National Strategic Framework for Rural and Remote Health

Key outcome areas

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In seeking ways to improve planning and delivery of health care in rural and remote Australia across all service types, health priority issues and population groups, a number of key themes consistently emerged.

These themes formed the basis of the five outcome areas now identified in this Framework, namely:

Outcome area 1: Access

Outcome area 2: Service models and models of care

Outcome area 3: Health workforce

Outcome area 4: Collaborative partnerships and planning at the local level

Outcome area 5: Strong leadership, governance, transparency and performance.

Each outcome area links directly to one of the five key goals. The following chapters discuss the opportunities and challenges that relate to each outcome area, and identify the objectives and strategies developed to help achieve the goal.

While each outcome area is important in its own right, the Framework acknowledges the interrelations between them all and recognises that specific action under one outcome area can also support the goals of others. For example, successfully addressing workforce development will depend on access to information and communication technology and telehealth initiatives to overcome isolation. E-Health can be used not only for clinical purposes but also for continuing professional education, patient education and administration, thus supporting the outcome areas relating to innovative and flexible models of care, and increasing access to services. 

By identifying overall objectives and strategies under each outcome area, the Framework will help governments to work more consistently and collaboratively, while maintaining the flexibility for governments, services and communities to find and implement solutions that best fit their needs.

Outcome area 1:

Access

Introduction

People living in rural and, especially, remote areas of Australia cannot access the range of health care services that are available to people living in urban areas.

While acknowledging that some high cost, specialised services cannot be provided locally, the ability to access health care services including primary medical care in rural and remote Australia tends to drop with increasing remoteness, as seen in the table below (NRHA 2010).

Table 3: Services received by remoteness, 2006-07 – as a proportion of services received in Major cities

Service Type

Inner Regional

Outer Regional

Remote

Very Remote

MBS GP services

84%

79%

71%

54%

MBS specialist services

74%

59%

38%

30%

MBS allied health services

75%

45%

24%

9%

Source:  NRHA (2010).

Improving access can be highly complex and challenging.  While many major health strategy documents address aspects of health care access, few target the unique challenges of delivering services in rural and remote communities or the specific needs of those who live there.

However, many jurisdictions have established or enhanced services in rural and remote areas by developing service models which are sustainable and achieve safe, quality care. This has resulted in more proximate access to a range of services such as renal dialysis, cardiac, and stroke.

This is why the Framework aims to provide a clear focus on the issues and factors that decision makers at all levels of the health system need to be mindful of when considering health services in the rural and remote context.

The factors that determine the level of access to health care service are often more complex in rural and remote communities. External factors such as workforce supply, the cost associated with delivering services to isolated areas, and the availability of infrastructure and equipment will influence which services are provided in a specific location. Additionally, the use of services by consumers is also an important determinant.

People in rural and remote areas needing to access health services are often influenced by:

  • travel distance to relevant health services, including the availability of transport and the cost of travel
  • uncertainty about how to use and access services, including the availability of emergency care and retrieval services
  • cultural and language barriers
  • poorer understanding of health issues and how to access health services.

In the rural and remote setting, an obvious barrier to accessing health services is language and culture. This is particularly the case for Aboriginal and Torres Strait Islander peoples, refugees, and people from culturally and linguistically diverse backgrounds. Other considerations, such as the availability of male or female health practitioners, can also influence a person’s decision to seek medical attention.

Past experience will also influence whether people seek assistance. Many consumers and providers report that people are often required to travel without support and over long distances to major cities for specialist appointments. These appointments are often poorly coordinated, and may be delayed or cancelled. An unpleasant experience can lead to people preferring to live with their condition than to go through another distressing process.

Similarly, lack of access to family support and child care can limit a person’s ability or willingness to be away for extended periods of time to receive treatment. This is an issue particularly when early treatment may prevent the condition worsening and, potentially, leading to avoidable morbidity and mortality.

State, territory and Commonwealth governments are responding to the challenges with a range of approaches including:

  • providing supplementary primary health care services where they may otherwise not be sustainable
  • establishing specialist services in regional centres
  • integrating and coordinating services, including health, aged care, and community services
  • providing culturally appropriate care to remote Indigenous communities
  • patient assisted travel schemes
  • providing specialist outreach services to areas of need
  • supporting emergency retrieval services, for example the Royal Flying Doctor Service
  • supporting the use of information communication technologies, including telehealth and e-Health initiatives.

Meeting community needs – the Central Highlands Community Health Centre, Ouse (Tasmania)

The Central Highlands Community Health Centre was developed to address an extreme mismatch between the services provided (ie acute in-patient beds) and community need, in a predominantly farming area with a rapidly ageing population. The Centre now provides a wide range of home-based care packages and services, including Extended Aged Care in the Home, Community Aged Care Packages, Home and Community Care services, Post-acute Care Programs, palliative care, and Meals On Wheels.

The Centre also provides a GP service, telehealth facilities, health promotion, chronic disease self management and a day centre, which are supported by a community transport program, regional ambulance services (including helicopter retrieval), nurse-led clinics and clear referral pathways to acute services.

Efforts are being made to support more integrated, flexible and coordinated approaches to improve access to services in rural and remote areas. These include better design and use of infrastructure, more flexible funding arrangements, and adapting the workforce to better meet rural and remote health needs. In some instances, services have co-located to make better use of scarce resources and increase operational efficiency, which is particularly important in small rural and remote facilities.

While GP practices and acute care services are more commonly taking this approach, a range of other services can also benefit, including aged care facilities, community health, private providers, and ambulance and retrieval services. In addition to providing an avenue to improve access to services, co-location can also support the long-term viability of these services.

