NSW Rural Health Plan Issues Paper NSW HealtH PaGe 1
Improvements in NSW rural health services since 2002 .................................3
NSW rural health in 2013: current initiatives supporting rural health..............5
Rural and remote health issues in 2013............................................................6
Current initiatives supporting rural health in NSW...........................................9
PaGe 2 NSW HealtH NSW Rural Health Plan Issues Paper
Just over a quarter of the people in New South Wales
live outside the three major cities of Sydney, Newcastle
There has been significant improvement and investment
in rural health services since the last rural health plan
was released in 2002, including a substantial increase
in the rural health workforce and investment in rural
The following information illustrates the improvements
to NSW rural health care since 2002:
■ People in rural NSW now receive 87% of their
health care within their Local Health District
(LHD) compared with 82% in 2002.
■ In 2013, 95% of the NSW population has
access to a Cancer Care Centre within 100kms
of their residence. In 2002, there was one Cancer
Centre in Rural NSW. In 2013, there are six.
■ The NSW Health rural workforce increased
by Medical – 59.3%, Nursing – 13.8%,
Allied Health – 43.2% from 2007 to 2012.
■ The NSW Government spent $3.56 billion in
2011/12 on rural NSW health services compared
with $1.72 in 2002/03.
■ The NSW Government has made a record
investment of $1.7 billion in rural and regional
health infrastructure in its first term of
But despite these improvements, health services and
people living in rural and remote NSW still experience
some challenges due to a range of factors including:
geographic isolation, socioeconomic disadvantage, poorer
access to health services, greater exposure to injury risks
and Aboriginal populations with a high prevalence of
health risk factors and diseases.
In November 2012, the Minister for Health and Minister
for Medical Research, Jillian Skinner, announced the
establishment of a Ministerial Advisory Committee for
Rural Health in recognition that issues faced by rural,
regional and remote communities in NSW are different
to those in metropolitan areas.
The Committee, which reports directly to the Minister,
will ensure that the voice of rural NSW is heard and
provide advice to the Minister about issues of concern
to rural communities.
The Ministerial Advisory Committee for Rural Health is
co-chaired by the Parliamentary Secretary for Regional
Health, Melinda Pavey and Associate Professor Austin
Curtin, a surgeon from Northern NSW. The membership
comprises clinicians, community members and members
of Local Health Districts (LHDs) from rural, regional
and remote NSW.
The committe will also assist in the development of the
NSW Rural Health Plan. It is intended that the next rural
health plan will identify innovative solutions for rural,
regional and remote health in NSW. Noting the
considerable new expenditure on health service
infrastructure and the devolution of decision making to
the Local Health Districts, the plan will focus on initiatives
and strategies where further work is required.
This Issues Paper has been drafted to support the
consultation process that will be sponsored by the
Ministerial Advisory Committee as part of the
development of the NSW Rural Health Plan.
The paper outlines the following:
■ improvements in rural health services in NSW since
the release of the last NSW rural health plan in 2002
■ current issues for rural health in NSW
■ a series of questions for the consideration of
■ information on how stakeholders can respond to these
questions and provide input into the development of
the NSW Rural Health Plan (see page 8).
NSW Rural Health Plan Issues Paper NSW HealtH PaGe 3
Significant progress has been made since the release of the last NSW rural health plan in 2002. Information on the key
achievements relating to the initiatives in the 2002 Plan is outlined below (with an emphasis on recent achievements):
KEY ACHIEVEMENTS SINCE 2002
nurses and allied
in rural communities
Considerable increases in clinician numbers illustrated by comparisons by financial year of average estimated
fulltime equivalent rural staffing of Medical, Nursing, Allied Health & Oral Health and VMO by headcount.
CLINICIAN TYPE JUNE 2007 JUNE 2012 VARIATION
Medical 724 1153 429 59.3%
Nursing 9018 10259 1241 13.8%
Allied Health 1263 1809 546 43.2%
Oral Health Practitioners 181 202 21 11.6%
Total FTE for
11186 13423 2237 20.0%
Visiting Medical Officer
(VMO) - Headcount
2311 2778 467 20.2%
Note: from 2007 to 2012 the NSW Rural Population increased by 2%
There are a significant number of initiatives underway to support, develop and recruit the NSW rural health
■ NSW Health Professionals Workforce Plan 2012-2022
■ NSW Area of Need Program
■ Medical Specialist Outreach Assistance Program.
