Doctors 'not used efficiently' in the bush

We must focus on the social and intergenerational determinants of health and develop more nuanced measures of need and access to improve health outcomes in rural and regional Australia, write Associate Professor Bernadette Ward and Dr Pamela Harvey …

Health outcome disparities across Australia’s population have been well documented, with differences in the aggregated health status of people living in rural and metropolitan areas regularly highlighted.

This difference, however, is more complex than just where you live.

The Australian Institute of Health and Welfare’s “Access relative to need” modelling is an example of a more nuanced approach that takes into account road distance from a service, population size, GP availability and health need, including the sociodemographic profile of the population.

Need is more than just clinical attention.

Chronic diseases have the greatest and growing impact on disease and injury but are commonly a consequence of underlying risk factors such as social and structural determinants of health commonly perpetuated across generations.

There is a 10–25% difference in life expectancy for people with the lowest level of education compared with the highest levels. Interpersonal discrimination explains 47% of the gap in psychological distress between Indigenous and non-Indigenous adults. The predicted need for primary care for non-Indigenous people in remote and very remote areas is not different to that in their metropolitan counterparts. In comparison, Indigenous people’s predicted need for primary care increases with remoteness.

Access is more than just the availability of health care professionals.

Individuals consider many access factors when seeking care, including a preference for a particular health professional, cost of service, opening hours, and urgency. Some will bypass a local provider, choosing to travel further for their preferred GP. Health care should be acceptable, affordable and structured in a way to make using the right care easy, particularly for those who have the highest need. For example, children from families at high risk of intergenerational poverty are significantly less likely to use specialist health services in early childhood than their non-vulnerable counterparts, instead visiting hospital emergency department services. Provider-to-population ratios are only a measure of supply of health care professionals. We believe they are of limited value on their own in assessing health care need or individuals’ decisions to seek care.

These examples accentuate the complexity of thought needed to rectify, or prevent, disparities in health outcomes, many of which lie outside the health system.

In recent decades, most of the resources invested to improve the health of rural Australians have been focused on workforce. The Distribution Priority Areas (DPA) for the medical workforce, for example, takes into account relative socio-economic disadvantage, but since July 2022, localities outside major cities (Modified Monash Model 2–7) are automatically classified as DPA, alongside some catchment areas in MMM1 outer areas. The maldistribution of GPs is a nationwide concern, and it is accepted that GPs are seeing people with more complex problems, many connected to social determinants. 

In 2022–23, $152.5 million of the Australian Government’s health budget was allocated to the rural health workforce, and of this, 75% was dedicated to medical schools to increase training in rural areas to attract graduates back.

Factors addressing the retention of doctors in rural areas are generally non-modifiable (eg, having a partner who wants to live or work in a city) or require extensive investment in individual doctors (eg, financial incentives), and do little to address the underlying determinants of health care need.

Recent discussions about strengthening Medicare highlight one of the fundamental problems with the Australian health care system: the persistent foci on health inputs — more dollars, doctors, nurses, allied health staff, hospitals and services, with minimal reflection of population need and health outcomes.

If we keep offering the same solutions to the issue of inequity in health care, why would we expect different outcomes?

Instead of location being the issue, and therefore a problem to be solved, we argue the focus should be on health equity and inclusion where in addition to addressing many of the underlying determinants of health, health care is orientated to ensure:

• Everyone gets what they need regardless of where they reside. We need a more nuanced approach to DPA where populations with the highest level of need are prioritised and incentive programs are expanded to equitably include other disciplines. Ensuring health professionals work at the upper end of their scope of practice will ensure GP time is spent with the most complex presentations.   

• Barriers to care are removed. If the goal is to improve health outcomes for those with the highest need, flexible team-based models of care are essential so people can access care at times and places that are right for them. This may include increasing the availability of after-hours and weekend primary care services and settings other than a general practice.

• People are involved and valued in decision making about their own needs. Funding based on need and not just population–provider ratios or consultation times will enable GPs and other members of their team to spend more time with and listen to patients with more complex needs. Involving communities in decision-making processes about health service model design will enable need to be taken into account.

It’s time to move away from a “one size fits all” approach and focus on the social and intergenerational determinants of health and more nuanced measures of need and access. Within the health care system, different funding streams and models are needed to ensure doctors’ time is used efficiently to provide the right care, at the right time, in the right place.

Associate Professor Bernadette Ward and Dr Pamela Harvey teach at the School of Rural Health, Monash University in Bendigo.

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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