Specialist outreach services in regional and remote Australia: key drivers and policy implications

Promoting the supply, distribution and sustainability of rural outreach services requires multilevel policy development and regional service planning

The need for more local specialist services to support rural communities is well established as a significant issue in Australia. Although the specialist workforce is growing, providers are increasingly choosing to subspecialise and work in metropolitan practice.1 Access to medical specialists in major cities is consistently high at 162.1 full-time equivalent specialists per 100 000 population, but diminishes for people living in inner or outer regional (82.7 and 61.5 per 100 000 respectively) and remote areas (34.2 per 100 000).2

Increasing access to specialist care in rural areas is nuanced. Rather than targeting universal access as relevant for primary health care, a key policy challenge is promoting access to an appropriate range of relevant and sustainable specialist services specific to population needs. This is complex because only a restricted range of specialists is amenable to working in smaller rural catchments. Further, the needs of different rural communities in the same region can be wide-ranging and changeable. It makes sense to foster the development, recruitment and retention of a core group of regionally based specialists who can address the bulk of community demand. However, there is an equal need for adjunct service models to (i) supplement the range of subspecialist and specialist services available regionally relative to population need, improving the potential to manage patients locally; and (ii) provide specific specialist services in small, distributed populations that often have the highest burden of disease and least local health services.

A major service option is rural outreach, involving specialists travelling away from their main practice to provide services for a few days at a time in a rural town on a regular basis. The World Health Organization endorsed outreach in 2011 as an efficient way to draw health workers into underserved communities, without requiring permanent relocation.3 However, they noted the poor evidence base regarding health worker interest and the enabling conditions. Although the international evidence about medical specialist outreach has slowly increased over the past 15 years, it has predominantly focused on describing and validating services via case studies, and Australian examples are mostly limited to remote Indigenous settings.3-9

Stimulated by the need for more systematic information to inform the use of rural outreach to promote rurally available specialist services, we undertook a 3-year program of research into the patterns of rural outreach work by Australian specialists. This involved quantifying the rate of participation and service patterns, as well as delineating factors influencing the supply, remote distribution and sustainability of outreach services, including sex, career stage, geography and practice sector. The research, the first of its kind internationally, was integrated within the Medicine in Australia: Balancing Employment and Life (MABEL) longitudinal survey of Australian doctors (http://www.mabel.org.au), with annual data collected from 2008 to 2014. A further aspect of the research explored the role of specialists receiving subsidies from the Australian government for their outreach work, such as from the Rural Health Outreach Fund (RHOF).10

In this article, we review the local evidence about patterns of medical specialist outreach in regional and remote areas.

At a system level, rural outreach service models support strong volume and range of specialist services for rural Australia. Of the 4596 specialists who responded to the MABEL survey, 909 (19%, weighted proportion) provided outreach services, particularly in general and renal medicine, otolaryngology, urology, ophthalmology and radiation oncology.11 Many specialists are interested in rural outreach work as a way of growing and diversifying their main practice.12 While they tend to visit only one town, their services add capacity in both inner regional (58%) and outer regional and remote towns (42%).13

About half of the specialists sustain rural outreach to the same town for at least 3 years,14 although additional data from the 2014 MABEL survey suggest that specialists maintain their main outreach service (the town where they spend the most time) for a median of 6 years.15

About half of the specialists undertake outreach work without any support from subsidies, with the remainder supported by the RHOF (19%) or other types of subsidies (27%). This suggests that specialists incur some personal costs of time and travel for outreach participation, although 33% of non-subsidised providers work publicly, potentially covered by salaried arrangements.16

A wide range of factors relate to participation and influence the distribution and sustainability of specialist outreach services. These can mainly be categorised according to individual, organisational or economic domains.