Since 2002 specialist services in rural and remote NSW have expanded considerably:
■ Cardiac Catheterisation Laboratory services in Tamworth, Orange, Coffs Harbour and Lismore. Wagga
Wagga has arrangements for this service through a private provider.
■ Specialist cancer services including radiotherapy services in Port Macquarie, Coffs Harbour, Tamworth,
Wagga Wagga, Lismore and Orange Hospital.
■ Acute stroke services have been established in Coffs Harbour, Armidale, Port Macquarie, Shoalhaven,
Orange, Bathurst, Tweed and Wagga Wagga. The NSW Stroke Reperfusion Program, led by the Agency
for Clinical Innovation (ACI), in partnership with the Ambulance Service of NSW and the state’s Local
Health Districts commenced in 2013 and is being rolled out across 20 hospitals, including Orange,
Bathurst, Wagga Wagga, Tamworth and John Hunter Hospital.
■ Renal Dialysis and Trauma services have also been expanded in rural and remote NSW.
■ Mobile services have been introduced including Mobile Xray services for TB Screening in indigenous
The Isolated Patients Travel and Accommodation Assistance Scheme (IPTAAS) has undergone significant
reforms to improve transport and accommodation support for rural patients, including:
■ From 1 January 2012, eligibility for travel and accommodation subsidies have been broadened to cover
patients travelling at least 200 kilometres per week (cumulative distance).
■ These changes particularly benefit patients, such as renal dialysis and cancer patients, who have to travel
regularly to access specialist medical treatment.
■ From 1 January 2013, changes have been introduced to greatly simplify the previously complex IPTAAS
Improvements in NSW rural
health services since 2002
PaGe 4 NSW HealtH NSW Rural Health Plan Issues Paper
KEY ACHIEVEMENTS SINCE 2002
Securing the future
of rural hospitals
There has been a significant increase in support for rural health services, including the establishment
of the Agency for Clinical Innovation (ACI) and the Health Education and Training Institute (HETI).
NSW has an extensive network of telehealth services supporting a wide range of specialist services including
a range of diagnostic, treatment and rehabilitation services. Telehealth services are currently available
in 396 rural locations. There are numerous telehealth specialist network services operating to link rural
and metropolitan facilities. Some examples are:
■ Paediatric Child Health Network linking rural sites for clinical education
■ Rural Stroke Care Co-ordinator Network linking rural stroke units with metro centres
to standardise clinical guidelines and care
■ Burns referral services linking rural sites to Concord, RNSH and Westmead for diagnosis
and treatment plans
■ Aged Care and Rehabilitation links with Royal Ryde Rehabilitation.
The NSW Government rural and regional hospital redevelopment (including Commonwealth Government
collaboration projects) schedule includes:
■ Tamworth Base Hospital – $220 million investment. New acute hospital. The project is due for
completion early 2016.
■ Wagga Wagga Base Hospital – $270 million investment. Construction of 50 bed mental health unit
to be completed late 2013. Hospital construction completion late 2016.
■ Dubbo Base Hospital – $79.8 million investment. Completion scheduled for mid 2015. Hospital upgrade
includes Dubbo Mental Health Rehabilitation Unit which was completed February 2013.
■ Port Macquarie Base Hospital – $110 million investment. Due to be completed in 2015.
■ Kempsey Hospital – $80 million investment. Scheduled completion late 2015.
■ Lismore Hospital – $80 million investment. New and expanded emergency department with 31 spaces,
plus Emergency Medicine Unit with 12 treatment spaces. Main works to commence 2014.
■ Bega, South East Regional Hospital – $170 million investment. New hospital will include an expanded
emergency department, emergency medicine unit and additional operating theatres. Construction due
to be completed early 2016.
■ Lachlan Health Service including the Parkes new hospital and Forbes hospital redevelopment.
$12.5 million has been allocated in the 2013-14 Budget to progress the development of the Lachlan
■ Cancer Centres, including the newly completed North West Regional Cancer Centre and the Shoalhaven
Regional Cancer Centre ($10 million project in 2013).
