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RRITH Week 1 Rural medicine is different - ACRRM (Australian College of Rural and Remote Medicine) states: o Different than city practice o Wider range of skills used o Wider range of settings o Whole age range o Involved in local community o More procedural until remote areas 5 Salient Aspects of Rural/Remote Health Practice - Rural-urban health differentials - Access o Physical barriers - Confidentiality o Different relationships with the same people you’re working on. Need to separate medical and social contexts in relationships. - Cultural security o Since not a lot of physicians to choose from, need to be respectful and mindful of individuals’ culture. - Team practice o Close team working together, with overlapping roles What Challenges Need Managing? - MABEL study: o Total hours worked (3-4 more hours work rurally) o On-call/after hours work o Type of procedures/public hospital work (more broad scope of practice) o Ability to take time off work (hard to do this) o Partner employment (spouse support) o Schooling Working Remotely - 8 key features: o Employed: state health or ACCHS o Isolation: geographically, fewer peers to debrief/learn from o Telehealth o Increased clinical acumen: takes longer to get lab tests back, make decisions safely and make safe management plans. o Extended practice: emergency, primary health care, obstetrics, etc.

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o Cross-cultural o Strongly multidisciplinary o Public health and security Less like likely to support private practice

Defining Rural & Remote - High quality, well-defined categories needed for: o Planning services o Resource allocation o Assessing health outcomes - Indices attempt to quantify rurality Basis of Rural Indices - Remoteness thought of as access to range of services, some of which would be available in smaller centers and some only in larger towns. - Remoteness measured in terms of road distance to centers of various sizes - ASGS-RA, ASGC-RA (basically same) - ARIA, RRMA exist ASGC-RA Categories - RA 1: major cities i.e. Brisbane - RA 2: inner regional i.e. Rockhampton - RA 3: outer regional i.e. Townsville - RA 4: remote i.e. Cloncurry - RA 5: very remote i.e. Weipa - Problem is for regions around Townsville such as Tully or Ayr, it starts to backfire because people are getting the same incentives to come to Townsville, as ayr and tully. Pulls people out of the remote areas. MABEL data on rural workforce recruitment used as basis of MMM - While there were the 6 sentinel indicators, they identified the following: o While geographical remoteness was statistically associated with all 6 indicators, population size provided a more sensitive measure in directing where recruitment and retention incentives should be provided. MMM (Modified Monash Model)  KNOW WELL

Who Lives Rurally? - 30% of Australians live in regional and remote areas ASGC-RA 2-5 o Different mix of people o Unique health patterns o Different health behaviours and beliefs o Different health needs o Often less access to services - Major cities: 72% - Inner regional: 18% - Outer regional: 8% - Remote: 1% - Very remote: 1% Distribution of ATSI Population 2016 - Major cities: 37.4% - Inner & outer regional: 43.7% - Remote & very remote: 18.4% Proportion of Population who are ATSI, by RA - Major city: not many ATSI patients - Very remote: ~45% patients ATSI Variety in Rural Communities - Population size & trends - Economics & jobs - Cultural composition - Access - Services

Week 2 Half the services, half the workforce - Limiting factor to providing more care: getting workforce into the rural areas. Not so much the #’s of ppl, but more so the distribution out there. - Can overcome this by redefining roles and sharing tasks around professionals.

Delegated Practice Models - RAN: o Remote area nurse o Nurse with some extra training for an extended scope of practice. o Employed in primary care clinics and small rural/remote hospitals. - NP: o Nurse practitioner o Nurses with skills in diagnosis and treatment – usually within particular specialty. o Masters degree & over 5 years experience in their area. - PA: o Physician’s assistant o Provide primary healthcare services in collaboration with the Dr. o Trained as generalists o Perform patient exams, order & interpret tests and imaging, diagnose, order treatment, formulate management plans, review patients, assist in surgery, perform minor surgical procedures, refer to specialists. o Can work independently of their collaborative medical practitioner.  No need for direct supervision with everything. - AHW: o Aboriginal health workers National Strategic Framework for Rural and Remote Health - Vision: people in rural and remote Australia are as healthy as other Australians (Department of Health). - For any health service, need a certain amount of ppl to justify it being there. o More specialized needs more ppl to sustain it. o i.e. GP in town of 1000 ppl ok compared to infant congenital heart disease surgeon (not reasonable because not enough patients). - NEED to see population base to support a specific need. Goals - Rural and remote communities will have: o Improved access to appropriate and comprehensive health care. o Effective, appropriate and sustainable health care service delivery. o Appropriate, skilled, and well-supported health workforce. o Collaborative health service planning and policy development. o Strong leadership, governance, transparency and accountability. Approaches for Improving Access - Based on above framework: o Organizing health services in different ways o Making specialist services more available o Use of technology and telemedicine

