Sea change, tree change and the rural health workforce
Sea change and tree change have fast become part of the Australian dream. Sea-changers leave their city lifestyle to live in a smaller coastal community. Tree-changers leave the city to live in an inland rural area. While both lifestyle changes have appeal for people from across the demographic spectrum who wish to escape the big-city ‘rat race’, sea change and tree change are increasingly attractive to older Australians. Many people plan their retirement near the beach, on a well-treed hobby farm within a few hours’ drive of a major capital city, or in or near a pleasant rural town.
The population shift associated with sea change and tree change has obvious implications for health services. Older people tend towards higher prevalence of chronic and age-related health conditions, and when they move to rural or regional areas they contribute to increases in the demand for these services. Australia’s ageing population is exacerbating this trend.
In this article, we examine the phenomena of sea change and tree change, and what they mean for the rural health workforce.
What’s driving sea and tree change?
The connection between place and health seems very obvious; most of us experience visceral feelings of happiness and wellbeing in certain places, for various reasons. Interestingly, researchers only began to consider this link formally after Leon Gesler proposed his theory of therapeutic landscapes in 1992.
Gesler defines therapeutic landscapes as specific spaces of ‘healing’, and particularly where the natural environment intersects with the social. Most Australians live in major cities, where a leafy backyard or urban park could certainly act as a therapeutic landscape, despite obvious intrusions from urban constants such as traffic noise, crowding, air pollution and litter.
It’s fair to say that for many Australians the beach is a highly therapeutic landscape, and the ‘bush’ or the ‘country’ is not far behind. Thus a desirable goal for many of us would be to live within a landscape that promotes wellbeing in a perceived, subjective or even spiritual way – as well as in practical ways, such as enabling more outdoor physical activity and offering cleaner air.
Escaping the rat race
Dr Angela Ragusa’s study of tree changers, based on articles in the news media and in-depth interviews, revealed that urban stresses (traffic, commuting and high population density), alongside the ‘stereotypical expectations that country life is less stressful, more spacious, and less expensive’ were key ‘push’ factors encouraging people to abandon city life.
These expectations of rural life were not always realised. In an interview published in the Sydney Morning Herald (19 April 2009), Dr Ragusa said that most of her tree-changer interviewees (who moved from Sydney) were disenchanted and planned to move again – to another town, the coast or back to the city – within five years. The reasons given were ‘poor health care, poor road quality, fewer work opportunities, expensive food, lack of entertainment, obesity, lack of ethnic diversity, difficulty making friends, conservatism and narrow-mindedness.’
Nevertheless, positive stories about tree and sea changers abound. In early 2017, an ABC online article depicted retirees moving from inner-city Adelaide to Kyneton in central Victoria for health and lifestyle reasons. The article also described a couple leaving behind a two-and-a-half-hour commute in Melbourne for the lower cost of living and relaxed atmosphere of Mildura, and a family of four swapping South Melbourne for Tarrawingee, in north-east Victoria, motivated by a desire to live a quieter life (and to start a goat dairy and cheese factory). These and the other people featured in the article described many challenges involved in country living, but said the benefits outweighed them.
Spiralling housing costs are an important component of people leaving major cities. Both Sydney and Melbourne were labelled ‘severely unaffordable’ in Demographia’s 2017 Housing Affordability Survey. In this survey of 406 housing markets in nine countries, both cities were among the top 10 least affordable markets. Sydney was second, with a median house price more than 12 times the median household income, and Melbourne 10th, with a median price almost 10 times the median household income.
Some young people keen to enter the housing market turn to regional and rural areas, where a house can cost a fraction of comparable accommodation in Sydney or Melbourne. However, they do so at the risk of moving into a less secure and diverse employment market. In early 2017, Cameron Kusher, CoreLogic’s Head of Research, told news.com.au that ‘job creation outside of Sydney and Melbourne, particularly over the last five or six years, has been extremely weak so people don’t necessarily have the confidence that if they move to another part of the country they’ll be able to get a similar or better job’.
