Supporting rural health care

Australia’s rural population, which comprises a third of our total population, presents distinct challenges for health care delivery. The low population density of much of rural Australia, the great distances involved, and the limited number of larger centres offering high-level medical care make equitable health care delivery difficult to achieve. Added to these difficulties is the overrepresentation of socioeconomic disadvantage and Indigenous people in rural and remote communities. The overall picture is that of a population with a heavier disease burden, more barriers to accessing appropriate care, and poorer outcomes from cardiovascular disease, stroke, diabetes and cancer than the metropolitan population.

The rural health workforce is ageing and, particularly in remote areas, remains heavily reliant on international medical graduates. There is also a significant maldistribution of the medical workforce, with the rural sector having only a third to half of the workforce of metropolitan areas, on a population basis. Surgical and medical specialists are most markedly underrepresented.1

Certain medical interventions will always be difficult to deliver to some rural populations. For example, primary percutaneous coronary intervention (PCI) for ST-segment-elevation myocardial infarction and thrombolysis for acute stroke, while increasingly available in regional referral hospitals, rely on timely delivery to be effective, and this will not always be possible for people in more remote locations. The SNAPSHOT ACS study reported in this issue of the Journal indicates that not only are patients in rural areas less likely than those in urban areas to undergo echocardiography, coronary angiography and PCI, they are also less likely to receive guideline-recommended medications, cardiac rehabilitation and dietary advice.2 This finding is consistent with shortages of allied health workers and specialists in rural and remote settings.

Nevertheless, there have been recent initiatives that will benefit rural health in the long term. The Rural Clinical School program, operating for over a decade, is now reaping rewards, with graduates returning to rural areas as junior medical officers, general practitioners or specialists.3 Health Workforce Australia and the Royal Australasian College of Physicians (RACP) are supporting dual training in general medicine and a subspecialty, with two positions to be based in Orange and Dubbo in New South Wales next year.4 This initiative addresses the lack of rural advanced training positions — a key concern in the April 2013 report of the Mason review.5 Given that the inability to undertake a major portion of advanced training in a chosen specialty in a rural location is a significant barrier to rural recruitment, such training positions require funding. Queensland Health’s Rural Generalist Pathway and the RACP’s dual training model are two examples of programs that could be expanded both internally and into other specialties.

Opportunities to strengthen medical training — both before and after medical school graduation — should be seized. The Rural Clinical School program’s expansion beyond medical training into interdisciplinary education and simulation centres prepares trainees well for rural practice. However, this approach is challenged by insufficient rural intern positions. State governments should consider increasing the number of rural intern positions available.

Unless the complexity associated with the cost of providing health services to sparsely populated and geographically stretched communities is fully appreciated, activity-based funding will pose risks to rural service provision. Patient transport is often a limiting factor in appropriate and timely service provision, and this also needs to be reviewed.

The federal government is well aware of the issues in rural and Indigenous health, and several of its initiatives, such as improving rural training opportunities, need to be acknowledged. It is important that the medical profession continues to work with both the federal government and rural communities to support, promote and strengthen these initiatives. It is no longer realistic to expect one or two doctors in small rural communities to provide 24-hour care every day of the year. Instead, best practice requires groups of practitioners with complementary skills to work together to achieve appropriate, and safer, health care. An important function for politicians is to explain the necessity of these changes in medical practice to the community. Nurse practitioners could have a major role, and expansion of these positions in rural group practices and multipurpose services would facilitate better care, especially for patients with chronic illness.

Australia has made steady progress in recent years in providing effective health care to rural and regional communities. Future governments require strength of resolve, clear vision and sound policies to maintain that progress for the third of the Australian population who live beyond the major cities.