Aeromedical services in Australia: a vision shared

Greater coordination is needed to shift from a “mantle of safety” to providing adequate health care for rural and remote Australians

The original vision of John Flynn when he established the precursor of the Royal Flying Doctor Service (RFDS) in 1928 was to provide a “mantle of safety” for rural Australia. While aeromedical retrieval has evolved considerably in the meantime, with advances in aviation, communications and medical interventions, people who live in rural areas of Australia still have lower access to health services and poorer health outcomes than their urban counterparts.1

Two articles in this issue of the Journal help us better understand some of the reasons for these inequities. Gardiner and his colleagues2 describe the growth in numbers of aeromedical retrievals of people with mental health problems or substance misuse disorders from rural Australia, while in their research letter Gardiner and his co‐authors3 identify the challenges in providing health care for an ageing population in rural areas. The authors rightly link the need for retrievals to the limited availability of health services in these areas, despite the clear health care needs of people in rural Australia.

An Australian Delphi study found consensus among people involved in rural, remote or Indigenous primary health care that services supporting “mental health and social and emotional well‐being” should be provided by a resident health worker in rural communities with at least 500 residents, and in remote communities with at least 100 residents.4 While this might be an obvious solution, it is likely to remain purely aspirational unless workforce demands, models of care, skill maintenance and costs are investigated, and evidence of improved outcomes provided.

Australia has been at the forefront in developing telehealth services. Telepsychiatry has proved successful in several Australian jurisdictions,5 providing earlier assessment and treatment of patients, improving continuity of care, reducing length of inpatient stay, and improving both preparation of patients for transfer and their outcomes. Telehealth care may also assist increase the capacity for managing patients locally and reduce the need for transfers, but it needs to be supported by allocating extra resources for increasing the capabilities of rural health services.6 Models of care that achieve net savings, mainly by reducing travel costs, could make money available to re‐direct to improving rural resources and service capabilities.7

Integrated systems are also important. A study in the United States8 found that use of helicopter emergency medical services (HEMS) for transporting patients with stroke increased during 2004–2011, and that HEMS could be used to transport patients from rural facilities to stroke centres, making it more likely that they receive appropriate specialist treatment. Importantly, the authors were able to access a database that included de‐identified data for 861 284 HEMS transfers by several different providers.

More consistency in definitions and better integration of data from pre‐hospital care providers, aeromedical retrieval services, primary health care, and the hospital system are also needed in Australia. To fully understand patient outcomes, we need to be able to follow their journey from home to hospital, and, hopefully, their subsequent return home. In the future, virtual care centres may support rural communities and practitioners with telehealth services, help navigate bed access and specialist support, and coordinate timely and appropriate aeromedical retrieval when needed.

Challenges faced by the authors of the reports in this issue of the MJA included the need to combine a number of data sources to review retrieval activity and health service availability. Further, the available diagnostic data were limited, in that only generic diagnoses, such as “mental disorder”, were recorded for 39.4% of transported patients; secondary diagnoses were not available at all, meaning that transfers of patients for whom a mental health problem was not the primary diagnosis but nevertheless contributed to the reason for retrieval — for instance, patients with drug overdoses linked with depressive illness — were not categorised as mental health‐related retrievals.2 The authors noted that retrievals data were not available for some jurisdictions, but the inability to include information from HEMS providers and road ambulance services was also a limitation. Further, Gardiner and his co‐authors noted that “patient data collection forms and systems differ between RFDS sections and operations, but all collect data for the same variables”.2 This disparity of process in a single organisation highlights the challenges for collating data from multiple providers in multiple jurisdictions, especially when the data may be commercially interesting because services are tender‐ or contract‐based, and for navigating questions regarding privacy, compatibility of data platforms, and data ownership.

A number of endeavours already underway should be commended, such as the adoption of core data linkage in Western Australia9 and the development of a national aeromedical retrieval data registry with consistent definitions, led by Retrieval Services Queensland and the Jamieson Trauma Institute (personal communication, Mark Elcock, executive director, Aeromedical Retrieval and Disaster Management Branch, Queensland Health, 26 July 2019). Professionalising pre‐hospital and retrieval medicine services by developing an agreed training and credentialing process, involving several professional colleges and led by the Australasian College for Emergency Medicine, is another effort that will improve practice.

The difficulties in achieving system‐wide data integration are not insubstantial, but, if we can achieve it, we can perhaps shift the vision from providing a “mantle of safety” to raising the level of health care for rural and remote Australians closer to that of their urban cousins.