Nuffield Joint Travel Scholarship to Remote and Rural Australia. October/November 2007

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1 REMOTE AND RURAL STEERING GROUP Nuffield Joint Travel Scholarship to Remote and Rural Australia October/November 2007 Introduction A successful application was made by Mrs Fiona Grant, Remote and Rural Project Manager and Mrs Gillian Swan, Rural Educational Projects Manager, NHS Education for Scotland (NES) for a Nuffield Scholarship to undertake a comparative study of remote and rural healthcare systems and educational preparation of staff within Australia. This paper is a summary report of the international study and its implications for the remote and rural project. Context Australia has similar challenges in terms of delivering sustainable models of care in remote and rural areas, Distances between communities in Australia are vastly greater than Scotland however, Scotland s travel times are similar to those in Australia due to our geography, weather conditions and lack of transport infrastructure. Remote and rural communities account for thirty percent of Australia s population and as Australian legislation dictates that voting is compulsory, the impact of the remote and rural vote on the Government is significant. Investment by Commonwealth and State Governments in Remote and Rural therefore tends to be considerable. Remote areas are also recognised as incubators of innovation. This is because demographic change is more acutely felt in areas of low population and combined with recruitment and retention difficulties is reflected in the need for service re-design. Although Australia faces similar epidemiology to Scotland, they have an additional challenge in terms of the health of their indigenous population. The percentage of indigenous population within communities increases incrementally with the remoteness of the area, as does the morbidity and mortality rates. 1

2 Conversely, remote and rural communities in Scotland enjoy better health than their international counterparts 1. Policy Development and Service Planning Each Australian State has a health plan. For example Tasmania has just developed a Health Plan 2 this maps healthcare services against population need and workforce availability, and shows remarkable similarities to Delivering for Remote and Rural Healthcare 3. Three years ago the Australian Minister for Health commissioned reports which found that research was not linking with policy and practice. As a result research, planning and education bodies now get together once a year to forward plan the research. For example, the Commonwealth and State wanted to develop a palliative care plan but there was very little evidence or research and therefore went to the National Health and Medical Research Council (NHMRC) to commission research to inform the plan. Models of Remote and Rural Healthcare Self Care A primary model of health care focussing on illness prevention, health promotion, and community involvement is provided in some remote and rural communities. This model is comparable with the public health philosophy described in Better Health, Better Care 4. An example of this model of care was visited in Westbury, Tasmania with similar ambitions being described by a Safe Community Co-ordinator in Mount Isa, Queensland. Each example utilised multi-agency partnerships but the approaches differed between a structured frame of working through use of local intelligence data and an iterative approach based on needs identified by the local community and underpinned by healthcare benefit evidence. Both methods demonstrated health gain. For example, the outcomes from the Westbury approach showed that people serviced by this centre use fewer specialist health services; 18% less than the national average uptake of secondary care services. 1 (2007) Better Still: Naturally, (2007) Scottish Executive Health Department 2 (2007) Tasmania State Health Plan 3 (2007) Delivering for Remote and Rural Healthcare: the final report of the Remote and Rural workstream, Remote and Rural Project Team 4 (2007) Better Health Better Care:A Discussion Document, (2007) Scottish Government Health Department 2

3 Funding for the projects is undertaken in partnership with local business. In Mount Isa the co-ordinator is employed by the University Department of Rural Health (UDRH) and the State funds the centre in Westbury following closure of its community hospital function. Figure 1: Westbury Community Health and Day Centre, Tasmania Primary Care There is a tiered approach to primary care delivery within remote and rural areas, dependant upon population density. Extremely remote areas with small numbers of people will have no resident service, for example sheep stations. Such communities with no healthcare professional on site (i.e.>80k from a GP Practice) have an emergency drug chest provided and maintained free of charge. Medicines from these chests can be prescribed from a remote location by the Royal Flying Doctors Service (RFDS) General Practitioner (GP). Areas of a slightly higher population density will have a Remote Area Nurse (RAN) and are serviced by a regular RFDS GP clinic and RFDS for emergency transfer. In one state (Queensland) there is an outreach Allied Health Professional (AHP) team of professionals who, as a team visit each remote community every six weeks under a contracted agreement with the State. More densely populated rural communities are supported by a Community Nurse, who provides an outreach service from the regional hospital. More populated areas have a resident GP service. In some areas the GP Practice is aligned to the Multipurpose Centre, which is similar to the Scottish Community Hospital setup, but in other areas, the GP Practice is disparate. For patients with critical care needs, each state has a Consultant and Nurse Team who provide a retrieval service to remote and rural communities. This is funded by the State Government. 3