■ As at September 2012, there were a total of 54 Multi Purpose Services operational and a total
of 59 services that have been redeveloped and are delivering services under the integrated care
approach of the MPS model. Current Multi Purpose Service projects include:
■ Lockhart MPS – NSW Government commitment of $8 million
■ Gulgong MPS – NSW Government commitment of $7 million
■ Peak Hill MPS – NSW Government commitment of $6 million.
A voice for
The NSW Government has ensured rural communities have a stronger voice, through:
■ Appointment of the Parliamentary Secretary for Regional Health.
■ Establishment of the Ministerial Advisory Committee for Rural Health
■ Greater local decision making through the appointment of Local Health Districts and Governing Boards
to allow decisions about health care to be made close to patients by local representatives who know and
understand their communities, have control of their budgets and manage their workforce in a way that
reflects the needs of patients.
■ Establishment of the ACI’s Rural Health Network supporting rural clinicians and services through further
development and improvements to rural models of care.
NSW Rural Health Plan Issues Paper NSW HealtH PaGe 5
NSW rural health in 2013:
current initiatives supporting
Recommendations and strategies included in the NSW
Rural Health Plan will build on the continuing and
considerable work that is underway to improve health
services in rural areas.
The Appendix provides information about initiatives to
develop health services in rural NSW that are currently
being undertaken by the Ministry of Health, Health Pillar
Organisations and other health organisations.
The NSW Rural Health Plan will focus on solutions,
initiatives and strategies where further work is required or
where there is an identified need for further
It is proposed that the NSW Rural Health Plan build on
the goals of The National Strategic Framework for Rural
and Remote Health released in 2012.
The goals of the Framework are that rural and remote
communities will have:
■ Improved access to appropriate and
comprehensive health care
■ Effective, appropriate and sustainable health
care service delivery
■ An appropriate, skilled and well-supported
■ Collaborative health service planning and policy
■ Strong leadership, governance, transparency
PaGe 6 NSW HealtH NSW Rural Health Plan Issues Paper
Prior to the first meeting of the Ministerial Advisory
Committee for Rural Health in March 2013, initial
consultation was held with Committee members and the
Agency for Clinical Innovation Rural Health Network. This
consultation identified the following as key issues for
rural and regional health:
1. Workforce issues relating to recruitment,
retention and training
2. The need to work together and improve
the coordination of care
3. The need for better access to specialty
services and tailored rural health services
models of care
4. Community expectations for health services
delivered in their local areas
5. Enhanced Information and Technology
6. Strengthened Administration, Coordination
A summary of each of these identified issues
is outlined below:
1. Workforce issues relating
to recruitment, retention
The rural health workforce needs to be developed in
keeping with cross-disciplinary and generalist requirements
which are particularly important in rural areas.
In the overall remodelling of health practice in rural and
remote areas, inter-professional education and ongoing
training is essential.
There is a critical need to expand existing scopes of
practice and create new roles to optimise workforce
capacity and to meet health care needs. The development
of more advanced roles for rural General Practitioners,
including in obstetrics, surgery and anaesthetics, and
nurse practitioners is seen as a useful strategy to
strengthen and maintain a skilled rural health workforce.
It is also important to consider the roles and scopes of
practice of a wide range of other health care workers
including remote health workers, nurses, allied health
workers, midwives, Indigenous health workers and
vocationally trained workers.
2. The need to work together and
improve the coordination of care
Improving coordination of care and reducing the silos
between local service providers such as Local Health Districts,
other government agencies, community General Practitioners,
Non Government Organisations, Medicare Locals and
pharmacies in small rural communities is crucial.
This will ensure a reduction in duplication and improved
patient care. Examples identified where the coordination
of care could be improved include: coordination between
community services working within communities such as
health and disability; Medicare Locals and their role in
working with Local Health Districts in community health/
primary care delivery; improved communication between
hospital, General Practitioners and pharmacies; and cross
border coordination issues.
3. The need for better access
to specialty services and
tailored rural health services
models of care
To achieve better outcomes in access and equity, it is
necessary to develop and apply service models and
models of care that are appropriate for, and respond to,
the unique challenges of delivering quality care in rural
and remote settings and that support continuity of care.
In NSW, significant investment has been made to improve
health services in rural and remote communities and to
create better, more flexible approaches to care. Yet there
remains scope to apply and expand new and innovative
approaches in delivery.
