19TH World Rural Health Conference

The Limerick Declaration on Rural Healthcare

2022

Introduction

The 19th World Rural Health Conference, hosted in rural Ireland at the University of Limerick, has carefully considered how best rural communities can be empowered to improve their own health and the health of those around them. The conference was addressed by experts in rural health from all regions of the world and this conference declaration is in response to the “Blueprint for Rural Health”(1), the declaration from the 17th World Rural Health Conference in Bangladesh, which was designed to inform rural communities, academics, and policy makers about how to reach the goal of delivering high quality health care in rural and remote areas most effectively.

 

Guiding Principles based on “Blueprint for Rural Health”

 

The 19th World Rural Health Conference and its partners and hosting organisations* assert the right of rural communities to equitable access to healthcare:

  • Rural Healthcare Needs and Delivery

Equitable access to rural healthcare should address all basic healthcare needs and be based around a comprehensive, locally-based healthcare infrastructure. Patient-centred care pathways should be co-designed with rural communities and enhanced, but not replaced, by technology.

  • Rural Workforce

A sustainable Rural health workforce should as much as possible come from the local communities they serve and be incentivised, supported, mentored and valued throughout the career pathway. Social accountability should be a key underlying principle for higher educational institutions who should orientate their training, research, and service provision to populations living in rural and remote areas.

  • Advocacy and Policy

Policy for rural health should include rural communities and rural organisations as key stakeholders and equal partners whose needs and views are sought and who participate in decision making as key informants about rural health. Government policies should be rural proofed to mitigate any deleterious effects of such policies in rural areas and Governments should develop a unified policy to promote rural health. A successful and sustainable rural health sector requires inter-sectoral collaboration and investment in training and career pathways, creating a desirable workplace that healthcare workers will commit to for the longer term.

Case Study: Irish Rural Healthcare

The delegates recognise:

  • That Ireland has one of the highest rural based populations in Europe – more than 1.6 million people, from a total population of 4.8 million(2). Irish rural practices have a higher proportion of older people, with more health needs, than other practices(3). Irish rural populations have already experienced the negative impact of loss of medical services followed by continuing depopulation; unless specifically managed, this phenomenon will only increase(4). It is crucial that issues of density and distribution of health workers are addressed in order to attain better health outcomes for rural communities.

  • The absolute and relative number of rural Irish General Practitioners (GP) has been falling over the past twenty years(2). Those that remain are older than the national GP average. Key rural GP recruitment and retention difficulties include significant challenges in finding both short-term cover and long-term replacements, together with inadequate infrastructural support for often smaller list sizes(4).

  • With the notable exception of the University of Limerick, Irish medical schools do not provide the internationally recognised gold standard for the promotion of generalism,  namely Longitudinal Integrated Clerkships (LIC) in general practice(5).

  • The significant potential for rural general practice nurses to both complement and support the work of GP’s is not being realised. Significant barriers to achieving this coalesce around a lack of advanced practice nursing roles and the absence of a clear career pathway and funded educational opportunities(6).

  • There is no government target regarding the proportion of Irish medical graduates required in general practice to deliver ‘Sláintecare’ (Irish government health policy)(7). Between the six Irish medical schools, the proportions of European Union (EU) graduates who apply for postgraduate general practice training places ranges from 25-55% - a 2.2 fold difference(8). The reasons for this are unclear. Sláintecare is predicated on having a health service with a foundation in primary care where the right care is delivered to the right patient in the right place at the right time. This is a very sensible and also evidence-based founding principle as we know that over 90% of healthcare contacts happen in the community and any healthcare system that has primary care as its foundation is more cost-effective and delivers better health outcomes for people.(9) However, this will not be achieved without recruiting and retaining a healthcare workforce, in our urban centres, but more critically outside our urban centres where they are most under threat.

Congruent with current evidence (10) and best international practice (1, 11), the delegates of the conference endorse the following recommendations:

Rural Healthcare Needs and Delivery

  • A national health needs assessment of Rural Healthcare should be carried out and communities should be enabled and resourced to identify and address, and indeed solve, their local health care challenges.

  • Rural services must provide first contact care which can be accessed within the community. Closure of rural healthcare services and practices or downgrading of such services to a “part time” basis must be avoided at all cost and innovative measures to ensure service continuity such as shared appointments, salaried posts and fellowship programmes must be funded and developed.

  • The current focus on large urban based healthcare infrastructure development should be widened to include investment in rural healthcare infrastructure to ensure decent working conditions for rural health workers. This will include funding to cover investment in innovative technological solutions to enhance but not replace the face to face service.

  • Essential rural and remote services such as dispensing of medication and house calls need to be specifically and properly funded and supported. Current funding mechanisms do not exist or are inadequate.

  • To support community-based education programmes and the associated ‘transformative learning’(5), medical schools need to develop rural academic educational and research infrastructure closely aligned to the communities which they serve.

 

Rural Workforce

  • We need targeted admission policies to enrol students with a rural background in health worker education programmes.