4 Figure 2: Nurse led Royal Flying Doctors Service, Adelaide Secondary Care Hospital infrastructures are similar to Scotland s and include Multipurpose Centres, Base Hospitals and Regional Hospitals. A base hospital is a regional centre that takes referrals from outlying areas and is similar to the Scottish Rural General Hospital (RGH).. The scope of the services provided is determined by the skills of the clinician available and the procedures undertaken are delineated by the General Medical Council (GMC). The base hospitals are formally linked with the State s tertiary hospital, which is supportive of the obligate networks recommended in Delivering for Remote and Rural Healthcare. An excellent example of the networking between one Base Hospital in Mount Isa (North West Queensland) and Townsville (tertiary centre for North Queensland) was provided whereby the Paediatricians from Townsville undertake a virtual ward round utilising Wi-Fi technology in conjunction with local general surgeons at the Base Hospital of Mount Isa. Figure 3: Base Hospital, Mount Isa, North West Queensland 4

5 Emergency Response, Retrieval and Transport Emergency response in most remote areas is undertaken by the RAN, supported by the ambulance service and/or the RFDS. If the patient has critical care needs, then a retrieval service is provided. One example of this was visited in Adelaide. Mediflight is the South Australia critical care retrieval service and staffed by Intensivists and critical care nurses. The service covers a population of 1.5m and a land mass of 983,482 square kilometers. Using three teams they provide clinical advice through e-health, safe transfer and retrieval of critical care patients. Helicopters are externally contracted by the State and this is a shared resource for multi agency use depending on the current priorities. For example each vehicle can be quickly modified to service police, fire health and ambulance needs. The cost of the contract is supplemented by private business sponsors. Figure 4: Mediflight Retrieval Service, South Australia 5

6 Workforce Rural populations are serviced by community nurses who work from a hospital centre unlike Scotland. Remote populations have RANs (also known as Bush Nurses) who carry out an extended role to that of a Community Nurse, covering emergency care and clinics either instead of a GP or in support of a GP. The Council for Remote Area Nurses Australia (CRANA) takes a political role and was crucial in influencing the Commonwealth Government to fund the establishment of University Departments of Rural Health (UDRHs). UDRHs in remote centres have established training programmes for RANs. For indigenous people, healthcare workers are recruited from the local and indigenous populations. These workers are able to bring to the service knowledge of cultural influences that affect the acceptance of services. As outlined in the service models above, remote and rural medical healthcare is delivered by a mixture of GP cover either remotely through the RFDS or with resident GP services. Out Of Hours care to under-serviced areas distanced from GP Practices are nurse-led in some places and doctor led in others, supported by RFDS and Critical Care Retrieval Services. Because of recruitment and retention difficulties one State has invested in development of the Physician Assistant model of care. This is GP driven and there is resistance from the nursing workforce because they feel that they can deliver a more holistic service to that provided by the Physicians Assistant. Base Hospitals are staffed mainly by consultants along with doctors in training. Nursing staff are mainly generalists, some with special interests, for example, paediatrics.. Figure 5: Amoonguna (Alice Springs) Indigenous Community Health Centre s Team with overseas visitors: Fiona Grant second from left and Gillian Swan second from right. 6