Information technology also offers substantial benefits in improving access to services in rural and remote areas and can be used to support a wide range of situations including:

  • accessing secondary and specialist clinical advice
  • managing emergency and unplanned presentations
  • outpatient presentations
  • pre- and post-operative care
  • clinical education and skills development
  • state- or nation-wide collaboration among clinicians.

Transport and distance are identified as major barriers to access. This can affect clients, their carers and service providers (in relation to the provision of outreach services).

Support is available to patients who need to travel to health services outside their local area. These are provided through a range of services and schemes including:  arrangements with local transport providers, community transport providers and non-emergency transport services. There are also Patient Assisted Travel Schemes (PATS) in each State and Territory, which provide financial support towards the cost of travel and accommodation.

There are variations between state and territory PATS, which can create challenges for consumers, carers and their families.  Issues identified by rural stakeholders include:  the range of services that can be accessed; the level of entitlements; and inconsistencies when consumers need to move across administrative, program or jurisdictional boundaries. These variations reflect the different geography, demography and service provision in each of the states and territories. These issues must also be considered in developing appropriate PATS responses in each state and territories, as many jurisdictions are also investing in increasing services closer to home.

Better access involves more than just delivering timely, affordable and quality health services to people living in rural and remote areas of Australia. The Framework also promotes the need to build peoples’ understanding of how to manage their health, and about when and how to use available health services.  It also encourages governments, the health sector and communities to look at smarter ways to use health service infrastructure, accommodation, transport and technologies.

Using technology to improve access to services

Mental Health Emergency Care Rural Access Project (New South Wales)

The Mental Health Emergency Care Rural Access Project aims to improve access to emergency mental health services and treatment in rural and remote hospitals emergency departments across western NSW. A specialist team at Bloomfield Hospital in Orange provides assessments for mental health clients in remote and rural hospitals via videoconference 24 hours a day, 365 days a year.

With the support of the expert team, people who needed to travel hundreds of kilometres to receive expert clinical assessment, can often be cared for in their local hospital.  The team also provides training and specialist advice to local clinicians, providing them with the skills to confidently manage mental health presentations.

Cardiac Clinical Management in rural emergency departments (South Australia)

South Australia is developing an integrated, digitally-based and state-wide cardiac clinical management network that includes:

  • upgraded equipment to Country Health SA hospitals and health units that have an emergency department
  • a state-wide, centrally-supported cardiac clinical management network, iCCnet SA
  • a digitally-based system to enable transmission and assessment of electrocardiograms (ECGs), comparison with past ECGs, and ability to provide these records to multiple health providers involved in the patient journey.

The upgrade will assist country emergency departments to manage potentially critical situations and achieve better health outcomes through more rapid assessment and reducing the necessity for inter-hospital transfers.

When combined, these different approaches will help to achieve the overarching Goal 1:

Rural and remote communities will have improved access to appropriate and comprehensive health care

Strategies to help realise this goal are outlined in the following table.

Outcome area 1: Access

Goal 1:       Improved access to appropriate and comprehensive health care for people living in rural and remote Australia

Objectives Strategies
Objective 1.1

Better access to timely, affordable and quality health services for people living in rural and remote Australia

  • Work with Local Hospital Networks and Medicare Locals and/or other appropriate governance structures to identify, assess and coordinate clinically appropriate health services to meet local needs.
  • Develop mechanisms to support, integrate and coordinate services to meet local needs, including services within medical, allied and primary health care and other health service streams, and aged care, community services and emergency retrieval.
  • Develop funding mechanisms and incentives that support best use of information communication technologies for delivery of health services.
Objective 1.2

Improved health and health system literacy for people living in rural and remote Australia

  • Develop community engagement and education strategies that promote preventative health and early intervention.
  • Better inform consumers about the services and support programs available to them.
  • Work with consumers and health professionals to promote understanding of how the health system works, including emerging technologies such as e-Health.
  • Work with target population groups, including older people, Aboriginal and Torres Strait Islander peoples, people with chronic disease, refugees, and people from culturally and linguistically diverse backgrounds, to develop and implement strategies that address barriers to access, including language and specific cultural requirements.
Objective 1.3

Better health service infrastructure and accommodation, transport and information communication technologies

  • Facilitate developing national standards for patient travel and assistance.
  • Invest in the development of technology and infrastructure tailored for local health service needs.
  • Support the adoption of information and communications technology for e-Health, telehealth and electronic health record applications.
  • Promote adherence to national e-Health standards.

Outcome area 2:

Service models and models of care

Introduction

Two key elements in delivering health services are:

  1. the way health services are structured and operate—that is, the service model
  2. the way care is provided to patients, including clinical pathways, the patient journey and clinical guidelines—that is, the models of care.

To achieve better outcomes in access and equity it is necessary to develop and apply service models and models of care that are appropiate for, and respond to, the unique challenges of delivering quality care in rural and remote settings and that support continuity of care.

In Australia, significant investment has been made to improve health services in rural and remote communities and to create better, more flexible approaches to care. Yet there remains scope to apply and expand new and innovative approaches in delivery.

The multi-purpose service model, progressively implemented since 1993, provides an innovative approach for small scale, integrated and flexible services designed to meet the health and aged care needs of small rural communities. It also provides the venue for innovative models of care with linked clinical pathways, able to focus on improving the patient journey.

A range of other innovative models are available including fly-in/fly-out services, hub and spoke, cluster, as well as the provision of outreach specialist services. Determining which model, or combination, is most appropriate will depend on the individual needs, resources, and social and cultural characteristics of the community it is to be applied to.

