The locations included in the community case studies are shown in Table 51 below. The case studies are detailed in Volume 2 of this report. This chapter focusses on providing an overview of the communities and drawing out some of the findings from the case studies.
Table 51 - Community and other case studies

Jurisdiction

Town

Remoteness classification

NSW

Dubbo

RA2 Inner Regional

Vic.

Leongatha

RA2 Inner Regional

SA

Crystal Brook

RA3 Outer regional

Tas.

Burnie

RA3 Outer regional

WA

Karratha and Roebourne

RA4-Remote

NT

Maningrida

RA5 Very remote

Qld

Aurukun

RA5 Very remote

National

National Tele-Derm service ACRRM

 


Key characteristics of communities

Table 52 describes some of the characteristics of the communities, including the ARIA+ index for the community, its corresponding remoteness area, the ABS Index of Socio-economic Disadvantage, the estimated resident population in 2006, the estimated Aboriginal and Torres Strait Islander population in 2006. The communities examined range significantly in size from 857 in Roebourne and 1,044 in Aurukun to around 38,000 for the broader Dubbo community. Aurukun and Maningrida have the highest proportion of Aboriginal and Torres Strait Islander people (over 90%) followed by Roebourne (61%). There are also significant Aboriginal populations living in Dubbo, Karratha and Burnie. In fact, of the communities studied, Dubbo has the highest absolute number of Aboriginal and Torres Strait Islander people.

In interpreting some of the information presented below it is important to recognise that Dubbo, Burnie and Karratha act as regional centres for a broader catchment population. Consequently, outreach services into these communities typically reflect the needs of the broader catchment population.
Table 52 – Characteristics of selected communities
Township/location ARIA+(GISCA 2010) Remoteness Area SEIFA(ABS 2008) Resident population 2006 (ABS 2011a) ATSI population 2006(ABS 2011a) % ATSI

Leongatha (State suburb)

1.49

RA2 - Inner regional

996

4,818

20

0.4%

Dubbo (C) Pt A (SLA)

1.95

RA2-Inner regional

957

34,319

3,812

11%

Dubbo (C) Pt B (SLA)

2.94

RA3-Outer regional

1052

3,525

97

3%

Crystal Brook (State suburb)

2.70

RA3 Outer regional

957

1,549

25

2%

Burnie (C) - Pt A (SLA) 

2.74

RA3-Outer regional

922

16,996

814

5%

Burnie (C) - Pt B (SLA)

3.73

RA3-Outer regional

980

2,056

70

3%

Karratha (Urban Centre/Locality)

9.00

RA4-Remote

846

11,728

742

6%

Roebourne (Urban Centre/Locality)

9.62

RA4-Remote

631

857

524

61%

Maningrida (Urban Centre/Locality)

11.34

RA5 Very remote

Na

2,068

1,904

92%

Maningrida Outstation (Indigenous Area)

 

RA5 Very remote

Na

369

356

96%

Aurukun SLA

13.92

RA5 Very remote

538

1,044

955

91%


Table 53 presents an analysis of Medicare supported services provided for the selected communities. For the smaller communities the data is presented for the SLA within which the communities are located. The data is presented as per capita rate, without adjustment for age profiles. While adjustment for age would potential effect some of the estimated differences between the selected communities, it would not have a material effect on the overall patterns observed. Differential use of services can be observed across the communities studied, for all the categories of Medicare services, including general practice, specialist and optometry services. Rates of use are substantially lower in the remote and very remote communities studied (Karratha, Roebourne, Maningrida and Aurukun). In these communities, rates of specialist consultations are less than half of the rates for the other communities studied. The lowest rates were observed for the SLA within which Maningrida is located.
Table 53 – Estimated Medicare related and services per capita, selected communities
  South Gippsland(s) Central SLA Dubbo Pt A and Pt B SLAs Burnie Pt A and Pt B SLAs Port Pirie C Dists (M) Bal SLA Roebourne(s) SLA West Arnhem SLA Aurukun(s) SLA
Services per capita (not adjusted for age)
General Practice 8.32 5.07 5.83 6.08 3.42 2.22 3.73
Specialists 2.33 1.37 1.33 1.60 0.56 0.31 0.70
Pathology/Diagnostic Imaging 8.77 5.99 4.85 4.91 3.91 3.64 2.74
Optometry 0.58 0.37 0.34 0.28 0.22 0.04 0.18
Other 0.72 0.42 0.39 0.44 0.14 0.12 0.21
Allied health 0.52 0.33 0.21 0.22 0.03 0.02 0.06
 
