Evaluation of the Medical Specialist Outreach Assistance Program and the Visiting Optometrists Scheme

Appendix 2.a - Aurukun, Queensland

Page last updated: 28 February 2012

Overview

Aurukun is a remote community located in Cape York, 800 kilometres by (largely unsealed) road from Cairns, the nearest regional centre and 2,500 kilometres from the State capital, Brisbane. The estimated population of Aurukun in the 2006 Census was 1,044, of whom 955 identified as Aboriginal or Torres Strait Islander (Table 24). While there are a small number of outstations around Aurukun, most people live in Aurukun itself. The ABS population estimates for 2010 show the Aurukun population at 1,216 residents (ABS 2011b). The accuracy of Census and population estimates is an issue for remote communities like Aurukun. One of the issues impacting estimates of the resident populations is its high mobility.
In the 2006 Census, 32.3% of the population usually residing in Aurukun were children aged between 0-14 years, and 9.2% were people aged 55 years and over. There were 31 people aged 65 years and older. The median age in Aurukun (Aurukun Shire/Suburb) was 25 years, compared with 37 years for people across all of Australia.

Table 1 – Regional population statistics (2006)

Township/ location

ARIA+
(GISCA 2010)

Remoteness Area

SEIFA
(ABS 2008)

Resident Population
(ABS 2011a)

ATSI Population
(ABS 2011a)

% ATSI

Aurukun Statistical Local Area

13.92

RA5 Very remote

538

1,044

955

91.4%



The nearest town to Aurukun is Weipa, which is 100 kilometres by unsealed road. For the 2006 Census, Weipa had an estimated population of 2,830, with 482 people who identified as Aboriginal or Torres Strait Islander. The broader population of the Cape York region (which excludes the Torres Strait) is 13,000 people, including the communities of Aurukun, Weipa, Cooktown, Coen, Hopevale, Laura, Lockhart River, Kowanyama, Mapoon, Napranum, Pormpuraaw and Wujal Wujal.

Freight is brought into Aurukun by road weekly during the dry season, and during the wet season, it is brought in fortnightly by barge. During the wet season Aurukun is generally unable to be reached by land, and supplies are either transported by ship or by air. Almost all movements of staff and patients are by air. There is one regular daily commercial flight from Cairns to Aurukun five days a week. The RFDS has a scheduled visit to Aurukun three times each week, through which primary care staff are transported to and from the community.

Aurukun is a self-managed community situated on the western coast of Cape York. Founded as a Presbyterian Mission in 1904, the Aurukun Community Council gained self-management status in 1978 under the Local government (Aboriginal Lands) Act.

The local economy is dominated by government services. The main employers in the town are the Community Council (which owns and manages all housing in the community), the school Western Cape College - Aurukun Campus (P to year 10 school), the police, and an early childhood centre. There is also an arts centre and motel. There is a general store that sells grocery items, meat, bread, milk and a range of fresh fruit and vegetables and is open seven days a week. Many residents shop direct with major chains in Cairns utilising the regular freight services for delivery.

A broader range of commercial services are located in Weipa. Several government services are based in Weipa and provide outreach to Aurukun. Cairns is the major regional centre for Cape York for commercial and many government services.

Since 2003, the Aurukun Alcohol Management Plan has been in effect and no alcohol is allowed to be brought into the Shire.

Aurukun is one of four communities participating in the Cape York Welfare Reform Trial which commenced on 1 July 2008. Work on an Aurukun Local Implementation Plan has progressed. The Plan focuses on economic participation and health. It outlines business development actions to increase employment opportunities for the local residents, including developing the Aurukun Business precinct, the Three Rivers Tavern and progressing the creation of the Arts Precinct. The Local Implementation Plan also includes the expansion the Wellbeing Centre to provide counselling services to support people with issues such as drug and alcohol overuse, mental health, gambling, family relationships and domestic violence issues.

Health service organisation

Aurukun is located in the Cape York Health Service (due to become the Local Health and Hospital Network). The Network services a population of just over 13,000 people. Aboriginal and Torres Strait Islander people make up more than half of the Network’s population (52.6%), which is 4.5% of Queensland’s total Indigenous population.
The Network has no major referral hospital. However, there are strong linkages with the Cairns and Hinterland health service. The Network operates two multi-purpose facilities at Cooktown and Weipa, and 10 Primary Healthcare Centres at Aurukun, Coen, Hopevale, Laura, Lockhart River, Kowanyama, Mapoon, Napranum, Pormpuraaw and Wujal Wujal.

The Weipa Hospital-Integrated Health Service has 12 acute beds and 10 aged care beds, as well as an emergency department, primary health service, ambulance, allied health, and outreach and preventative health services. In 2009-10, the facility had 522 same day and 584 overnight admissions. The hospital is able to provide a facility in which minor procedures can be undertaken by visiting specialist (e.g. cataract surgery, ENT and endoscopy procedures). Visiting specialist services include ENT, dermatology, dental surgery, women’s health, ophthalmology, paediatrics, endoscopy and mental health.