Multipurpose Service Program

The Multipurpose Service(MPS) Program, established in 1993, is a partnership between the Commonwealth and State Governments to address the problems of access to, and sustainability of, health services in small rural communities.  The program pools Commonwealth and State funding and sets aside the normal program guidelines and constraints to allow small communities to integrate acute and aged care services.

Multipurpose services bring together a range of health and residential aged care services on one site. GP and ambulance services may also be co located. The program benefits small rural communities by enabling older residents to ‘age in place’ and provides small rural communities with access to a range of coordinated acute, aged care and community services.

For example, New South Wa les has made a significant commitment to the development of Multipurpose services since 1993 through the construction of facilities to bring together a range of health services and residential aged care services on one site.

A total of 52 MPS facilities are now operational across New South Wales, delivering services that might otherwise have been unsustainable.

To addess the specific challenges of rural and remote settings, successful models have demonstrated the following features:

  • a multi-disciplinary approach
  • integration and coordination
  • flexibility in design, funding, workforce and resource allocation
  • sustainability and responsiveness to local need and capacity
  • culturally safe and appropriate.

There are many examples of innovative models being implemented at the state, regional and local levels across Australia. It is clearly important to identify which are successful and to consider their potential for application across other rural and remote settings.

Establishing and strengthening links and patient referral pathways with services in metropolitan and larger regional centres will enable rural and remote services to better access secondary consultation, specialist advice and emergency services when needed.

As well as developing the appropriate networks and communications links, there may also be a need to establish partnerships and agreements to facilitate cross-network and cross-border coordination, resource sharing and patient transfers—particularly when patients need to cross a state or territory border to access health services.

Another element identified as needing improvement is the provision of health promotion and prevention programs.

While many programs provide health education, screening, immunisation and prevention services that are easily accessible in urban centres, their reach becomes more limited as distance from these centres increases.

Networking Cancer Services - CanNET (Western Australia)

The Cancer Australia Cancer Services Network National Demonstration (CanNET) Program was established to develop networked cancer services between rural and specialist services, providing opportunities to share learnings and to reduce duplication of effort and resources.

The program aims to develop a model that would enable appropriate access to specialist oncology services in regional Western Australia, using multidisciplinary team processes and services that reflected the point of view of rural cancer patients.

The program led to a higher than expected increase in referrals for radiotherapy and chemotherapy, following the introduction of multidisciplinary led care planning for cancer care.

Successful elements of this program will be rolled out across the remainder of rural Western Australia, including multidisciplinary team processes, appropriate referral pathways and multidisciplinary cancer education. Continuing challenges include securing long term funding for the program and promoting culture change among specialists regarding the delivery of specialist cancer care away from metropolitan Perth.

Information communication technology will improve the provision of, and access to, these services. However, alternative approaches may be needed for specific health issues such as breast or prostate cancer screening, and for particular target groups including older persons, Aboriginal and Torres Strait Islander communities and remote populations.

While designing appropriate delivery models and models of care is important, these models must be sustainable and deliver quality care in line with contemporary practice. Many innovations in rural and remote communities have been driven by dedicated individuals but later lapse as they lack the appropriate facilities or ongoing support to maintain them.

To achieve sustainable health services it is critical to support service delivery with the appropriate funding arrangements, infrastructure and technology, training and development, and skilled workforce. 

The Framework seeks to improve the delivery of services to rural and remote Australia under Goal 2:

Rural and remote communities will have effective, appropriate and sustainable health care service delivery

This goal focuses on improving the design and integration of services, encouraging innovation and flexibility, and optimising service capacity to ensure rural and remote health services can meet consumer and community needs now and into the future. Strategies are outlined in the following table.

Outcome area 2: Service models and models of care

Goal 2:       Effective, appropriate and sustainable health care in rural and remote settings

Objectives Strategies
Objective 2.1

Improved integration between service providers across and within primary health care, specialist care, acute care, Indigenous health and aged care

  • Ensure local work practices coordinate locally based and visiting health service providers.
  • Build relationships between local service providers and larger centres to complement locally provided care.
  • Support infrastructure development that promotes more integrated and multi-disciplinary care.
  • Introduce and support service models that recognise alternative models of primary health care that use a range of innovative approaches, including innovation in workforce roles.
Objective 2.2

Enhanced innovation in service design, including flexible funding for rural and remote health services

  • Support research to improve health service design and delivery.
  • Identify successful innovations in health service delivery and assess them for sustainability, scalability and transferability across other rural and remote settings.
  • Implement appropriate and flexible funding mechanisms for rural and remote health services, including telehealth services delivered from a distance.
Objective 2.3

Health service design that better meets local consumer and community needs

  • Support the involvement of local consumers and health providers in health service design.
  • Develop health policies and programs that acknowledge and address the uniqueness and challenges of delivering health services in rural and remote communities.
  • Promote multi-disciplinary and flexible models of care, and provide the necessary supports for these models to ensure sustainability.
  • Support collaborative care and planning through training and support for key professionals outside the health sector.
  • Support development of evidence to underpin service planning, design and delivery, and to inform the community.
Objective 2.4

Improved capacity for health promotion and disease prevention

  • Support the development of integrated, coordinated and appropriate health promotion and prevention activities that target key health priorities and target groups in rural and remote communities.
Objective 2.5

Improved cross-border and cross-network coordination and patient flows

  • Negotiate cross-border and cross-network agreements for the provision of health care services, transport and accommodation.