  • Under the principle of social accountability, all medical schools should develop, with appropriate funding, LIC’s in general practice, with a particular focus on rural practice and have a curriculum which has a minimum of 25% of clinical placements based in the community setting.

  • A specific rural curriculum and pathway should exist within GP training where Rural GP trainers/mentors should be recruited and retained and exposure to rural practice should be maximised.

  • On completion of GP training, postgraduate Rural General Practice fellowships funded by the National Doctors Training and Planning (NDTP) and the Health Service Executive (HSE) should form the next step of this Rural General Practice career pathway.

  • Training at the medical school and postgraduate GP training levels should be based on curricula that include rural context and criteria for effective rural practice.

  • In single-handed rural practices, a statutory minimum of locum cover for sick leave, maternity leave and holiday leave should be provided.

  • Local HSE management, working with GP Network leads and GP principles should identify and offer support, guidance and mentoring in succession planning for retiring and pre-retiring GP principles on an ongoing basis.

 

Advocacy and Policy

  • An All–Party Oireachtas Health Committee inquiry and report into Irish Rural Healthcare needs and services should be convened. This will provide a clear blueprint for the Irish Department of Health, the HSE and the Irish College of General Practitioners for Irish Rural Healthcare into the future.

  •  Development of a clear rural general practice career pathway (or ‘pipeline’). A target regarding the proportion of Irish medical graduates required in general practice to deliver ‘Sláintecare’ should be set. The equivalent figure in the UK is 50%(12).

  • We need to deploy a package of fiscally sustainable financial and non-financial incentives for health workers practising in rural and remote areas. The Rural Practice allowance is one such key support but access to it needs to be widened and it needs to be increased. To maximise rural GP retention, ‘family friendly’ infrastructural supports such as provision of holiday, maternity and sick leave support should be guaranteed and facilitated through innovative job-sharing, retainership and joint appointment schemes or through locum arrangements. In certain individual settings, provision of salaried rural positions should be considered.

  • To provide clinical, academic and advocacy leadership in Rural healthcare,  Chairs of Rural General Practice should be funded within higher education institutions with, in addition, an ICGP Clinical Lead in Rural Healthcare .

  • The Irish Department of Health should lead an inter-agency response to develop and support GP nursing career development which leads to advanced practice nursing roles together with the provision of clear nursing career pathways.

  • Different types of health workers for rural practice such as expanded paramedic roles and advanced nurse practitioner roles to meet the needs of communities based on people-centred service delivery models including enhanced scopes of practice should be developed.

 

Conclusion

All participants in this conference and the partner organisations commit to proactively adopting these principles and actions. In addition, we call on Governments, Policy makers, Academic institutions and communities globally, to commit to providing their rural dwellers with equitable access to healthcare which is properly resourced and fundamentally patient-centred in its design.

 

References

1.            Health WWPoR, editor Blueprint for Rural Health. 17th World Rural Health Conference

Conference Declaration; 2021; Bangladesh.

2.            Office CS. Urban and Rural Life in Ireland, . Dublin: CSO, 2019.

3.            Homeniuk R, OCallaghan, M., Casey, M., Glynn, L. Rural general practice: past, present and future. Forum. 2021;November; 24-5.

4.            Cowley J. Re-imagining ireland’s rural health service. . Forum. 2021;December: 40-1.

5.            O’Regan A. Rural WONCA’ and ‘C-LIC’ – a great match for Limerick Forum. 2022;April 23-4.

6.            Doogue R. GPN’s can build general practice capacity. Forum. 2022;March: 37.

7.            Health Do. Sláintecare. 2022 [cited 2022 3rd May].

8.            Murphy AW, Moran, D., Smith, S.M., Wallace, E., Glynn, L.G., Hanley, K., Kelly, M.E. Supporting medical students towards future careers in general practice: a quantitative study of Irish medical schools. .  Annual Scientific Meeting of the Association of University Departments of General Practice in Ireland,; Dublin2022.

9.            Starfield B, et al. Contribution of Primary Care to Health Systems and Health. The Millbank Quarterly. 2005.

10.          Strasser S. Retention of the health workforce in rural and remote areas: a systematic review. . Geneva: WHO, 2020.

11.          Abelsen B, Strasser R, Heaney D, Berggren P, Sigurðsson S, Brandstorp H, et al. Plan, recruit, retain: a framework for local healthcare organizations to achieve a stable remote rural workforce. Human resources for health. 2020;18(1):63.

12.          Health. UDo. Delivering high quality, effective, compassionate care: Developing the right people with the right skills and the right values. A mandate from the Government to Health Education England. London: Department of Health, 2015.

 

* The Irish College of General Practitioners; University of Limerick, School of Medicine; Rural, Island and Dispensing Doctors of Ireland; WONCA Working Party on Rural health; European Rural and Isolated Practitioners Association (EURIPA); the National Centre for Rural and Remote Medicine (UK); the Scottish Graduate Entry Medical Programme (ScotGEM); HRB Primary Care Clinical Trials Network Ireland; and the Association of University Departments of General Practice in Ireland (AUDGPI).

Please send all feedback and comments to : academicWRHC2022@ul.ie