Medical benefits per capita (not adjusted for age)
General Practice 331 193 226 223 140 105 148
Specialists 206 130 118 148 64 22 64
Pathology/Diagnostic Imaging 288 231 161 158 123 80 84
Optometry 27 18 16 13 10 2 8
Other 122 63 78 80 32 24 38
Allied health 48 29 15 22 3 2 5
Total 1,022 663 614 646 372 236 348


Outreach services to the communities

Top of pageTable 54 provides an analysis of MSOAP Core activity for 2009-10 across the selected communities. The number of MSOAP services for each community range from 8 to 13, a surprising narrow range given the different population sizes. An analysis of the types of services supported is provided in Table 55. This suggests that the regional centres such as Dubbo, Burnie and Karratha are more likely to have MSOAP supported services for specialties such as oncology, palliative care and dermatology. Most communities received MSOAP supported consultant physician services (including cardiology and endocrinology) and psychiatry outreach services.

For all of the communities examined the level of actual services/expenditures was around 80-90% of planned services/expenditures, except for Maningrida where actual expenditures were only 23% of planned expenditures. Budget allocation per visit range from $599 in Leongatha to $4,892 in Maningrida. Actual expenditures per patient varied from $32 per patient in Leongatha to $194 in Maningrida. In general, costs increase with remoteness. An exception is Burnie where costs per visit and per patient are relatively high, potentially because of the cost of airfares for specialists visiting from the mainland.

Across these communities, 19,391 patients were seen by MSOAP supported services in 2009-10. Of these, 1,341 (7%) were Aboriginal and Torres Strait Islander people. Relatively few Aboriginal and Torres Strait Islander patients were reported for Leongatha, Crystal Brook and Burnie.

Table 56 shows the planned budget allocations for the communities for 2010-11 under MSOAP Core and MSOAP-ICD. The Core budgets for 2010-11 are generally reflective of the actual expenditures in the previous year. This includes Maningrida where the proposed budget was scaled back considerably on the previous year.

Table 54 – MSOAP Core program 2009-10 for selected communities
Specialty: Leongatha Dubbo Burnie Crystal Brook Karratha & Roebourne Manigrida Aurukun
MSOAP services supported: 11 13 12 8 11 8 8
Planned budget 2009-10 $ 111,977 492,623 480,260 102,393 133,605 185,889 126,209
Actual expenditure 2009-10 $ 92,327 373,417 391,226 93,908 120,141 42,380 110,040
Actual as proportion of planned 82% 76% 81% 92% 90% 23% 87%
Planned visits 187 272 233 75 156 38 40
Planned budget per visit $ 599 1,811 2,061 1,365 853 4,892 3,155
Reported total patients 2,920 10,450 2,730 1,384 1,067 219 621
Reported Indigenous patients 1 378 7 22 133 199 601
Proportion Indigenous 0% 4% 0% 2% 12% 91% 97%
Expenditure per patient seen $ 32 36 143 68 113 194 177