Outcome area 3:

Health workforce

Introduction

Attracting and retaining a skilled health workforce are key challenges facing health services across Australia as a whole—but workforce supply has reached a critical level in many rural and remote communities.

The number of doctors, dentists and oral health practitioners, mental health professionals, and allied health professionals in rural and remote areas is substantially lower per capita (DOHA 2008).

There is a greater reliance on overseas trained professionals and international medical graduates (IMGs) to address critical shortages in rural and remote areas.

In remote communities a high percentage of health care services are provided by nurses and Aboriginal health workers.

Governments recognise the need to actively address the maldistribution of the health workforce and have introduced programs to encourage health professionals to live and work in rural and remote areas.

While financial incentives may go some way to addressing the problem it is evident that a much broader, multi-pronged approach is needed, firstly, to attract all types of health professionals and, secondly, to encourage them to stay longer.

Rural Workforce Incentives (National)

To improve the health workforce in regional, rural and remote Australia, the Australian Government’s Rural Health Workforce Strategy, covers a range of programs providing both financial and non-financial support for rural doctors.

Introduced in July 2010, the General Practice Rural Incentives Program (GPRIP) aims to encourage doctors to relocate to rural and remote areas for the first time with financial incentives of up to $120,000.  Doctors already working in rural and remote locations may also access increased retention payments.

Enabling rural doctors to access adequate time for rest and professional development is an important factor in encouraging workforce retention.  To assist this aim, the National Rural Locum Program (NRLP) has provided locum support for Rural GPs, Specialist Obstetricians, and GP Anaesthetists since 2009-10.  In addition, the Rural Locum Education Assistance Program (Rural LEAP) began in February 2010 and provides financial assistance to urban GPs who provide four weeks of paid locum placements in a rural or remote area.

Medical students who choose to train and work in rural and remote communities are able to have their HECS debts reimbursed under the HECS Reimbursement Scheme. 
As of 1 July 2010, doctors are also able to reduce the period for reimbursement of the cost of their medical studies.

Recruiting the right workforce

The need for rural health practitioners to be multi-skilled is widely recognised.  While the scope and nature of their work requires good generalist skills, much of the training for rural health professionals is conducted in metropolitan institutions by specialists who are removed from the realities of working in the rural health setting (Humphries et al 2002).

In terms of attracting skilled health professionals it is important to recognise the preconceptions about working in rural and remote communities. These generally relate to:

  • professional and social isolation (for the health professional and their spouse and family)
  • poorer local amenities and infrastructure
  • limited training and professional development opportunities
  • the difficulties of delivering services in geographically isolated areas, including long-distance travel, extended working hours, and lack of locum support.

The disparity in the incomes earned between specialist medical practitioners and generalist medical practitioners also contributes to the shortage of general practitioners. ‘Procedural’ specialties, such as surgery, will typically command higher levels of income and therefore attract more practitioners than general or family practice (Cheng et al 2010). 

While these factors all contribute to the workforce maldistribution in rural areas, rural practice is also seen as a natural environment for workforce innovation.

Recent innovations include expanded roles for practice nurses, nurse practitioners and allied health therapy assistants. The Productivity Commission (2005) has noted that many such innovations have the potential to provide the basis for system-wide changes in health workforce arrangements.

While rural practitioners appear to be more comfortable with a more multi-disciplinary team approach and broader scopes of practice, there is still a need to overcome the barriers that exist between professional disciplines and within training institutions to further develop and implement these approaches.

While earnings vary slightly between states and territories, GPs who practise in outer regional, rural and remote Australia are eligible for payments under government incentive schemes, and there may be a lower number of competing practitioners in rural and remote areas.

Governments and communities can also actively challenge the common perceptions of working in rural and remote settings by:

  • promoting the advantages of rural and remote practice, including opportunities to develop a broader range of skills and experience
  • increasing local capacity to ‘grow your own’ workforce, as students originating from rural and remote communities are more likely to return to work in these communities
  • improving available health facilities and accommodation, including addressing the cost and availability of quality and safe housing
  • ensuring health professionals have access to peer and locum support, and opportunities for training and continuing professional development
  • utilising information technology to support distance-based social and professional relationships and activities.

It should also be recognised that health services also experience workforce shortages in non-clinical areas, such as management, finance and health information. To minimise the impact it is necessary to provide support and training for non-clinical workers, and to explore opportunities for small health and hospital networks to share their administrative, financial, and health information infrastructure and staff.

Retaining rural and remote health professionals

Workforce development has tended to focus on medical practitioners, however, the entire health workforce needs to be developed in keeping with cross-disciplinary and generalist requirements. In the overall remodelling of health practice in rural and remote areas, inter-professional education and ongoing training will be essential.

There is a critical need to expand existing scopes of practice and create new roles to optimise workforce capacity and to meet health care needs. The development of more advanced roles for rural GPs, including obstetrics, surgery and anaesthetics, and for nurse practitioners is seen as a useful strategy to strengthen and maintain a skilled rural health workforce. 

It is also important to consider the roles and scopes of practice of a wide range of other health care workers including remote health workers, nurses, allied health workers, midwives, Indigenous health workers and vocationally trained workers.

Rural Generalist Medicine(Queensland)

In August 2005, the Queensland Government announced the recognition of a new category of senior doctor called the ‘Rural Generalist’.  Rural Generalist training commenced in 2007 within the Rural Generalist Pathway.

Queensland officially recognised Rural Generalist Medicine in 2008.  As a specialist equivalent medical discipline, Rural Generalists can:

  • gain a professional status and a service value equivalent to that of a medical specialist
  • receive a specialist-level remuneration package, including a ‘private practice’ allowance.

