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ONLY half of specialists involved in rural outreach work return to the same town on an ongoing basis, according to new MJA research suggesting incentives could be better targeted. (1)
Of 848 specialists for whom data were available and who provided outreach services to rural locations, only 52% visited the same town more than once in 3 years, according to the research, which was based on the large national longitudinal survey of Australian doctors, the Medicine in Australia: Balancing Employment and Life (MABEL) study.
The MJA study authors said a range of strategies were needed to promote more stable rural outreach services.
They found males aged 45‒64 years who worked in both public and private practice were most likely to provide ongoing outreach services, while doctors who worked exclusively in private practice were least likely.
Of specialists providing outreach services 23% were female, in line with the overall proportion of specialists who are women. However female specialists’ involvement in outreach was more likely to be ad hoc than their male counterparts.
The authors suggested that their findings could be used to better target federal government subsidies through the $31 million a year Rural Health Outreach Fund (RHOF), saying financial incentives could be directed to specialists working exclusively in the private sector. (2)
However Dr John Quinn, executive director of surgical affairs at the Royal Australasian College of Surgeons, said it made sense that doctors with public hospital visiting rights did the bulk of the outreach work, as they could bring patients requiring surgery back to a public hospital in a major centre.
Dr Quinn, who is a vascular surgeon, provided outreach surgical follow-up to patients in Rockhampton for more than a decade. He told MJA InSight incentive payments only provided “cost recovery” to doctors involved in outreach services.
“Doctors don’t do outreach to make money, but don’t particularly do it to lose money either”, he said.
Dr Dennis Pashen, Rural Doctors Association of Australia president, said doctors who came from rural areas had a “better understanding of the rural ideology and communication styles of the bush” and so were more likely to commit to ongoing outreach work.
Dr Pashen said duplication and cost shifting were major challenges with funding medical outreach.
“There is always a risk that bringing in specialists absolves local health districts from funding services they were previously providing, or that specialists will go into rural areas to drag business back to the large metropolitan private hospitals”, he said.
Dr Pashen said that, in general, he applauded the RHOF program and was hopeful that the new Primary Health Networks and local hospitals could work together to ensure money from the fund was wisely allocated.
An editorial in the same issue of the MJA raised the potential for telehealth to help meet the needs of rural doctors. (3)
Associate Professor Tim Baker, director of the Centre for Rural Emergency Medicine at Deakin University, asked why rural hospitals could not have a specialist backup service similar to those used by airlines such as Qantas, where “a doctor on shift in the emergency department is called to provide advice, with all the specialist and subspecialist resources of a large tertiary hospital available for backup”.
“A centralised telemedicine system may have to be located at an actual hospital with a full complement of specialty units resourced to help local doctors”, he wrote.
Dr Jim Muir, who helped establish the Australian College of Rural and Remote Medicine (ACRRM) Tele-Derm program, which provides free dermatology advice to rural and remote doctors and ACRRM members around Australia, said telehealth combined with outreach visits could help make rural specialist care sustainable. (4)
“Ideally you have an integrated service where you visit [a rural centre] and then provide telehealth ongoing support to referring doctors”, he said.
“GPs utilising a telehealth service are much more integrated into the consultation compared with when they just refer a patient with a rash or lesion and get a letter back from the specialist 2 weeks later.”
Townsville ophthalmologist, Dr Lee Lenton, who used tele-ophthalmology to back up his regular visits to Mt Isa, agreed that upskilling local doctors was an important part of sustainable outreach services.
“In my experience, telemedicine provided good feedback and learning opportunities for the local doctors, to the point that those local doctors no longer needed the ophthalmologists so often”, he told MJA InSight.
Dr Muir said a major barrier to efficient telehealth was that only real-time video conferences were reimbursed by Medicare even though most tele-dermatology could be done via email.
(Photo: Apples Eyes Studio / shutterstock)
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You also need stability in flight services. In NSW these have recently been significantly changed.
I agree for many proceduralists, FTF travel to rural areas is important. For many other specialists, telehealth is a viable option. While telehealth technologies are improving and resources are becoming more available through government and hospital funding, it may not be necessary for many specialists to fly out to do follow up consultations. In reality, urgent cases would have been seen through interhospital transfers or urgent reviews at larger centres. Most routine follow up cases are feasible through shared care telehealth models with rural GPs. Other new patients can sometimes end up waiting for an outreach visit with a longer waiting time than that is at larger centres.
So, telehealth can in many cases speed up the timing of initail reviews and triages. In addition, savings accrued by reducing patient travel can be reinvested back into growing the rural workforce. Since most specialist consultations require a GP to facilitate a consultation, telehealth consultation itself is a training and upskilling modality.
In North Queensland, the home of the “Cowboys”, cancer patients from many small rural towns not only receive consults through telehealth, but also receive selected intravenous chemotherapy regimens locally through a tele-chemo model called QReCS (Queensland Remote Chemotherapy Supervision Model).
All rural towns have at least one tertiary centre as their referral centres. Why aren’t those tertiary centres either doing telehealth or doing FTF outreach? Why aren’t the state governments demanding public tertiary centres to improve their services to rural people?
While such a survey is a step forward, this does not solve the question of workforce snapshot of what is actually happenning in regional and rural areas.
This needs to be done via utilising the actual resources that utilise the visiting specialists, ie, rural health services.
Personally, I have been doing this FIFO specialist job in SA for 3 years, with clinics growing from a lazy day out in the country to 3 days a week of solid 8am-5pm clinics now. I am female, and have no plans to retire from providing care to regional and rural SA.
Comments about private consultants are quite true, as they really are not supported by State Governmental funding, so impossible to ask for that kind of commitment. However, while most SA visiting specialists are from the public system, the problems remains about the seniority of who goes out to regional and rural areas. New specialists find themselves struggling for meaningful employment in days of saturation of public jobs, yet do not wish to provide such service. I think it should almost be a point where State Health Services look at this as part of employability and contractual obligation in the days of most of us getting older and closer to retirement. Also, some specialties are represented in visists to regional and rural sites, but others are not. This again needs action in order to decentralise care, drop costs it takes for patients to travel, and improve outcomes in rural patient care. These in my view are the challenges of today. Money alone is not enough to offer as incentives, but perhaps contracts are; similar to teachers who elect to work for 5 years in rural area, then get a transfer back to the city school of their choice.
I have been attending a central Queensland remote area for 10 years. The other side of this issue is the need for stability in funding. Every year or so there is a change in the funding regime and a whole lot of uncertainty added. Currently I am covered by a funding package that works but is manifestly inappropriate.
So the issues are not just those pertaining to the practitioners.