Table 55 – MSOAP Core program 2009-10 expenditure by specialty
Specialty: Leongatha Dubbo Burnie Crystal Brook Karratha & Roebourne Manigrida Aurukun
01. Physician - General - 41,530 - - 961 - 10,883
02. Physician -Cardiologist - 67,568 - 14,467 - 3,764 -
03. Physician - Endocrinology - - 2,696 33,562 - - 12,609
04. Physician - Oncology - - 73,599 - - - -
05. Physician - Palliative - 20,362 75,816 - 8,345 - -
07. Physician - Other 6,939 114,559 65,408 24,482 6,980 - -
08. Paediatrician 16,494 - - - 37,681 - 13,017
09. Dermatologist - 81,616 36,301 - - - 10,540
10. Ophthalmology - - - - 19,644 4,617 -
11. Obstetrics and Gynaecology 16,600 - - - - 8,744 9,581
12. Surgeon - Orthopaedics - - - - 34,871 - -
13. Surgeon - ENT - - - - - - 35,310
14. Surgeon - Other 20,360 10,465 - - 11,660 6,175 -
15. Psychiatry - Child and Adolesc - - - 19,036 - - 8,025
16. Psychiatry - Other 31,933 37,318 137,407 2,361 - 19,080 10,075
Total 92,327 373,417 391,226 93,908 120,141 42,380 110,040


Table 56 – MSOAP budget allocations for selected communities, 2010-11
  Leongatha Dubbo Burnie Crystal Brook Karratha & Roebourne Manigrida Aurukun
MSOAP Core 115,543 502,943 434,242 110,872 161,110 39,163 115,950
MSOAP ICD - 43,989 - - 54,684 16,202 -
Total budget 115,543 546,933 434,242 110,872 215,793 55,365 115,950


Table 57 provides summary statistics on VOS supported services provided in the community case studies from 2010-11. There were no VOS supported services provided to Leongatha, Dubbo, Burnie or Karratha.
Table 57 – Characteristics of VOS supported services for selected communities, 2010-11
Specialty: Leongatha Dubbo Burnie Crystal Brook Roebourne Manigrida Aurukun
VOS service supported No No No Yes Yes Yes Yes
Expenditure 2010-11 $       1,818 10,297 4,306 1,596
Planned visits - - - 7 3 4 3
Reported total patients - - - 15 51 41 73
Reported Indigenous patients - - - - 51 41 73
Proportion Indigenous       0% 100% 100% 100%
Expenditure per patient seen $       121 202 105 22


Estimates of program impact in case study communities

An estimate of the impact of MSOAP supported services on access to specialist services was developed using MSOAP program data for 2009-10 and MBS data (Table 58 and Figure 17). This analysis is limited by the lack of data on specialist services for which no MBS claim was made, but nevertheless provides a sense of the importance of MSOAP services for these communities. Across the communities studied, MSOAP appears to have had a significant impact, providing 13% of services in Burnie to 85% in Aurukun. For the more remote communities the underlying level of service access is very low. While MSOAP makes a significant contribution to bridging the gaps for these communities, the gaps in access are still very significant.
Table 58 – Estimated impact of MSOAP supported services on access to specialists services, 2009-10
Specialty: Leongatha Dubbo Burnie Crystal Brook Karratha & Roebourne Manigrida Aurukun
MSOAP supported 0.61 0.28 0.14 0.89 0.08 0.09 0.59
Other 1.73 1.09 1.19 0.71 0.47 0.22 0.10
Total specialist services 2.33 1.37 1.33 1.60 0.56 0.31 0.70
Impact (MSOAP as % of total) 26% 20% 11% 56% 15% 29% 85%


Estimated of impact of MSOAP supported services on access to specialists services, 2009-10
Figure 17 – Estimated of impact of MSOAP supported services on access to specialists services, 2009-10Top of page

Key themes from community visits

Greater challenges in more remote communities

One theme emphasised was that the establishment and ongoing support of outreach services into remote communities presents a range of additional challenges. These include:
    • Finding service providers willing to undertake outreach visits. The time commitments, impact on remuneration, issues with coordination, and on the ground challenges mean only some specialists are willing to make long term commitments to providing outreach in more remote communities. In addition, there are typically fewer specialists available in the regional centres closer to remote communities. Demands on these specialists are generally quite high.
    • Lack of stability in primary care services. In less remote centres GPs and local hospitals often provide a reliable basis for specialists to provide outreach services and are often able to assist with managing appointments. In remote communities there is typically a high turnover of local primary care staff. There may not be a local GP resident in the community and remote area nurses typically play a significant role with local primary care clinics. (In several instances we found that the visiting specialist service was in fact the most stable aspect of health service delivery for communities.)
    • Pressures on physical space. While local and outreach services are typically very flexible, space in the local clinics is often constrained. Problems are more severe when there is limited coordination of visiting services with several services arriving at once.
    • Coordination of MSOAP, VOS and other visiting services. In remote communities, there are high levels of need and a significant volume of visiting services in addition to MSOAP and VOS. These include health, social and other government supported services. Coordination challenges are therefore more severe.
    • Community social and health issues. In addition to very poor health status, remote communities face a broader range of social and economic issues, which means the ways in which visiting services need to work are very different to practice in a regional or metropolitan area. Members of communities often have very different perspectives on a broad range of life issues. Visiting services often find it challenging to communicate the importance of a particular health issue and the steps required to address this.