The Rural Generalist Pathway provides supported training through medical school to Rural Generalist Medicine practice.

The practice of Rural Generalists includes rural general practice and hospital-based practice with at least one advanced skill in a specialist discipline. Rural Queensland will benefit from the priority advanced rural skills of obstetrics, anaesthetics, Indigenous health, emergency medicine and surgery. 

In the future, Rural Generalist Medicine increases the prospect of rural and remote communities being well supplied with doctors seeking rather than being coerced into rural service. 

It also potentially improves the chances of Indigenous communities being well supplied with doctors whose advanced skills in Indigenous health will provide a medical service dedicated to their unique needs.

In developing initiatives for a sustainable rural and remote health workforce, there is now sufficient evidence to bring the focus of recruitment strategies towards shorter retention cycles. In place of expectations of GPs staying in town for decades, workforce planning should focus on three to seven year cycles, dependent on the workforce group. This re-orientation of strategy requires ongoing efforts and continual succession planning.

Planning for education and training in rural and remote areas needs to recognise that the professional, personal and community-based activities of health care providers often overlap in small communities. Health care providers and health service managers are often effectively ‘on call’ continuously and, therefore, special effort is required to enable them to undertake their continued training and development.

Workforce planning, education and professional development should involve active partnerships with the tertiary education sector and other national bodies, such as professional colleges, national peak bodies, and the national accreditation and registration system.

An example of a successful model that combines specialist roles for nurses, with the appropriate training, guidelines and partnerships to support them is outlined below:

Remote Area Nursing Emergency Guidelines and Training (Victoria)

There are fifteen Bush Nursing Centres (BNCs) located in remote and isolated communities throughout rural Victoria. BNCs provide key primary health and emergency stabilisation services to these communities. Due to the remoteness of these communities, BNC nurses may be the only health care professionals available to provide first line care in the event of a medical or trauma emergency.

BNCs can employ Remote Area Nurses (RANs) who are up-skilled to provide time critical emergency response and stabilisation care in the absence of a medical officer or paramedic. The regulatory framework in Victoria provides for RANs to have the delegated responsibility to provide emergency care provided that they have completed annual competency based training based on the Victorian Remote Area Nurses Emergency Guidelines (RANEG).

A key component of this model is the partnership between BNCs and Ambulance Victoria. Ambulance Victoria conduct annual competency based training and provide peer support and mentoring to the RANs. RANs through joint dispatch arrangements with Ambulance Victoria provide a first response to emergency calls in their community and are able to arrive and commence emergency care to patients substantially prior to paramedic or medical officer assistance.

The Framework seeks to build a health workforce that meets the needs of rural and remote communities through better recruitment, training and continual professional development, and retention of skilled health professionals and non-clinical health workers to achieve Goal 3:

Rural and remote communities will have an appropriate, skilled and
well-supported health workforce

Strategies are outlined in the following table.

Outcome area 3: Health workforce

Goal 3:       Rural and remote Australia has an appropriate, skilled and well-supported health workforce

Objectives Strategies
Objective 3.1

Improved recruitment, retention and distribution of rural and remote health service providers

  • Support training placements to rural and remote practices across all health professions.
  • Consider supply of appropriate infrastructure for health service staff including housing and health service facilities, where market failure has contributed to a lack of availability or high cost.
  • Introduce flexible workload management and support by providing after-hours call centre services, professional networks and readily accessible locum support.
  • Promote safe and healthy workplaces, particularly in high risk areas, ensuring professional and inappropriate physical isolation are addressed.
  • Bundle financial and non-financial incentives to address the broad range of factors that affect workforce supply and distribution.
  • Develop communication strategies that promote the rewards of careers in rural and remote areas.
  • Identify strategies to attract and retain health service support staff.
  • Routinely evaluate and improve workforce support programs to ensure they contribute towards a more equitable distribution of rural and remote health service providers.
Objective 3.2

Build a health workforce that meets the needs of local communities

  • Identify opportunities for new or expanded roles and varying of the skill mix of multi‑disciplinary team members to enhance services.
  • Explore flexibility in the scope of practice for all health service providers and promote more advanced skill roles for GPs and nurses. 
  • Implement innovative funding mechanisms for services delivered by non-medical health service providers.
  • Identify and explore options for addressing legislative, regulatory and other barriers that limit the full service capacity of rural and remote health professionals.
  • Recognise and support the role of GP proceduralists and nurse practitioners in delivering health services in rural and remote settings.
  • Promote interdisciplinary training to reduce barriers between health care professionals.
  • Introduce new professional and semi-professional roles such as vocational and tertiary trained assistants, transport providers and coordinators, and telehealth/e-Health coordinators.
  • Ensure preventative health becomes an important element of skills development for the rural health workforce.
  • Introduce technology and other efficiency measures to assist the workforce to address the health needs of communities.
Objective 3.3

Improved availability of training and continuing professional development programs for rural and remote health professionals

  • Ensure workforce has access to appropriate and well supervised clinical training, education and continuing professional development opportunities, including better use of ICT for training delivery and support.
  • Develop opportunities for rural and remote GPs to access training in advanced skills.
  • Promote expansion of scholarship, clinical placement, and bonded scholarship programs to all health disciplines.
  • Target clinical training placements to areas of workforce need.
  • Develop appropriate funding mechanisms to support distance supervision of remote practitioners and new and emerging health service providers.

Outcome area 4:

Collaborative partnerships and planning

Introduction

To address the complexities of rural and remote health it is necessary to plan and design health services and health policy specifically ‘for rural by rural’ rather than trying to adapt and apply a metropolitan health care model.