1. Organizing health services in different ways A. Supplementary primary care services - Places where population is too small to support having own private GP and practice, or can’t recruit anybody. - Examples: o RFDS and other visiting primary care clinics, RANs too o Primary care clinics in rural public hospitals o Allied health services via Primary Health Networks - Other organizational strategies: o Maybe done to overcome ppl wanting to go out, make their own practice, but when they’re done with it, they can’t sell it. Deters future physicians from moving it. o Ex:  Easy entry, gracious exit model  Facilities and businesses are owned and managed by the community.  Networked model  Clinics across several towns link up in a co-operative arrangement. Pool of employees and resources large enough to share after-hours load, cover each other’s leave, and facilitate professional development. B. Establishing specialist services in regional centres (regional cancer centre) - After research came out saying that rural/remote Australia was having poorer cancer outcomes believed to be due to less access to treatment, Australia established regional cancer centres. o Attract top physicians, for clinical trials, research, access to multidisciplinary teams, offers best practice of care, telehealth, etc. - Cancer care coordination in NQ – hub and spoke (telehealth) o Trying to keep people in their town rather than all coming to Townsville for example. o Main hubs = Mackay, Townsville, Cairns.  Townsville: Mt. Isa, Bowen, Charters Towers  Cairns: Torres Strait, Cape York, o Model is based on population size, and maximum feasible facility size within each catchment. C. Integrating and coordinating services, including health, aged care, and community services (multipurpose health centres) - Insufficient catchment populations to sustain separate acute hospital, residential aged care, community health, and home care services (1,000-4,000 people). o Hard with federal, and state, and different funding resources. - Range of services co-located under one roof. - Resources shared, costs cut. D. Providing culturally appropriate care to remote indigenous communities

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Ex: o o o o o

ACCHS’s Cross cultural training for students and workforce Aboriginal liaison officers Aboriginal health workers Deadly ears program

2. Making specialist services more accessible A. Bringing patients to the service - Patient assisted travel schemes o Patient Travel Subsidy Scheme (PTSS) – commonwealth funded, state administered program.  Subsidizes travel to doctor-referred specialist appointments >50km from nearest public hospital.  Covers some transport (fuel subsidy or fares) and accommodation ($60/night).  Also escort in some circumstances.  Limitations:  Subsidy usually much lower than actual costs  Cost comes out of closest hospital’s budget o Hard for rural and remote because it becomes a huge part of their actual budget. B. Taking services to the patient - Specialist outreach services (fly specialists out to rural/remote locations) - By both private specialists (stick to same town = continuity of care) or from public hospitals. - Work best if: o Longer or frequent visits, predictable o Continuity – same person/team visiting each time. o Continuity – prioritized and not cancelled if sending from a short-staffed hospital. o Well integrated with local services – shared care o Co-ordination with resident service and other visiting services o Priorities and scope match local health needs o Support – by resident staff and supporting them by upskilling. - Who does outreach clinics? o Private specialists  visit one particular place o “hub and spoke” model: paediatricians working at TTH, also doing regular visits to outreach centres in their district o part of disease specific program (deadly ears – ENT surgeons from all over Aus to ENT clinics in Aboriginal communities). - Rural Health Outreach Fund o Extra out of pocket costs to fund the visiting services – travel, not seeing patients while traveling. The above fund helps overcome these barriers.

o Doesn’t pay their salary, but funds transit time, and travel. C. Taking services to the patient – supporting emergency retrieval services - Australia’s one of the best. - CareFlight, RFDS, etc. 3. Supporting the use of information communication technologies, including telehealth and e-Health initiatives (later down in notes)