Regularity and continuity of services

These were mentioned by informants as being key to the success of achieving good attendance rates for a service. That is, if the service was provided at set times weekly, monthly or during the year, and if it continued over a long period of time, then the community would build up confidence in the service and trust in the specialists providing it, impacting on their willingness to change behaviours and accept treatment. A good example of this was seen in Aurukun, where the general physician and paediatrician had conducted clinics in the community on a set cycle for more than 20 years. They were well known by the community, seeing many of the residents for a good span of their lives, for example children who are now adults with their own children.

Time on the ground

Many informants mentioned that time on the ground is critical to the effectiveness of a service during any one visit. The more that this can be maximised (i.e. through flying in the specialist early and/or flying them out as late as possible, or by staying overnight and offering back-to-back clinics), the more service can be provided.

In some of the communities this was an issue due to availability of flights (e.g. Devonport to Melbourne for the Burnie case study) and/or due to the availability of accommodation in the community (e.g. Karratha and Aurukun).

Availability of specialist equipment

Specialist equipment is necessary for both diagnostic and treatment purposes in a few different specialties. Diagnostic equipment includes an ultrasound machine, an electrocardiograph (ECG) machine or an audiometer for assessing hearing loss. Treatment equipment includes medical lasers for eye surgery and a colposcope for minor gynaecological procedures.

In the communities visited, some of the clinics had their own equipment, while others required visiting specialists to bring equipment. However, while some clinics had a good suite of equipment for some specialties, they did not have it for others; no clinic was fully equipped with all the equipment required. Equipment that was commonly brought in by specialists related to eye diagnostics and procedures.

One of the issues in specialists bringing their own equipment is the size and/or the weight of equipment. This was reported to be particularly difficult on commercial flights, and with chartered flights, it limited the number of people that could be flown in on a single flight.

Maintenance of equipment

Where local equipment was available, the degree to which it was maintained and in good working order varied. Informants mentioned situations where equipment was not well maintained to the point that it was unusable on the day that a specialist arrived, creating a situation where the specialist could not be sufficiently effective during the visit.

Extent of skills of local staff in using basic equipment

In some of the communities, local health staff were trained in the use of some specialist equipment, which was especially useful to determine the extent of a patient’s problem (i.e. doing an ECG), or they would be able to speed up the diagnosis for a patient in between a specialists’ visit (e.g. they could do a retinal scan or an ultrasound to send to the specialist concerned for an opinion).

Where local staff were trained up, this was reported to be of great benefit by the specialists.

Extent of local co-ordination of referrals and follow up visits

The degree to which local services assisted with co-ordinated referrals to specialists and also managed follow-up appointments was the degree to which a specialist’s visit was effective. This usually involved a large effort by local staff to go through patient records and/or manage referrals by GPs/primary care providers, and also ensured that follow up visits for patients did not ‘drop off’. When this occurred well (which generally only occurred with dedicated staff with some capacity to undertake this role during their very busy schedules), appointments tended to run smoothly during a specialists visit.

However, another aspect of co-ordination is prioritisation. Even if local staff were proactive with co-ordinating referrals and ensuring that follow-up visits took place, they reported ‘being lost’ on the prioritisation side, not knowing which patients should take precedence. This was especially a concern in multi-issue areas, such as chronic disease. Sometimes the prioritisation process was assisted by the specialist’s staff from their base practice in between visits. Other times local GPs assisted. With others there were clear cut markers with a condition rating it as having high priority which guided staff in the decision making. However, there were many other instances where local clinic staff felt overwhelmed by the prioritisation process.

