Aniello Iannuzzi: Rural repetition

IN August, the Australian Senate belatedly released a much-anticipated report — The factors affecting the supply of health services and medical professionals in rural areas.

Politicians established an inquiry because of concerns about poorer health outcomes and life expectancy in rural and remote communities compared with their metropolitan counterparts, as evidenced in the Australian Institute of Health and Welfare’s first report on rural health in 1998 — Health in rural and remote Australia — and subsequent updates.

Those of us in rural and remote practice received the Senate report with some scepticism — not because of the findings, but because we have heard it all before with little result.

In 1999, Dr Jack Best AM was commissioned by the Department of Health to conduct The Rural Health Stocktake, released in June 2000. Dr Best’s report was far-reaching, addressing needs of rural communities, recruiting and retention of health professionals, classification of rurality and coordination of government policy.

About 4 years later, the Rural Doctors Association of Australia released a report on viable models in rural and remote practice. This very comprehensive report was impressive because it was composed by rural doctors, rather adopting a top-down approach.

Now here we are in 2012 with the Australian Senate recommending, amongst other things, the need for better data collection, an expanded role for generalists, expanded incentives for nurses and allied health workers, strengthening definitions of rural students to only include those who spent most of secondary school in a rural area, revised workforce incentive schemes, and better financial incentives for rural and remote doctors who provide education to medical students.

We have heard this all before — and are still awaiting action. The conclusions are nothing but a re-hash of previous reports and inquiries.

Generalism is the only way forward for rural communities and it is encouraging to see state governments, especially Queensland, embrace generalist training. Geography and scarcity of resources, in particular personnel, dictates the need for multiskilled, flexible professionals who can sort out diverse clinical issues without needing to transfer everyone to cities and regional centres.

It may surprise some readers, but often things are more efficient in smaller rural hospitals than in the large hospitals, as we are not bogged down waiting for consultants from other specialties to come and make fairly straightforward decisions.

Political inaction and recurrent consultations and reviews are not the only impediments to sorting out rural health. The other enemy is that silent killer of clinical autonomy — dogmatic protocols.

Friday, September 13th (scary, huh?) was World Sepsis Day. The NSW Clinical Excellence Commission has been doing some excellent work on the detection and management of sepsis in hospitals, and in the lead-up to Sepsis Day our hospital managers handed down some sepsis protocols to clinical staff in our district.

Now, while these sepsis protocols work well in large hospitals, smaller hospitals do not have any hope of complying as many do not have the staff, monitoring or pathology equipment and even the drugs available to manage the protocols, which provide no concessions or recommendations that take this into account.

When I raised this concern with local management, the best reply I got was that “standardising treatment is safest for patients”. This convenient political mantra fails to take into account the dislocation it causes patients’ families when a loved one has to be transferred to a hospital hundreds of kilometres away from home.

And one can argue that travelling in an ambulance at night on a country road with tired ambulance officers ain’t necessarily safe when the only reason for the transfer is a tick-a-box protocol.

This dogmatic protocol mentality has already resulted in the inability of many NSW country hospitals to provide paediatric admissions. Rather than promote paediatric services, it has been easier to declare the smaller hospitals unfit to meet protocols and so ban kids from being admitted.

Protocols such as that for sepsis run the risk of setting up rural hospitals for further failure and the resultant cutting back of further services.

Or is this perhaps the real, but silent, agenda?

Dr Aniello Iannuzzi is a GP practising in Coonabarabran, NSW.

Posted 24 September 2012

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