What needs to be in place to support ALL the above models? - Government policy committed to providing rural services, including willingness to fund. - Sympathetic, flexible, and supportive health department administration. - Workforce training and supply with long-term perspective, not just gap filling. - Community readiness, involvement & leadership - Infrastructure - Economic viability

Week 2 – GLS Torres and Cape Hospital and Health Service ( TCHHS ) - Responsible for ~27,000 people. - 64% population = ATSI - 4 hospitals & 31 primary health care centres Torres Strait Islands (TSI) and Northern Peninsula Region - Thursday Island Hospital = administrative centre of TSI region. - It’s the referral hospital for 17 PHC centres in TSI & Bamaga Hospital. o Bamaga hospital: 4 communities in Northern Peninsula region TCHHS Telehealth Vision Statement - “Delivering care closer to home” o Access and control to patient healthcare via telehealth technologies o Providers can deliver patient-centred care effectively regardless of geographical location. Telehealth - Healthcare at a distance. Electronic transmission of clinical information via telecommunication technologies. o Videoconferencing o Live transmission o Image store and forward Types of Telehealth

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Types of services events o Scheduled outpatient o Schedules inpatient o Unscheduled emergency Specific modes o Live video conferencing: live two or multi-way interaction with a receiver (patient). o Store and Forward Telehealth: transmission of stored motion or static images or audio through secure electronic communication system i.e. Wound Image. o Remote Patient Monitoring: live transmission of clinical data from patient to clinician at a different location via a secure electronic communication system i.e. pulse rate.

Who? - Any patient in our service area who lives 15km from QLD health provider facility and needs to engage with any clinical service - Eligibility for telehealth over face to face consult decided by referral nurse or doctor. Why? - Improve patient access to specialist care - Negating need to travel away from family - Consultation with GP/nurse/Health worker at same time improving patient outcome - Reduces travel costs and inconvenience - Easier for family to attend appointments with patient - Education and support to clinical staff Where? - Inpatient in hospital - Outpatient in PHC - Medical practice - Home - Any place where software can be downloaded onto a computer and you are guaranteed privacy and confidentiality When? - At time mutually convenient for: o FIFO (fly-in-fly-out) primary healthcare teams. o Specialists (internal & external) o Patients o Family and/or carers o Staff and PHC facilities

TCHHS - > 90 specialties providing Telehealth to TCHHS (DREAMT – ATSI dementia ) - 2018-2019: o Telehealth appointments: 2748 o Telehealth appointments attended: 1936 o Travel costs saved: ~$1.1 million o Km saved: ~1.6 million o CO2 emissions saved: ~300 tonnes

Week 2 – Rural Health Workforce Inverse Care law - Availability of good medical care tends to vary inversely with the need for it in the population served [and] operates more completely where medical care is most exposed to market forces. Australia concluded that it was ‘short’ of doctors in ~1999 - In 2000 = 2.6 doctors/1000 population - In 2018 = 3.8 doctors/1000 population Australia is now one of the highest per-capita producers (and importers) of medical labour in the world - Kicked up in the mid-2000s. One of the world’s leading producers of medical practitioners in the world per 100,000 population. - Not only does Australia produce a lot, they bring in a lot of overseas doctors. - Now have 21 medical programs in Australia, while prior to 2000 had 11. Paradox: shortage and oversupply - Major supply in major metropolitan areas: 3.8 - Cities: 4.2 (1 doctor/240 ppl) - Issue with oversupply in major cities, with regional undersupply. - Australia is becoming quite dominated by overseas trained doctors. Particularly in regional and remote areas, where they are the majority of the medical workforce. - Overseas don’t last long in the regions and go to major cities. Then they need to be replaced which is a problem. End up with a gross system of metropolitan oversupply, with a lack of domestic medical production in regions outside of cities. Continued reliance on overseas recruitment of GPs for rural is driving unsustainable growth in the city - GP medicare billings (drawn from NIS for medicare services): o Overseas medicare billing overtook Australian medical graduates providing GP medical services ~2012. o In regional and remote Australia