In the individual domain, 74% of outreach providers are from metropolitan areas and their remote area service coverage is greater than that of rural-based specialists, probably influenced by their better access to commercial air travel.11,13 As a group, they are more interested in outreach work to maintain a pre-existing connection to a region;12 The nature of this connection has not been studied; however, outreach participation is not related to a childhood rural background.11 Further research is required to explore links with rural exposure within medical training, internships or rural locum work, which are amenable to policy intervention.

Specialists in rural areas more commonly participate in rural outreach and provide services in nearby towns within their region.11,13 Improved recruitment and retention of regionally based medical specialists might increase the rate of outreach work but would likely not address service gaps in more remote locations.

Female specialists are less inclined to participate in rural outreach (15% v 20% of males) and less likely to continue visiting the same town over at least 3 years (41% v 55% of males),11,14 although the key personal or professional barriers for this require specific exploration. Reducing travel demands could increase their participation, including supplementing physical visits with video consultation services where appropriate. The types of outreach clinical services that can be effectively provided by video consultation and their capacity to substitute physical visits are the subject of further study.

Organisationally, notwithstanding the involvement of large tertiary hospitals in specialist outreach,7 specialists in private consulting rooms constitute over half of all providers and more commonly participate (22% v 18% of public sector specialists). Their flexible employment conditions make it possible to follow interests, and outreach work supports their practice diversity.11 While privately based metropolitan specialists have similar outreach travel times to those in the public sector, rural private specialists are more inclined to travel shorter distances from their main practice.13 It may be relatively easy for this group to identify nearby regional service gaps, being familiar with the rural context. However, this also suggests the need for sustainable business models that reduce strain on smaller rural practices.

Early career specialists (47%) and those nearing retirement (47%) are less likely to sustain at least 3 years rural outreach compared with those aged 45–64 years (55%),14 suggesting that targeted support is needed for specialists who are either growing their main practice or planning to retire. One option, facilitated by how common outreach work is, could be to increase outreach work within vocational training, especially through the Commonwealth Government Specialist Training Program, linking emerging specialists with experienced providers.

In the economic domain, specialists only working privately are less likely to continue outreach services to the same town (37% v 49% in the public sector).14 This suggests that there may be cost implications related to specialists self-funding their travel costs and absorbing the costs of travel time, which are likely to increase as specialists travel to more distant or hard to reach communities. We found that subsidies, whether provided to outreach specialists from the RHOF or another source, increased the rate of more remote area services by up to 4.4 times.16 Additionally, RHOF subsidies relate to more regular outreach services in remote locations, with 62% of these specialists intending to continue for 5 or more years. Non-subsidised specialists tend to target outreach services to larger, nearby towns, where clinical throughput is likely to be higher and more financially sustainable. However, it is possible that market pressure encourages such specialists to cherry-pick profitable caseloads, leaving complex and expensive cases for local specialists and rural generalists. Establishing rural health care priorities at a state or regional level to complement national priorities (the RHOF targets services in maternal and child health, chronic diseases, eye health and mental health) could strengthen alignment of such services with local population health needs.

Apart from individual, organisational and economic drivers, the utility of the volume and range of outreach services at the regional service delivery end is contingent on a level of integration and coordination. It is important to formally plan for outreach services as part of the regional specialist service platform, and to draw outreach services into key service gaps, where locally sustainable services are not supportable. This is especially relevant in more populated regions where specialist outreach services are more likely to intersect with services by local rural specialists, including their outreach services. Outreach specialists could add value to planning regional health service initiatives, supporting up-skilling of local staff and providing back-up between visits. Funding for the coordination of outreach services is currently limited to the small proportion of specialists subsidised by the RHOF but could be more widely applied, given that it increases service efficiency.17

Overall, our findings suggest that rural outreach service models are a legitimate and feasible approach to supplementing and increasing access to specialist medical services in regional and remote Australia. Promoting the supply, distribution and sustainability of specialist outreach will depend on multilevel policy approaches, incorporating subsidies to encourage more remote services. Given the extent of specialist participation, some of the challenges to implementation include ensuring that outreach services are well targeted to community needs and are appropriately coordinated.