This would ensure consideration of the specific needs of Aboriginal and Torres Strait Islander and geographically isolated populations, and the great diversity between rural and remote communities.

Enhancing health services in the Pilbara (Western Australia)

The health system in the Pilbara region, in the north of Western Australia, was placed under serious stress due to a rapid pace in resource development, increasing population, and demand for services in the region.

The Pilbara Industry’s Community Council (PICC) was formed in 2007 to provide a multi-lateral approach to plan for the current and future sustainability of the Pilbara, involving a range of government and industry sectors.

The PICC aims to strengthen investment in services and achieve outcomes that are critical to the State’s development in a coordinated and collaborative manner. The PICC identified supporting sustainable health services as a priority, given its role as a key enabler for continuous resource development in the region.

In late 2009, the WA government and PICC announced the three year Enhancing Health Services in the Pilbara initiative.

A range of projects have been funded through this partnership to strengthen emergency response capability across the region, improve access to specialist medical services, increase Indigenous employment in local health services, expand sexual and family health services, provide staff accommodation units at Newman, upgrade three small hospitals in the region, and undertake service planning for two other small hospital services.

Local planning

Local and regional level planning has an important role in ensuring sustainable health care in rural and remote areas by helping to identify: 

  • the individual characteristics of an area and the specific needs of the people who live there
  • the services, infrastructure and workforce that are already available, and what aspects may need to be improved or developed
  • gaps in health service provision in the area and some possible reasons for this
  • opportunities for creating linkages and partnerships between key stakeholders, governments, health and other community services, and other sectors including local industries.

The benefits of local planning include:

  • delivering more integrated and sustainable health services
  • services that better target the local need
  • more effective utilisation of existing facilities, resources and workforce
  • greater community input and engagement.

Implementation of the Strategy for Planning Country Health Services (South Australia)

Recognising the need to improve health outcomes for country people, the Strategy for Planning Country Health Services in South Australia (the Strategy) was released in December 2008, following detailed discussions and consultation with rural and regional residents and health professionals.  The Strategy provides a framework, including planning principles, planning milestones and a delineation framework to inform the development of the 10 year health service plans for local hospitals and health services.

Throughout 2009-2010, Health Advisory Councils, local health services and the Country Health SA Planning Projects Team worked towards developing a total of thirty three 10 year local health service plans across country South Australia.  In several locations, Health Advisory Councils and local health services agreed to use a cluster or sub-cluster wide approach in their planning.  This approach presented an integrated picture across the cluster and effectively enabled an approach to share and strengthen health services for the overall catchment needs.

The 10 year plans outline the health service’s vision for their catchment area in regard to service delivery, capital works, workforce development and other needs. The work presents a ground-up approach to planning future health service needs across country South Australia. A range of community engagement strategies have been implemented including surveys, focus groups, community stalls, online questionnaires, interviews and building on previous consultations.  The contributions made by the Health Advisory Councils is well acknowledged and a key factor in the success of the local planning process. 

The national health policy, planning, funding and resource allocation landscape is changing with the implementation of the national health reforms3.

With the introduction of Medicare Locals and the Local Hospital Networks, these changes will offer a major opportunity to promote collaboration and partnerships that support the development of local solutions.

The expertise needed to formulate and implement local area health service plans is not well distributed across rural and remote Australia. Accordingly, there is a need to build the capacity of health service managers and providers and provide the necessary skills to work within a more multi-disciplinary and integrated framework.

Building partnerships for healthier communities

A fundamental element in local and regional planning is identifying and establishing strong and effective linkages and partnerships.

Fostering local partnerships and collaborations helps to draw together and get the best out of the local, state and Commonwealth investment in health and human services.

These partnerships can be developed between different levels of government, or between sectors (including health, education, housing, employment and regional development). Within the health care sector it is also important to consider the opportunties to develop partnerships across the public, private, not-for-profit and community controlled sectors.

Stronger partnerships help promote a more effective use of available resources, improve the transition of patients between health services, and help to coordinate action to improve patient access and outcomes or address the social determinants of health.

Healthy partnerships in the Ntaria Aboriginal Community (Northern Territory)

The Northern Territory Department of Health, the Western Aranda Health Aboriginal Corporation (WAHAC) and community members have developed a strong partnership to develop supportive environments for healthy choices and respond to community health needs in the Ntaria Aboriginal community.

A nutritionist, Preventable Chronic Disease Nurse and Health Promotion Officer work in partnership with community members to respond to community-identified health issues by supporting:

  • nutrition and exercise groups for family groups and chronic disease groups
  • education for mothers at the Families As First Teachers playgroup
  • promotion of healthy choices at the local stores
  • School Nutrition Program workers and building the capacity of Health Centre and WAHAC Staff, including Aboriginal Health Workers, to provide nutrition education.

3 As agreed by COAG on 13 February 2011.

Beyond the delivery of services, collaborative partnerships also have a valuable role in developing tools for providing safe and quality services and for supporting continuous quality improvement and evaluation.

Community engagement and consultation are important factors in ensuring health care planning in rural and remote settings is both relevant and appropriate. Accessing local knowledge not only provides a more accurate picture of the particular health issues and requirements of a rural or remote community, it can also help identify otherwise missed opportunites and resources that can help deliver these services. Additionally, stronger connections between health services and communities help to build a better understanding of the relationship between peoples’ health and the wider social, economic and physical environment, which will ultimately have a positive influence on overall health outcomes.

As discussed in outcome area 2, the networks between services located in rural and remote areas and their counterparts in urban centres need to be cultivated.