Availability of local resources to gather and transport patients

Another factor contributing to the effectiveness of a service was the degree to which local resources were available to gather patients seeing specialists and transport them to the clinic. Where these services were available, there tended to be higher attendance rates reported versus where they were not.
Often the limits on these resources meant that many specialties were competing for them in any one day, which was made even more difficult when multiple specialists were scheduled to deliver services on the same day/time block.
Another factor which increased the effectiveness of the local resources was the ‘appropriateness’ of the person sent out to gather people. ‘Appropriateness’ seemed to be related to the experience of the person (i.e. those with longer experience being more effective), the confidence of the person (i.e. the degree to which they could be assertive in calling in elders or individuals from other clans), and gender appropriate (i.e. a male driver to collect male patients and a female driver to collect female patients).

Bulk billing versus charging patients for services

Where services were bulk-billed, they were more highly accessed by communities. Only a few instances were encountered where patients were required to pay out of their own pocket for the service, and these situations were awkward for local staff who knew that certain patients could not afford the charge. One example was given where the staff member from the hospital paid for the consultation on behalf of the patient.

Involvement of the community and local health staff in identifying services for the community

There were a few reports of local communities and/or local staff of health services not being consulted in identifying the specialists that are needed locally. This not only means that services that are not likely to be well used are brought in, it also demoralises local staff and the community.

Availability of physical space of the delivery of specialist services

This was universally mentioned as an issue for visiting services. No facility seemed to be built to accommodate multiple visiting specialists on any one day, to the extent that consultations had to be undertaken in corridors, on verandas, or in open space outside of the clinic. The availability of additional space could be one issue that if resolved, could substantially improve the effectiveness of visiting services. It is understood that it cannot be resolved immediately, but should be considered in capital planning developments for rural and remote health facilities in the future.

Integration and collaboration between primary care physicians and visiting specialists

One of the success factors for visiting services is where a visiting specialist collaborated closely with local primary providers, and was received as an integral part of health service delivery was cited as. This was witnessed in a few of the communities visited. This was evident in Maningrida, Crystal Brook and Leongatha. In these instances, the GP and the specialists worked closely together to deliver care to patients. While there was often formal upskilling, the relationship also involved informal upskilling and information exchange about patients with particularly complex issues. In Leongatha, the GPs have responsibility for patients before and after any procedure delivered by a visiting specialist, including administering their anaesthetic prior to a procedure performed by the specialist.

Succession planning

There was a concern expressed by most of the communities that were visited about what would happen when a particular specialist or a few key specialists were to retire. They did not feel that outreach services would be attractive to new specialists, unless they were exposed early in their career (e.g. as interns and registrars). One instance of this was Aurukun, where it was built into the training for post graduate medical students as a means of broadening their experience, and also as important for the future outreach services. In one other instance, the visiting specialist had nurtured the interests in medicine of local children during his years of visiting he provided them with mentoring to go on to undertake medical studies, with a hope that they may be able to bring these skills back to their local communities in the future. Succession planning is not instantaneous, and needs to be recognised as an important part of the provision of outreach services.

Upskilling of local staff

This was an extremely important part of visiting services to all the communities being studied, and one of the major benefits of MSOAP. Formal upskilling was recognised as an extremely important part of the role of visiting specialists, and provided for effective local management of patients in between specialists’ visits (e.g. in local staff being more effective at recognising warning signs and/or monitoring patients on an ongoing basis). Equally important however was informal upskilling, which occurred during meal and tea breaks, and in some instances outside of the specialist’s visit where local staff contacted them for advice.

Use of telemedicine

The use of telemedicine for outreach to remote communities has not been fully exploited, and in some areas, not exploited at all. There was some use of telemedicine amongst health services in the communities visited, but there is a large scope for enhancement of these. Nevertheless, while in some specialties they are able to substitute fully for a consultation, in others, they can only be used partially for the service (e.g. initial consultation to make an assessment).Top of page