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There is still a long way to go to ensure that we are delivering equitable access to specialist surgical services in Australia, especially in the field of complex head and neck surgery, where expertise and outreach services in regional areas are generally lacking, writes Dr Rebecca Venchiarutti.
Addressing the well documented health care inequities experienced by Australians living in regional areas remains an ongoing challenge, amplified by centralisation of some health care services, such as complex surgery, in major cities.
Complex surgery requires specialised surgical teams, nurses, and allied health professionals who are not available in most regional areas.
While centralisation does reduce mortality and morbidity rates, for people in regional Australia travel to major cities creates significant time and financial burdens.
In addition to direct costs of transport and accommodation, there are indirect costs such as time off work, childcare, and loss in productivity.
Once acute care has been given, and patients are safe for discharge back home, ongoing specialised health care is critical for ongoing patient care and review.
Delivery of consistent and robust ear, nose and throat (ENT) services has been challenging in regional and remote Australia.
Some success has been achieved with improved access to care and outcomes in priority populations including children and First Nations people.
However, a particular area of concern and challenge exists in the related field of head and neck surgery, where expertise and outreach services in regional areas are generally lacking.
Head and neck cancer includes tumours of the face, mouth, voice box, throat and neck, but also advanced non-melanoma skin cancers.
In general, head and neck tumours, especially those that are complex, require highly specialised and experienced multidisciplinary teams working in high volume centres that include intensive care facilities and well resourced rehabilitative services.
Addressing the gap
In 2016, head and neck surgeons at Chris O’Brien Lifehouse in Sydney began offering a monthly outreach clinic in Port Macquarie, New South Wales.
The clinic offers assessment by specialist head and neck surgeons (often dual-trained in ear, nose and throat surgery), work-up prior to surgery, referral to other specialists, and follow-up care after surgery.
Established without government support, the clinic is co-located in a local medical practice and, in 2022, increased clinics to weekly in response to high demand for services.
In 2019, a second clinic in Tamworth, NSW was established, offering monthly clinics.
Similar clinics at Nowra, Orange and Dubbo are run by Chris O’Brien Lifehouse head and neck surgeons on a monthly basis.
Patients are referred to the service for assessment, diagnosis and post-treatment follow-up, offering patients continued confidence in their care.
Where possible, diagnostic services are accessed locally (such as medical imaging and biopsy), limiting travel to major cities if treatment is not possible within local health services.
The head and neck services are led by surgeons dual-trained in ENT and head and neck surgery.
This increases the breadth of services offered to patients, addressing limited accessibility of both head and neck and ENT surgeons in regional towns and ensuring viability of the service.
Elements for success
Since establishment, the service has grown to include both educational and research programs alongside the clinics.
Partnering with local services and communities in delivering clinical care and offering education on prevention, diagnosis and treatment of head and neck conditions has led to increased engagement with and demand for the service.
Working with local health care providers early and often in the establishment of the clinic was essential in ensuring the needs of local communities are being met.
Training and education is offered not only to local clinicians, dental and medical students, but also trainee surgeons.
Clinics are run by a senior specialised surgeon under a fly-in fly-out service model, accompanied by overseas fellows and training registrars, allowing more patients to be seen and exposing fellows and registrars to the benefits of delivering care in the regions.
Given the relatively small proportion of rural-based surgeons in NSW and Australia and the maldistributed specialist workforce, it is hoped offering exposure to outreach during training will encourage greater participation in outreach or even establishment of permanent services in the regions.
Further to the principle that whatever health care can be delivered safely close to home should be, one consultant surgeon now also operates at a rural base hospital, which has the dual benefit of offering patients treatment locally, as well as knowledge and skill exchange with local clinicians.
For patients requiring treatment in Sydney, a dedicated team of care coordinators at Chris O’Brien Lifehouse work closely with patients and clinicians in the regions and Sydney to provide support.
This includes making appointments, booking transport and accommodation, ensuring clinical documentation is available prior to treatment, and assisting in securing government financial support.
Research has been a cornerstone of the program since its inception. Evaluation of the service is critical to understanding whether the service is meeting its intended outcomes and where improvements are required.
Staff in Sydney work with regionally based clinician–researchers to undertake research that is focused on, or inclusive of, the regional population to examine patterns of care, outcomes, and evaluate service provision. The research is currently under peer review.
In a similar vein to the capacity-building of local clinicians through education and training, such research collaborations help support locally led research that addresses the needs of regional patients and health professionals.
Challenges
Funding remains a key challenge in ensuring the sustainability of the service. Chris O’Brien Lifehouse is a unique public–private not-for-profit partnership that delivers true equity in complex cancer care.
The regional head and neck access program was only possible because of highly motivated individuals, working with a supportive hospital executive and philanthropic support.
To date, no government interest in this scheme or support has been forthcoming, despite the suggested benefits, improved outcomes and major cost savings.
Economic research (currently under review) into our regional head and neck access program has shown, for example, that the direct cost saving to the government by not having to reimburse travel through the Isolated Patients Travel and Accommodation Assistance Scheme has run into the hundreds of thousands of dollars each year.
Coordination of care is also a challenge, especially between general practitioners and specialists.
There is an estimated seven times fewer specialists in remote areas compared with major cities, and high turnover of GPs and workforce shortages can be barriers to well coordinated care.
In for the long haul
There is still a long way to go to ensure that we are delivering equitable access to specialist surgical services in Australia.
If our health system continues to centralise complex surgery, we need to invest and explore innovative and novel ways to sustainably deliver appropriate outreach services and reduce burdens on regional patients.
Unless our governments come onboard, listen, and support programs such this, regional specialist services will not improve anytime soon.
Dr Rebecca Venchiarutti would like to acknowledge the contributors to this article: Jonathan R Clark, Michael S Elliott, and Carsten E Palme.
Dr Rebecca Venchiarutti is a research fellow at Chris O’Brien Lifehouse and honorary lecturer at the University of Sydney.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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