7 Workforce Education and Continuing Development A University Department of Rural Health (UDRH) is a multidisciplinary university department that includes medicine. Rural Clinical Schools, with the Australian College of Remote and Rural Medicine (ACRRM) developed education to promote and provide more doctors for rural practice. Both UDRHs and ACCRM are funded by the Commonwealth. Remote context specific education is available. Examples of these are: Advanced Nurse Practitioners have a legislative legal framework and undertake specific training for remote practice (Remote Isolated Practice Endorsed Rural Nurse); Pharmaco therapeutics for remote areas nurses; Specialised additional nurse education for retrieval includes Emergency Rural Nurse Initiative, Postgraduate Certificate in Nursing Science (retrieval nursing) and Aviation physiology nursing. Paramedics are educated to degree level and can access a postgraduate diploma in remote and rural paramedic practice, which is the RIPERN course with the addition of a population health module; Remote health management programmes; Postgraduate studies for remote and rural AHPs. Quality, Competences and Educational Governance arrangements for rural staff There is a raft of arrangements in place for ensuring competency of remote and rural practitioners. Those with particular relevance to Scotland s practice were: Surgical staff skills are subject to scrutiny by GMC who will determine the scope of clinical practice. This may mean a period of clinical supervision until competency is demonstrated; Standard multidisciplinary treatment manual for primary health care practitioners; Distance learning is available for remote learners; Reflective learning was demonstrated in the retrieval services for example immediate team debriefing, patient follow up and 24 hours feedback to the referring team; Ongoing professional development is informal and said to be under resourced in terms of funding and time however one group of AHPs is awarded $5000 per anum each for their personal development and associated travel; Some staff are part sponsored; Clinical skills educational interventions are held at the UDRH and this facility supports the rotation of medical students and placements for remote doctor training in the local hospital. Accommodation is often available. 7

8 Figure 6: Mount Isa Centre for Rural and Remote Health Lessons for Remote and Rural Scotland The comparative study of international service delivery models for remote and rural areas was generally very reassuring in that many of the systems developed were similar to those being proposed in Delivering for Remote and Rural Healthcare. Australia also has evidence underpinning some of their models of care. There are marked differences in some areas where Scotland would benefit from considering the Australian approach and these are detailed below. Public Health Model of Primary care The model of care delivered in Westbury is an exemplar model of care which demonstrated clear health, social and economic benefit. The model is similar to the Keep Well and Anticipatory Care approaches coupled with Community Resilience and maximising funding resource from outwith public funds. It is recommended that primary and public healthcare within Scotland should adopt such approaches. Remote Area Nurses Scotland should develop specific training programmes for nurses working in remote communities similar to those in place for the Remote Isolated Practice Endorsed Rural Nurse. RFDS Model of Service Delivery Scotland should explore the feasibility of introducing this model of outreach and emergency GP services. However the mode of transport may be different and more in keeping with Scotland s resources for example ferry and helicopter transport. This service could also support the transport of AHP teams and outreach clinic staff. 8

9 Multiagency Collaboration for Helicopter Contracting The contracting arrangements for helicopter services provide economies of scale in public service provision and a flexibility of arrangement to suit local priorities. Because the helicopter crews were serving three agencies their activity was higher and therefore opportunity for downtime less. This integrated approach along with the possibility of private business sponsorship should be explored in Scotland. Ambulance Services Managed by Hospital services. It was reported that ambulance services were more responsive to service needs as a result of being an integral part of the hospital system. Embedded management structures within NHS Health Boards for SAS should be considered. Routine Strategic Planning Design, workforce preparation and evaluation is conducted in partnership with research, education and service delivery agencies annually and supported by funding from AHMRC. Research is more responsive, relevant to practice and informs strategic planning. Investigation of this funding model should be considered by Scotland s Chief Scientist Office. Figure 7: Learning the Lessons in Tasmania Report By: Fiona Grant, Remote and Rural Project Manager, Gillian Swan, Rural Educational Projects Manager, 5 th December 2007 Acknowledgements: The authors would like to thank the Nuffield Trust, Institute of Healthcare Management and the Royal College of Nursing for this unique opportunity of international study, and their managers for supporting their leave. They would also like to thank their Australian colleagues in the Royal Adelaide Hospital, Centre for Remote Health Alice Springs, Centre for Rural and Remote Health and Base Hospital, Mount Isa, University of Tasmania and Westbury Health Centre, Tasmania, and the UDRH Townsville for their enormous generosity in terms of sharing policy, practice, knowledge and for their warm hospitality. 9

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