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o International graduates have overtaken Australian-trained doctors in their billing/services provided in the city. VERY sharp trajectory of growth for overseas-qualified physicians. Unprecedented investment in expansion of Australia’s medical workforce is not delivering where it is needed. Trickle-out is a failed strategy that is not only expensive (aging population with increasing levels of multi morbidity), it undermines generalism, rural medicine, team-care, and primary care. o Trickle-out = start in major city and ppl move out. Risks of driving excessive sub specializations in major cities = real because lots of people requiring lots of different needs. o Over-medicalizing medical problems  Depending where you go geographically, there is a wide range of difference if you get a colonoscopy, cataract surgery, hysterectomy, etc.  Maybe didn’t need to be taken off.  Non-evidence based clinical practice driven by supply from so many doctors (and patient-demand) is a real issue! Flexner report: half medical schools closed down, and now see modern medical education. o “reckless over-production of cheap doctors has resulted in general overcrowding; but it has not forced doctors into these hopeless spots. It has simply huddled them thickly at points on the extreme margin…they prefer competition in some already over-occupied field…” Medical workforce is not the largest/most important, nursing is. o Medical workforce tends to be influential of structure and function of healthcare systems. o If you produce lots of highly specialized doctors concentrated in major cities, that will shape the healthcare system much more powerfully than the healthcare system shapes the medical workforce.

International perspectives: WHO Global Strategy on HRH 2030 and the HighLevel Commission on Health Employment and Economic Growth - Universal healthcare access: by 2030, everyone should have access to essential comprehensive healthcare without the risk of undue financial hardship. - Critical to ensuring equitable deployment of healthworkers are the selection of trainees from, and delivery of training in, rural and underserved areas. - Social mission: JCU accepts responsibility as an institution to rely on teaching/service/leadership to the priority needs of populations that need to be served. - Need to support generalism, because if produce too many specialized = ineffective and inefficient. Density of health workers per 10,000 population

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General rule: minimum health workforce requirements to achieve the health related sustainable development goals. o ~45 health practitioners/10,000 population Even lower threshold to meet even the most basic health needs o African, South-east Asia, PNG too. o Australia: 3700/year graduates, bring in ~2000 overseas education o PNG: 45/year.

Globally: If Universal Health Coverage (third global health transition) is to be achieved by 2030, which is the right formula for medical education? - Transitional, city-based, sons and daughters of an urban elite, sub-specialist focus, large acute hospital-based. o Most of the world does this. - Socially accountable located in areas of need, diverse, including rural & underserved, generalist focus, community & team-oriented o Need to focus on this to make a change Key issues for rural health workforce - Understanding health care needs - Aligning models of care, based on rural community/patient needs. - Reform of health professional education based on evidence for what works - Promoting clinical generalism and flexible team-based care. Training pipeline to generalist specialist practice in the regions is unfinished business in medical training reform… - Have increased production of graduates, but haven’t paid attention to the regional production of GPs and consultant specialists. Pattern of rural distribution across professions - Doctors tend to be more distributed in cities (not other regions) - Nurses & midwives = more evenly across remoteness areas o Not really short of these  it doesn’t tell the whole story o They’re the emergency health workforce, medical administrators, they’re doing all the work. o This is why there’s so many of them: because there’s a lot of work to fulfill all of these roles. o They might even be in shortage! - GP levels are actually quite evenly distributed in remoteness areas. Seems like it isn’t a problem, but it is: o In cities more specialists, but in rural areas GPs doing most of the things specialists are doing o Numbers in rural areas are quite transient and dominated by temporary international medical graduates.

Physician Assistant - 2-3 year post grad clinical training with variety of health backgrounds. - Delegated practice model. - Now adopted by Canada, Netherlands, South Africa, England, Scotland - Queensland trials – Cooktown, Mt. Isa, Brisbane - Australian PA training – UQ initially (ceased), JCU 2011

Rural Generalist Medicine - Primary care core, with potential to work in emergency setting, hospital care setting, population health context, extended skills, etc. - Similar to the general practice family. - Also have GPwSI (general practice with special interest) - Can get a common pattern of work requirements in rural and remote areas. Broad scope driven by need. Rural: what works? WHO evidence-based recommendations - Education o Targeted admission policies to enroll students with...