the SLA’s population density - the area of an SLA divided by its population) and distance indices (relating to the distance of the centroid of an SLA to the nearest urban centroid, as the crow flies). The population census and the SLA boundaries have changed significantly in Victoria since 1991, making RRMA difficult to update to reflect the current population profile of Victoria.
Although RRMA is the predominant classification system used by DoHA as a basis for the allocation of program funding, one of the largest programs for the retention of General Practitioners (GPs), the Rural Retention Program (RRP), is determined by the GPARIA classification. ARIA is based on access along the road network from populated localities to each of four categories of service centre. GPARIA adds in other criteria to the indices, such as proximity to other GPs and length of service. Recently another program, the Registrars Rural Incentive Payments Scheme (RRIPS), shifted its eligibility criteria from RRMA to a GPARIA "sliding scale". A criticism of GPARIA is that it fails to address Victoria's difficulty in recruiting and retaining GPs in medium sized regional centres.
Indeed, one of the problems of a purely geographical measure is that it does not distinguish the small town context of GP work from that of a large town. In small towns primary services are inextricably entwined with hospital services. Rural GPs have a dual responsibility because they manage primary care as well as the hospital-level care and serious emergencies, which often incur an on-call commitment. Population density of a town is measured (albeit inaccurately) by RRMA, but not in ARIA or ASGC.
Another problem of a purely geographical measure is that there is no consideration of the socioeconomic status or burden of disease in a community. Remoteness is an indicator of access to services, but it is not the only indicator relevant to shortage of health services in a community. Towns with higher socioeconomic status can attract GPs with the promise of private practice, but lower socioeconomic communities will not sustain private work. A GP has to invest heavily to set up a practice, and need to be sure that there will be a return. If the Medical Benefit Scheme (MBS) rebate to GPs is the same in every location within a geographical zone, then it will be the smaller, lower socioeconomic towns that will fail to attract the GPs.
The funding of health services is set up in such a way that the only way to attract the health workforce to an area of need is to provide financial incentives and relocation support. Neither of the proposed geographical reclassifications, ARIA and ASGC, is sensitive enough for DoHA to adequately differentiate the degree of geographic remoteness of an area in rural Victoria, nor act as an indicator of disadvantage.
The VHA is working together with the Rural Workforce Agency Victoria (RWAV) and the Divisions of General Practice Victoria (GPV) to build a strong case for the use of indices other than road distance to calculate areas of poor access to services. Part of the submission will be a case study of the potential impact of changes to a small rural health service if the current workforce incentive funding was to cease.