Rural and remote health
issues in 2013
NSW Rural Health Plan Issues Paper NSW HealtH PaGe 7
The infrastructure and care models of Regional Base
Hospitals and Multi Purpose Services have been
developed considerably over the last ten years. Further
consideration of the models of care provided by District
Hospitals is required. Rurally based general hospitals with
less than 100 beds are District hospitals. Further
deliberation on ways to maximise the value of these
hospitals to their communities is sought.
The nation-wide focus on out-of-hospital care and
hospital avoidance strategies has resulted in increased
numbers of patients with acute, complex conditions
being cared for in the community. This requires an
increase in resources and skills for Community Health
services, to incorporate and utilise these changing models
of care which benefit rural communities.
Further solutions in patient transport also need to be
considered as an issue affecting rural community access
to specialty services.
The difference in life expectancy between the general
population and Aboriginal people, many of whom live in
rural NSW, is estimated to be approximately 7-9 years.
The greatest contributors to higher mortality rates and
excess deaths experienced by Aboriginal people are
chronic disease, in particular cardiovascular disease,
mental health, diabetes, cancers, and injury. Additionally
access to care (including transport issues) can be a
significant issue for Aboriginal people living in rural and
remote areas. A continued focus on improving the health
of NSW rural Aboriginal people is required.
4. Community expectations
for health services delivered
in their local areas
Community expectations of what services can, or should,
be provided in each community was cited as a key issue.
Currently, all health services are not able to be provided
in all cities and towns in NSW. This is due to a variety
of factors including: the viability and sustainability of
service delivery; ensuring safety and quality standards;
complexity of services; health workforce requirements;
limited specialised equipment; and the cost of service
provision. Further, ensuring that what services are
deliverable is made clear, and the equity and quality
n of access, is crucial.
5. Enhanced Information
Improving the use, capacity and availability of technology
for training, information management and delivery of
health services is an issue for rural health.
Further, the use of – eHealth, remote monitoring and
Telehealth – as part of a coordinated and integrated
service model will assist in achieving improved access and
outcomes for rural and regional communities. eHealth
services reduce travel time for service users, as medical
expertise and advice can be provided remotely.
6. Strengthened Administration,
Coordination and Research
Improving administration, research capacity and support
for rural Local Health Districts, particularly for small and
diverse rural Local Health Districts is needed.
The Health Pillar agencies and NSW Ministry of Health
need to develop programs, policies and clinical guidelines
in ways which rural districts can easily roll out as the
health problems faced by rural and remote communities
are complex and not amenable to simple or short-term
Investing in research is important in developing
sustainable long term solutions as outlined in the NSW
Government Response to the NSW Health & Medical
Research Strategic Review. This will enable the
development of a better evidence base for rural health
policy and service development.
PaGe 8 NSW HealtH NSW Rural Health Plan Issues Paper
This Issues Paper has been developed to facilitate
consultation with stakeholders. The following questions
are for the consideration of stakeholders:
1. Do the issues outlined in this Issues Paper
reflect the key issues for rural and regional
health in NSW?
2. How should the delivery of NSW rural health
services change in the next five years?
3. What solutions /initiatives should be
considered to address the key issues
for rural and regional health?
4. Are there other relevant matters which have not
been identified in this Issues Paper?
Consultation on this Issues Paper and on the
development of the NSW Rural Health Plan will include
online, written and face-to-face consultation with
communities, other agencies and health services/
providers. Further information can be found on the NSW
Rural Health Website: http://www.health.nsw.gov.au/rural
How to make a Submission
NSW Health encourages stakeholders to make submissions
on any matters raised in this Issues Paper or in relation
to rural health in NSW. It is requested that stakeholders
provide submissions by 30 September 2013.
To support the involvement of stakeholders in decision
making on Government policy, services and projects, the
NSW Government has developed a website for agencies
and stakeholders to provide feedback. Input into the
development of the NSW Rural Health Plan can be made
using NSW Government Have Your Say website.
Submissions on this Issues Paper may be lodged through
the Have Your Say website: http://www.haveyoursay.nsw.