Strengthening mutually respectful relationships between rural and remote services and the more specialised services in larger regional and metropolitan centres is essential. This will ensure the safety and continuity of quality health care for rural and remote consumers who must travel to access high cost, high technology, and specialised health services.

Providers of health services in these larger centres also need to demonstrate a greater appreciation of the different life context of rural and remote consumers and the additional challenges they face to access these services.

Collaborative development of primary health care clinical guidelines (Queensland)

Clinical practice guidelines to support clinicians in state-wide, rural and remote primary health care facilities have been developed by the Office of Rural and Remote Health (Cairns) Primary Health Care Team. These include the Primary Clinical Care Manual and Chronic Disease Guidelines.

The development and review of the guidelines are undertaken by expert clinical and non clinical personnel across a range of government and non government agencies, including:  the Apunipima Cape York Health Council; Royal Flying Doctor Service; Queensland Ambulance; New South Wales Health Service (Greater Western Health Service); James Cook University; Queensland Aboriginal and Torres Strait Island Health Council; Queensland Poisons Information Centre; Royal Australian Navy – Fleet Health Support Unit; and Queensland Health.

This collaborative engagement ensures that clinicians in rural and remote facilities have access to concise, evidence-based clinical guidelines that apply in both the geographical and clinical setting.  This supports rural and remote clinicians in providing expert care, therefore improving patient outcomes.

The guidelines are aimed at multidisciplinary team members including nurses, midwives, health workers and medical officers. The target population is rural and remote residents including Indigenous peoples. The Primary Clinical Care Manual is also used by Health Departments in Victoria, New South Wales, Western Australia, and Queensland.

This Framework recognises the importance of collaborative health service planning in rural and remote Australia and sets Goal 4:

Rural and remote communities will have collaborative health service planning and policy development

The strategies outlined aim to help achieve this goal by challenging planners and policy makers to better meet the specific needs of rural and remote communities, to utilise available resources and workforce, and to develop positive and effective partnerships within and beyond the health care sector.

Outcome area 4: Collaborative partnerships and planning

Goal 4:       Collaborative health service planning and policy development in rural and remote Australia

Objectives Strategies
Objective 4.1

Improved planning and decision making that address locally identified health needs

  • Support consumers and community members to be meaningfully engaged in health service planning and monitoring and evaluation.
  • Identify and address barriers to health service access through effective policy development and planning processes.
  • Improve the collection and availability of local health services data to enhance local health service planning.
Objective 4.2

Enhanced use of locally available health and human service resources

  • Maximise the use of existing health and human service infrastructure across government, non government, private and community controlled sectors.
  • Identify opportunities for collaboration and information sharing between health services and other local social service sectors in the planning and delivery of health services.
  • Support resourcing arrangements that allow the flexible use of funds to reduce gaps and duplication of effort.
Objective 4.3

Improved health service planning within and beyond the health service sector

  • Implement collaborative partnerships in health service planning, policy development and funding that involve services across the health care sector including public, private, not-for-profit, and community controlled services.
  • Foster partnerships and cooperation with different levels of government (local, state and Commonwealth) and with other relevant sectors, including education, housing, employment, industry and regional development.
  • Support coordinated clinical networks at the local level that includes acute care, aged care and primary health care practitioners.
  • Promote flexible and cross-border and cross-network health service planning and delivery arrangements.
  • Introduce innovative resourcing arrangements that encourage regional and metropolitan care providers to support service provision in rural and remote communities.

Outcome area 5:

Strong leadership, governance, transparency and performance

Introduction

Leading and managing health services in rural and remote areas can be more challenging than in larger centres. The specific issues faced by smaller rural health services, including more limited resources and budgets, can create even more pressure for staff in the day-to-day running of services.

This Framework seeks to identify ways in which stronger leadership and governance can better serve the health needs of rural and remote communities, and to ensure the sustainability, quality and safety of their health services.

To provide a sound foundation for sustainable, efficient, safe and quality health services there is a need to:

  • support good governance and management through improved access to training, skills development and tools that reflect the needs of rural and remote settings
  • attract and retain skilled and experienced managers and administrative support
  • support performance and continuous quality improvement.

The Commonwealth, state and territory governments all have a role in providing policy leadership, developing support tools and incentives, and monitoring the performance and quality of the health system from the local to national level.

Many jurisdictions have programs aimed at building a complement of skilled health service managers, yet there remains a need to build upon these efforts to meet the particular needs of rural and remote health services.

With the introduction of new primary health care organisations these changes offer a major opportunity to promote leadership through greater collaboration and partnerships that encourage and support the development of local solutions.

Health board members and service managers may also face the particular challenge of balancing their fiduciary duties with the needs and wants of local special interests. In smaller communities people often sit on several, sometimes competing, boards or management committees that may cross a range of government, non-government, community-controlled and private sectors. In these instances, providing strong orientation and training and ongoing mentoring and support will help to avoid potential conflicts of interest.

At the patient care level, appropriate clinical governance is essential to assure the community and those responsible for maintaining quality and safety that a competent clinical workforce is in place.

Supporting Clinical Governance (Queensland)

Credentialing and Scope of Practice for Rural and Remote Districts

The Office of Rural and Remote Health Clinical Support Unit (established in 2008) provides clinical governance services to five Queensland rural and remote Health Service Districts of Mt Isa, Cape York, Torres and Northern Peninsula, Central West and South West.

The Office set up a Credentialing and Scope of Clinical Practice Committee to assist District CEOs regarding the credentials and scope of clinical practice for general practitioner staff within rural and remote facilities. The committee has uniform standards for assessing practitioners’ qualifications and experience, and applies these across both locum and permanent staff.

