Perkins D, Farmer J, Salvador‐Carulla L, Dalton H, Luscombe G. The Orange Declaration on rural and remote mental health. Aust. J. Rural Health. 2019;00:1–6. https://doi. org/10.1111/ajr.12560
Contribution by Dr. Fiona Doolan-Noble
The Orange Declaration on rural and remote health evolved out of a meeting in Orange, New South Wales in October 2018 between mental health researchers and service providers from New South Wales, Victoria, the Australian Capital Territory and Western Australia to examine the issue of rural mental health and well‐being. Following the meeting five iterations of the document were developed, with participants agreeing upon a consensus statement that outlined ten problems related to current models of rural mental health and well‐being and ten potential solutions to the problems.
Reading the paper the identified problems and associated solutions could easily be applied to any health and social care service. As the authors highlight this is driven by the association and relationship between the challenges associated with provision of services in rural areas- geographical, demographic, social, economic and environmental. All of which are not addressed satisfactorily by the current mix of services, the distribution of the health and social care workforce, nor the associated skill mix within those workforces.
Sadly what is missing from the Declaration is any mention of the need to prioritise addressing the crisis in Aboriginal and Torres Strait Islander mental health and well-being.
The publication of the Declaration is a useful way to start a conversation about rural mental health and well-being and as a strategy for bringing the varied organisations and academic institutions working in the space together. However, it is to be hoped that any funding secured will be used in the first instance to co-develop programmes and interventions that are culturally appropriate for rural Aboriginal and Torres Strait Islander people.
“4 TEN PROBLEMS
Ten problems related to current models of rural mental health and well‐being were identified. They are as follows:
- Rural communities are different from cities and are not homogenous: they are distinctive, each with different local assets and challenges. Community contexts can change rapidly due to economic instability, dependence on particular leaders or natural disasters. One‐size‐fits‐all service models that cannot adapt to time, place and context are therefore inappropriate.
- The rural mental health system is not working: Indicators of rural health and illness suggest that current service models are failing, not fit for service or overly stretched; this situation has been recognised in the public imagination, the media and in political debate.
- Top‐down service models are based on urban assumptions: Rural service models in Australia are based on large region‐wide analyses of service activity data, with relatively little evidence of community co‐design or co‐production. People in rural communities can draw on available local evidence and participate effectively in service design. This requires providing them with appropriate data so that they can partner with local providers and commissioners. An example of these productive partnerships is the rural and remote Aboriginal Community Controlled Health Services that provide integrated and locally managed services which have achieved notable health gains.
- Services are not based on needs: Emerging evidence suggests that service provision does not always map to population need, nor does spending necessarily achieve better mental health outcomes. This suggests that the available services are failing to provide what is needed and could be due to demand exceeding supply, service fragmentation, challenges in service navigation or services not reaching vulnerable rural clients.
- The current forms of public financing are misaligned disproportionately rewarding outreach, telehealth and city‐centric models at the expense of the local public, private and NGO services from medical, allied health, nursing, peer and care partners. Short‐term funding constraints such as 12‐month contracts offered by Primary Health Networks discourage providers from making investments in rural and remote communities.
- Fragmentation and competition hinder sustainable, robust service provision: With a large number of service providers in small communities competing for short‐term contracts, addressing different performance targets and often based elsewhere; the role, past performance and track record of services can be highly confusing and their work uncoordinated. Navigating fragmented services increases transaction costs is a challenge for both clients and for health practitioners.
- Structural inequity in mental health service provision is amplified in rural areas: While there are rural residents with acute mental health needs, many of the current gaps in rural mental health might lie in areas of awareness, acceptability, prevention, mental health literacy and social connectedness. An over‐emphasis on specialist and hospital services neglects the first‐line “self‐care” that community members could provide for themselves.
- The rural mental health workforce cannot be a miniature version of that found in large cities. Its location, skills, scope of practice, supervision, support and development are all problematic. Mental health jobs are very demanding, responses are needed around the clock, personal and professional boundaries are hard to maintain in small communities and burnout is common.
- While telehealth and online services should augment mental health services for all clients whether rural or urban, people with mental health challenges often need to speak in person with a health professional, and on some occasions, very quickly. Rural residents need a range of appropriate options to cater for the different situations in their lives.