In contrast, would-be retirees can take advantage of historically high house prices to finance their sea or tree change, as employment is not such a concern. Australia’s inflated urban housing market is increasingly a driver and enabler of retiree sea and tree change.
Sea and tree change statistics
Quantitative data on sea and tree changers is scarce. In 2013, the Australian Bureau of Statistics (ABS) released the results of a study of people aged 55 years or older who lived in selected coastal local government areas (LGAs) of Queensland in 2011 and had moved between 2006 and 2011.
Around 22 000 (44 per cent) were sea changers who had moved from elsewhere, while around 27 000 (56 per cent) had moved within the selected areas. Most sea changers came from LGAs in or surrounding the major cities of Brisbane and the Gold Coast or the state of New South Wales.
Retirement appears to be a factor in many of these sea changes. The same ABS study showed that, of the 14 000 55–64-year-old movers to selected coastal LGAs in Queensland, 37 per cent were in the labour force in 2006 but not in 2011 – nearly twice the proportion of all 55–64 year olds in Australia in that category (19 per cent).
Recent ABS data show that an increasing proportion of inter-state and intra-state population movements are to sea or tree change regions on the outskirts of capital cities. Of the top 25 regions for net internal migration in 2015–16, 13 were sea-change and tree-change locations (mostly in areas close to capital cities).
Net internal migration to regional NSW, Melbourne, regional Victoria and Brisbane was the greatest it has been in at least 10 years. Coastal, regional areas of NSW and Victoria, along with Melbourne and Brisbane, are significant benefactors of deteriorating housing affordability in Sydney.
Responses to sea change: the Australian Coastal Councils Association
In early 2004, so-called ‘sea change’ councils from around Australia, representing areas experiencing substantial migration from urban regions, banded together to form the National Sea Change Taskforce. Their membership included 62 local councils, representing over four million people.
In July 2015, the National Sea Change Taskforce morphed into the Australian Coastal Councils Association (Inc.). It describes itself as ‘a national body which represents the interests of coastal councils and their communities’. In addition, it states that its role is to commission research on behalf of councils in coastal areas in relation to a range of coastal issues, including:
- the shortfall in resources to meet increasing demand for infrastructure and services
- coastal erosion and the projected impacts of sea level rise
- the legal risks faced by coastal councils in relation to planning for climate change
- proposed changes to arrangements for natural disaster funding, which will shift more of the recovery costs onto the States and local government
- the impact of tourists and other visitors on coastal communities
- the continuing impacts of high population growth in peri-urban and regional coastal councils.
While this list shows the Association is largely concerned with protection of local environments, ‘increasing demand for infrastructure and services’ and ‘the continuing impacts of high population growth’ suggest that it is at least aware of the population health issues associated with sea change.
Older people’s health
Australia has an ageing population. The Census counted 2.6 million people (13 per cent of the population) aged 65 years and over living in Australia in 2006, and over three million people (or 14 per cent of the population) in 2011. People aged over 65 years are projected to make up 19 per cent of Australia’s population by 2031.
The most common long-term health conditions (excluding short and long-sightedness) among older Australians are arthritis (affecting 49 per cent of those aged 65 and over), hypertensive disease (38 per cent) and hearing loss (complete or partial) (35 per cent). Just over one in five older people (22 per cent) have heart, stroke and vascular diseases, 15 per cent have diabetes and 7 per cent have cancer. The cohorts of Australians that will enter the ‘65 and over’ age bracket in coming decades will do so with even larger burdens of lifestyle-related diseases (notably type 2 diabetes).
As we noted in a previous article, Australians living outside capital cities are already older and have significantly poorer health and lower life expectancy than their urban counterparts. They experience higher prevalences of back pain, asthma, deafness and overweight or obesity. An ageing population and an increasing proportion of older sea and tree changers will accelerate the demand for more age-related and chronic disease-focused health services outside capital cities.
The rural health workforce
It’s long been recognised that we have a problem attracting health professionals to live and work outside major capital cities, and national and State-based initiatives have been implemented to try to overcome the problem. The National Strategic Framework for Rural and Remote Health (NSFRRH), released in 2011, was described in an earlier In Brief article. It aims to ‘improve health outcomes and return on investment for rural and remote Australians’ – meaning people living in all areas outside Australia’s major cities – and presents a strategic vision for health care for Australians living in regional, rural and remote areas.