The Committee has representatives from each of the five Districts, as well as the Royal Australian College of General Practitioners, Australian College of Rural and Remote Medicine, and James Cook University.  It also includes specialist representation in Emergency Medicine, Obstetrics and Gynaecology, Anaesthetics and Surgery.

Continuous Quality Improvement in Primary Health Care

The Primary Health Care Quality Improvement and the Audit and Best Practice in Chronic Disease (ABCD) team supports continuous quality improvement and evaluation in primary health care settings across Queensland, with a focus on Indigenous health.

Collaborating with key stakeholders, the team supports continuous quality improvement in primary health care by:

  • facilitating annual clinical audit and systems assessment cycles and workshops on quality improvement to support the delivery of evidence-based services
  • providing evidence-based tools and training to enable primary health services to incorporate evidence into practice for child, maternal, preventive and chronic disease health services
  • providing access to web-based information and reporting system that enables primary health care centres to integrate continuous quality improvement processes into routine work activities
  • linking quality initiatives such as the Healthy for Life program, National Primary Care Collaboratives, accreditation requirements, and Queensland Health key performance indicators
  • supporting ongoing research and publication of findings.

All jurisdictions have policies and processes in place for accreditation and credentialing, defining scopes of practice, and for developing clinical practice guidelines. The challenge is to ensure these policies, guidelines and processes appropriately reflect the specific needs and requirements of delivering and managing health services in rural and remote settings.

Improving accountability and performance

The collection, analysis and reporting of performance data is necessary to inform policies, program development, resource allocation and quality improvement. Using timely and good quality data will also enhance the capacity of health service systems to understand and respond to changing local health needs.

Governments have also recognised that greater transparency on the performance of health services will help to drive improved performance, and will help patients make informed choices about their health care.

Under the national health care reforms, a new performance and accountability framework will be introduced that includes national standards and transparent reporting. The aim is to provide Australians with transparent and nationally comparable performance data and information on their local hospitals and health services.

The ability to deliver on these overarching national health goals and targets will rely, in part, on achieving better health outcomes in rural and remote Australia. 

Data indicators and performance targets on system performance and health outcomes are specified at both the national and jurisdictional levels, and are generally applied equally across urban, rural and remote areas. Yet indicators and targets that are appropriate for urban areas are not necessarily appropriate for rural and remote settings. And in many cases, targets and indicators that may be appropriate for rural areas are not necessarily appropriate for remote areas.

There is therefore a need to:

  • develop and identify suitable data indicators for assessing health status, system performance and outcomes in the rural and remote context
  • improve the quality and consistency of data collection, including the use of geographic classifications and the need to better reflect the socioeconomic features of rural and remote communities
  • improve collection of health status and outcome data for remote localities and Aboriginal and Torres Strait Islander communities.

Aboriginal Health Key Performance Indicators (Northern Territory)

The Aboriginal Medical Services Alliance of the Northern Territory, the NT Department of Health and Families, and the Commonwealth Department of Health and Ageing worked in partnership to develop Key Performance Indicators for Aboriginal Health.

In 2009, collaboration between the partners resulted in the achievement of a major milestone: the generation of community-level, Aboriginal Health Key Performance Indicator reports for 82 Government and Non-Government Aboriginal Primary Health Care service providers across the Northern Territory.

With the support of Continual Quality Improvement facilitators, the data from these reports is increasingly used in communities and by service providers to plan, monitor and improve Primary Health Care service delivery in the Northern Territory.

Recognising the more limited resources and capacity of rural and remote health services to provide service data, it is imperative that any reporting and monitoring arrangements:

  • are appropriate and relevant to rural and remote settings
  • provide meaningful, timely and useful data
  • do not increase unnecessary administrative burden on services
  • feed back to services to support further quality improvement and recognise achievements.

To address the challenges and issues this Framework seeks to work towards Goal 5:

Rural and remote communities will have strong leadership, governance, transparency and accountability

A number of strategies are outlined to help enhance the leadership and governance skills and capacity for rural and remote health services, to improve the use and quality of data needed to support sound planning and decision making, and to improve accountability and performance.

Outcome area 5: Strong leadership, governance, transparency and performance

Goal 5:       Strong leadership, governance, tranparency and accountability for rural and remote health services

Objectives Strategies
Objective 5.1

Improved capacity for local leadership and governance of health services

  • Recognise the role of rural community leaders and the challenges of leadership in rural and remote settings.
  • Develop relevant leadership and governance tools.
  • Identify strategies to attract and retain good managers.
  • Provide clinical and non-clinical governance training that is tailored to rural and remote settings as a part of ongoing professional development.
  • Develop effective support mechanisms for health service managers.
  • Develop mechanisms that support regional collaboration and cooperation in leadership.
  • Ensure a balance between clinical and corporate governance to achieve safe sustainable health services.
Objective 5.2

Enhanced availability and use of data for planning and decision making

  • Collect and make available local health services data to enhance local health service planning.
  • Promote the use of high quality, local population health data in planning and decision-making, and identify gaps or areas for improving data collection.
  • Support research that evaluates the impact of new and emerging governance and management structures, and provides an authoritative evidence base for future design.
Objective 5.3

Increased accountability and transparency in the delivery of rural and remote services

  • Establish reporting arrangements that maximise the use of existing indicators and data collections, and avoids unnecessary administrative burden on health services.
  • Identify gaps in reporting where further development of performance indicators may be required.
  • Develop health service planning and reporting templates and frameworks appropriate for use in rural and remote settings.