Please note that the Have Your Say website is the
preferred method for written input into the development
of the NSW Rural Health Plan, however submissions can
also be made to the contact person below. For more
information about the NSW Health Rural Health Plan
Ms Simone Proft, Secretariat
Ministerial Advisory Committee for Rural Health
NSW Ministry of Health
Phone. (02) 9391 9182
NSW Rural Health Plan Issues Paper NSW HealtH PaGe 9
NSW Ministry of Health
NSW Aboriginal Health Plan 2013-2023
Other Initiatives: The Knockout Health Challenge
(linked to obesity and chronic disease prevention
initiatives); Aboriginal Injury Prevention Demonstration
Health Protection NSW
NSW Health Drinking Water Monitoring Program; NSW
Health Water Unit Quality Assurance Program (QAP);
Housing for Health; Aboriginal Environmental Health
Officer (EHO) Training Program.
Health System Planning and Investment
Rural Capital Program, Rural Adult Emergency Clinical
Guidelines; Telehealth (services are currently available
through 628 videoconference units across the state,
of which 396 are in rural locations); development of Multi
Grants Management Improvement Program (GMIP);
HealthOne NSW; Pharmacy Health Check; S19(2)
exemptions; NSW Government plan to increase access to
Palliative Care 2012-2016; NSW Health Framework for
Women’s Health 2013; Policy and Implementation Plan
for Healthy Culturally Diverse Communities 2012-2016;
NSW Refugee Health Plan 2011-2016; Aged Care
Assessment Teams Protocols & Procedures; Home and
Community Care Program (HACC); NSW Health Disability
Action Plan 2009-2014; Isolated Patients Travel and
Accommodation Assistance Scheme.
Community Engagement & Action Program; Specialist
Mental Health Services for Older People; Housing
and Accommodation Support Initiative (HASI).
Nursing and Midwifery
Post Graduate Rural Student Midwifery Scholarships;
Rural and Remote Connect Program; Essentials of Care
Program – cultural change in hospitals/health care
services; Aboriginal Nursing and Midwifery Cadetship
Program; Enrolled Nurse Scholarships; Increasing
employment of clinical nurse, midwife educators and
specialists; Re-entry to Nursing Scholarships; Development
of Nursing and Midwifery Leadership Programs (HETI
partnership); Intensive Care Best Practice Manual Project.
Oral Health 2020: A Strategic Framework for Dental
Health in NSW including initiatives for workforce
incentives, improved education and training
opportunities, enhancement of Regional and Rural
Oral Health Centres and improved linkages and
partnerships with University programs.
Voluntary Dental Graduate Year Program; Water
Fluoridation Program; NSW Aboriginal Oral Health
Program; NSW Oral Health Capital Strategy 2011-2020;
Mobile dental vans; School-based dental clinics;
Integrated health promotion; Aboriginal Oral Health
“Hub and Spoke Program”; Flying Doctor “Tooth”
Outreach Dental Service.
supporting rural health
PaGe 10 NSW HealtH NSW Rural Health Plan Issues Paper
Preventive Health: Healthy Children Initiative including
support for: Munch and Move Program; Live Life Well @
School Program; Go4Fun; Get Healthy Information and
Coaching Service® (GHS); Social Marketing to Young
People – prevention of lifestyle related chronic disease.
HIV & Sexually Transmissible Infections: NSW HIV
Strategy: A New Era 2012-2015; NSW Sexually
Transmissible Infection (STI) Plan 2013-2016; Needle and
Syringe Program (NSP); Hepatitis B & C education and
Tobacco: NSW Tobacco Strategy 2012-2017, including
development of Quit for New Life Program for pregnant
Falls Prevention: NSW Health Falls Plan – Prevention of
Falls and Harm from Falls among Older People 2011-2015
including: Stepping On Program; Active and Healthy
Website; Falls Network Rural Forums – with Clinical
Excellence Commission, Agency for Clinical Innovation
and other partners.
Healthy Workers: Healthy Workers Initiative.
Diseconomies of Scale Project; Locum Review – Rural
Strategy; Rural Information Technology (IT) Solutions;
Cross border patient flow solutions; Rural Medical Staff
Employment initiatives; LHD Diagnostics.
Health Professionals Workforce Plan 2012-2022.
Key components of the plan include: Integrated and
comprehensive workforce planning; Effective working
arrangements; Collaborative health system; Support
for local decision making; Effective health professional
managers and leaders; Recognition of generalist and
specialist skills; Support for a skilled workforce; Effective
use of health care workforce
Rural Scholarships for Medical Trainees; Area of Need
Currently in development
NSW State Health Plan; Bilateral Plan: Implementation
of National Primary Health Strategic Framework;
NSW Health Drug & Alcohol Plan.