Numerous initiatives in rural health, aligned with the NSFRRH, are designed to increase the size of the workforce and improve coordination. They include the following.
Primary Health Networks
Thirty-one Primary Health Networks (PHNs) operate across Australia. They are designed to improve patient outcomes by reducing fragmentation of care. General practice is central to the PHN concept. PHNs’ GP-led Clinical Councils and representative Community Advisory Committees must work closely with public and private hospitals, Aboriginal Medical Services, nurses, allied health providers, health training coordinators, State and Territory government health services, aged care providers and private health insurers.
The Western Victoria PHN covers the same geographical footprint as Western Alliance (and is a key partner in the Alliance). Regional centres have been established in Ballarat, Geelong, Horsham and Warrnambool. The PHN focuses the four strategic pillars of regional health planning, commissioning, GP and primary care development, health system integration and clinical services.
The Rural and Remote General Practice Program
The Rural and Remote General Practice Program (RRGPP) funds Rural Workforce Agencies in each state and the Northern Territory to improve the recruitment and retention of GPs to rural and remote areas. It helps communities to recruit GPs, find placements for doctors who want to relocate to rural Australia, assist with relocation costs, support their families to fit into a new community, and helps doctors to access the infrastructure, support and training they need.
In 2016, the Rural Workforce Agencies:
- recruited 549 new doctors, nurses and allied health professionals for rural communities and Aboriginal Medical Services
- supported 6000 health professionals and 1800 rural practices
- arranged locum relief for 606 rural doctors so they could take a break
- supported more than 2500 rural doctor families
- provided rural relocation grants to 58 dentists
- engaged hundreds of university health students in positive rural experiences such as rural high school visits and Go Rural career events.
Incentives for rural GPs
The General Practice Rural Incentives Program (GPRIP) provides substantial financial incentives for GPs to work outside large urban centres. GPs working in rural or remote areas, and in (or near) towns of up to 50 000 people are eligible for payments on a sliding scale based on geographical remoteness/population size and years of service.
Like the GPRIP, the Bonded Medical Places (BMP) Scheme aims to increase the numbers of doctors in areas experiencing shortages. The BMP Scheme funds universities to offer 600 additional medical school places each year for students willing to commit to training and/or working in a district of workforce shortage.
Twenty-five per cent of all first-year, Commonwealth-supported medical school places are allocated to the BMP Scheme. Candidates commit to working in their chosen DWS area (outer metropolitan, rural and remote areas) after graduating, for a period of time equal to the duration of their medical degree.
Regional training hubs
In April 2017, it was announced that Deakin University had obtained federal funding to establish a Western Victorian Regional Training Hub to deliver generalist specialist training and assist with general practice training, based at South West Healthcare in Warrnambool. The Western Victorian Hub is one of 26 regional hubs located across Australia.
Federal Member for Wannon, Dan Tehan said the Western Victorian Regional Training Hub would give medical students in western Victoria more opportunity to live, study and work closer to home. ‘This will enable students to continue rural training through university into postgraduate medical training, and then working within regional and rural Australia,’ Mr Tehan said.
The effectiveness of rural and regional health workforce initiatives
Governments and universities continue to acknowledge rural health workforce shortages and agree that existing initiatives are not working as well as they should. Charles Sturt University and La Trobe University have argued that Commonwealth backing for medical student places at regional universities is the key to solving the shortage of country doctors, a position supported by the National Rural Health Alliance CEO David Butt. The regional training hubs are therefore a welcome addition to the suite of programs intended to expand the rural health workforce.
Sea change and tree change are established Australian phenomena, and are likely to accelerate as our ageing population retires and house prices in capital cities escalate. The effects of sea change and tree change are recognised by all levels of government, as is the existing health deficit in regional and rural Australia. Existing programs that seek to improve health care outside capital cities must be sustained and expanded in order to cope with growing demand for age-related health services in sea change and tree change areas.