- Data sets are incomplete, disjointed and limited: many different and incompatible data sets are gathered and there is little data‐sharing or linkage. It is therefore complex to analyse service data and find out which services are associated with improvements in access or health outcomes in which communities.
5 TEN SOLUTIONS
Ten solutions are proposed for rural mental health and well‐being that together would benefit from robust testing and evaluation. They are as follows:
- Whole‐of‐community, place‐based approaches are promising: These approaches are established in many countries and place‐based planning is increasingly popular in Australia. Resources and toolkits have been developed by organisations such as the World Health Organisation (WHO). The WHO model has been shown to be successful in an international systematic review but has not yet been trialled in Australia.
- New service models tailored to context must be considered: There are numerous innovative models, methods and ideas being tested at a community level that could be scalable. These models need to be tested at a larger scale using appropriate investigative methodologies. Ideally, much of this research would be conceived and conducted by rurally based researchers and partnerships, helping to build rural research capacity. Moreover, these new ways of working (different models) are likely to require new skills in health care providers and new organisational arrangements, which will also require development.
- Co‐designed bottom‐up processes should be pursued in collaboration with state and federal partners: Involving place‐based communities in collaborative co‐design can help to build local partnerships, awareness and generate appropriate solutions. These are beginning to be tested using rigorous methodologies. Such approaches can build empowerment, capacity, resilience, social connection and empathy in diverse cultures. Local partnerships are best placed to plan models about how to care for people in crisis locally who could be at serious risk if they cannot access timely assistance.
- Holistic and integrated care models need testing: Many rural communities and primary health services have already given‐up on one‐size‐fits‐all centrally imposed models. Many new non‐clinical, community‐based roles are emerging, including service navigators, connectors, peer supporters and outreach workers who can visit isolated‐community members, provide navigation and support. Such workers can provide a cost‐effective source of local prevention, connection and support. However, models engaging lay personnel to complement health and community services would benefit from large‐scale testing.
- New better‐aligned funding models are needed: New funding models that reward collaboration provide rural residents and service providers with choices and referral options, enable clinical supervision and professional mentorship need to be developed, modelled and tested.
- Whole of community approaches are needed, not pilot studies: These should be co‐designed with rural communities and tested over longer time periods (at least 3‐5 years). Incremental design and improvement is a much better model with a clear recognition that one size will not fit all and that those without personal experience of living in rural communities might not be the best source of wisdom.
- Prevention and early intervention must be considered: Local providers and community leaders suggest that prevention is a largely neglected strategy. Building local strategies to address social connection, transport accessibility, mental health literacy and stigma reduction is a fundamental step. Further research summarising and exploring effective and ineffective approaches at the community level would help identify locally relevant strategies.
- New rural workforce models are needed: To address specific rural mental health workforce challenges “grow‐your‐own” and “skills escalation” strategies appear promising. These approaches seek to identify existing local practitioners and residents with the potential to become future health and community service workers, peer supporters or volunteer navigators. These strategies require local incentives to encourage staff to work at the top of their scope of practice; “task‐shifting” to non‐clinical or community roles; effective supervision and governance structures. Workers involved could include personnel from the health sector in general, alcohol and other drugs workers, social care, police, social workers and finance/banking workers.
- Digital technology contributes now and can do more as part of new systems: Digital and telehealth services continue to play an important role in extending services to rural communities, but they are not a panacea and people might also need immediate face‐to‐face help or specialist advice and care. Understanding the place and value of online, digital and telehealth offerings is a significant research gap. Social media such as Facebook pages that are created and maintained by local practitioner‐community member collaboratives might be useful for people isolated by distance, culture, poverty, negative relationships or lack of connection. The use of online sources of care and support is partly dependent on increased access and expanded bandwidth.
- Enhance data collection, monitoring, linkage, analysis and planning: To address the issues of service fragmentation, gaps, duplication and lack of information sharing, there needs to be a substantial investment in better data collection, monitoring and evaluation to enable services to assess outcomes in a timely manner, thereby facilitating responsive service improvement activities.”