NSW Health Organisations
Ambulance Service of NSW
Stroke Reperfusion; Paramedic Connect; Authorised Care;
State Cardiac Reperfusion Strategy; Aboriginal Cardiac
Education Program; Rural Paramedic Scoping Project;
Rural Mental Health Emergency Transport (RMHET)
Project; Clinical Emergency Response System Assistance
HealtheNet; Expansion of Electronic Medical Records
(EMRs) in NSW; Primary Care Connectivity; Telehealth/
Teleconnectivity; e-Learning; Health Wide Area Network.
Sydney Children’s Hospital Network
Outreach clinics for remote and rural areas;
Videoconferencing between clinicians at tertiary centres
and regional sites; locum relief for isolated paediatricians;
network support incorporating rural LHD partners to help
rural clinicians provide quality care for children and
families as close to their homes as possible.
NSW Rural Health Plan Issues Paper NSW HealtH PaGe 11
NSW Health Pillars
Agency for Clinical Innovation (ACI)
ACI has 29 Clinical Networks, Taskforces and Institutes
providing forums for health professions and consumers to
design and support implementation of models of care
The ACI Clinical Networks are: Aged Health; Anaesthesia
Perioperative Care; Blood and Marrow Transplant; Brain
Injury Rehabilitation; Burn Injury; Cardiac; Emergency
Care Institute; Endocrine; Gastroenterology;
Gynaecological Oncology; Institute of Trauma and Injury
Management; Intellectual Disability; Intensive Care
Coordination and Monitoring Unit; Musculoskeletal;
Neurosurgery; Nuclear Medicine; Nutrition;
Ophthalmology; Pain Management; Palliative Care;
Radiology; Rehabilitation; Renal; Respiratory; Rural Health;
Spinal Cord Injury; Stroke; Transition Care; Urology.
There are 18 models of care that will be further
developed in 2013.
Cancer Institute NSW
Anti-tobacco campaign; investment in cancer research;
increase in access to multidisciplinary cancer teams in
rural and regional areas of NSW; online tool ‘eviQ’ which
provides up-to-date treatment information includes an
Opioid Conversion Calculator for clinicians to safely
convert one opioid regimen to an equianalgesic dose of
Clinical Excellence Commission (CEC)
CEC Strategic Plan, 2012 – 2015
Between the Flags Program; Blood Watch Program;
Chartbook Program; Collaborating Hospitals Audit of
Surgical Mortality; Central Line Associated Bacteraemia in
Intensive Care Units project; Clinical Leadership Program;
Clinical Practice Improvement Training Program; NSW Falls
Prevention Program; National Hand Hygiene Initiative; In
Safe Hands Program; Medication Safety and Quality
Program; Paediatric Clinical Practice Guidelines Audit
Project; Partnering with Patients Program; Patient Safety
Program; Quality Systems Assessment Program;
Quality Use of Antimicrobials in Intensive Care Units
Project; Special Committee Investigating Deaths under
Anaesthesia; Severe Infection and Sepsis Project; Special
Reviews; Undergraduate Education Program.
Health Education and
Training Institute (HETI)
District Health Education and Training Institute Online
Programs Rural Generalist Training Programs (RGTP), Rural
Preferential Recruitment Program (RPR), People
Management Skills Framework (PMSF), Financial
Management Education Program (FMEP), Inter
Professional Education (IPE), Clinicians and Executives
Team Leadership (CETL) Program, NSW Rural & Remote
Scholarship Program, Sister Alison Bush Mobile Simulation
Centre (MSC), Rural Health and Research Congress
NSW Kids & Families
A strategic plan is currently being developed.
Child & Youth Health: NSW Youth Health Policy 2011-
2016: Healthy bodies, healthy minds, vibrant futures;
Youth Health Forums; Sustaining NSW Families; Specific
Child Health Network projects: RESUS4KIDS; Allied Health
Education and Support project; Development of
paediatric capacity across the Northern Child Health
Network (NCHN); Obesity program (in Orange).
Aboriginal Child Health: Aboriginal Maternal and Infant
Health Service (AMIHS) program. Building Strong
Foundations for Aboriginal Children, Families and
PaGe 12 NSW HealtH NSW Rural Health Plan Issues Paper