The Aboriginal health service for the Cape is Apunipima Cape York Health Council. Apunipima has a similar geographic coverage to the Cape York heath service, but extends further south to include Wujal Wujal and Mosman. Apunipima is a community controlled health organisation governed by an Indigenous Board, representing the communities of Cape York. Through Apunipima, Aurukun established the Aurukun Health Action Team in August 2008 with a membership of 10 people. The Health Action team are also the ‘Advisory Group’ for the Aurukun Well-Being Centre. The Centre is designed to improve the availability of health services. It provides a community-based approach to treating addiction and related mental health issues, addressing family violence, reinforcing social norms and facilitating pathways out of treatment to employment and education. The services offered include assessments, counselling, support, case co-ordination and referrals to other services. The Centre is being initiated under the auspices of the Royal Flying Doctor Services (RFDS) with the intention of moving to community management over time.

The RFDS is also an important provider of primary care services in the Cape.

Aurukun is located within the Far North Queensland Division of General Practice. The Division covers a wider area than Cape York, including the Torres Strait, the Cairns Hinterland and parts of the Gulf of Carpentaria region. It does not include Cairns. A new Far North Medicare Local will include Cairns and its hinterland, the Torres Strait, and Cape York. Top of page

Health services in Aurukun

Primary health care services for Cape York are complex. The Cape York health service plays a key role in most communities through the two hospitals and community health clinics. These clinics are generally the physical and organisational base through which the vast majority of health services are delivered in these communities. Cape York employs community nurses, including clinical nurse consultants (CNC), Aboriginal health workers, allied health staff and other support staff.
In Aurukun, the health centre currently employs two clinical nurse consultants and three registered nurses and one director of nursing (funded for five nurse positions), two Aboriginal health workers (funded for nine positions Aboriginal health worker positions are for: senior Aboriginal health worker (1), sexual health (1), child health (1), women’s health (1), general health workers (3) and trainees (2).) and eight support staff (including drivers, security and maintenance, funded for twelve positions).

One of the nurse CNC positions is specifically allocated to chronic disease issues. She has a major role in coordinating referrals to specialists and following up patients. One of the nurses is a school based nurse, funded through the Weipa outreach service as well as the Cape York Aboriginal Academy.

The Aurukun Health Service is open seven days a week and provides an after-hours service. Officially the service is identified as a public hospital, but it operates as a primary care clinic. The MyHospitals web site shows the service had 43 same day admissions in 2009-10 and less than 10 overnight admissions. The service does not have ‘beds’, although patients requiring urgent care are managed until they can be evacuated.

Patients can attend the clinic for primary care and acute medical issues or other chronic disease issues. On attending the clinic they will be seen either by the visiting GP (four days a week) or a nurse. Many patients attend the clinic to see visiting specialists (see below).

The Aurukun health clinic has many regular visiting staff. The RFDS has a significant role in providing fly-in outreach primary care staff to Aurukun and other communities in Cape York. In Aurukun, one GP flies into Aurukun on Monday and stays for two days, and a second GP flies in on Wednesday and also stays two days. The RFDS manages chronic disease program, funded by DoHA, which has increased general practice clinics and added new visiting allied health services. Another initiative involving DoHA, Medicare Australia, Queensland Health, and the RFDS involved increasing medical officer presence to five locations on Cape York Peninsula, including Aurukun, through the implementation of the Rural and Remote Medical Benefits Project. Through this initiative, Medical officers are able to stay overnight in the communities, increasing the capacity to provide a more comprehensive primary medical service compared with a fly-in fly-out service.

The RFDS also employs and flies in child health nurses. There are typically two nurses on the ground in Aurukun and surrounding community for four days a week (there are three positions with two nurses on the ground and one relieving). The child health nurses work with schools to undertake child health checks. They receive referrals (from the checks and clinic) and they follow up children and families.

The Well-Being Centre, which is managed by the RDFS in conjunctions with Apunipima, has three positions (one vacant) related to community counselling and community development. Top of page

Visiting medical specialist services

Visiting specialist services are delivered through a combination of public hospital staff specialists, largely based in Cairns, and some private practitioners.

Table 2 – Visiting health services – Aurukun

Specialty/Service

Number of visits per year

Number of days in community per visit

Estimated number of patients seen per visit

RFDS – General Practitioners

52

4

Approx. 50

RFDS - Rural Women's GP Service (GPs)

 

 

10

RFDS – Child Health Nurses

50

4

Approx. 40

Mental Health Adult Psychiatrist (MSOAP supported)

4

4

25

Mental Health Clinical Nurse Consultant

 

 

10

Child & youth mental health and ATODS , CYMHS), Health workers (2)

 

 

 

Child & youth mental health clinician (MSOAP supported)

12

4

10

Dentist Team – Cairns

12

1

3

Dentist Team – Weipa

10

5

20

Australian Hearing (Audiologist)

2

1

10

ENT surgeon (also provides surgery services for Aurukun residents in Weipa) (MSOAP supported)

8

1

30

Paediatrics (transitioning to Apunipima) (MSOAP supported)

8

1

15

General Medicine Outreach (MSOAP supported)

8

1

20

Frogs

6

1

 

Family health team CYHSD (CNC, Advanced Indigenous Health Worker, an advanced School Youth Indigenous Health Worker)

50

2

 

Family health team CYHSD -Social worker/Child protection liaison

12

2

20

Obstetrics and Gynaecology specialist

6

1.5

10

Women's Health Worker  - Apunipima

 

 

 

Dermatology

2

 

13

Chest Clinic

2

1

 

Podiatrist (Apunipima - Healthy Lifestyle Program)

 

 

 

Diabetes Educator (Apunipima - Healthy Lifestyle Program)

 

 

 

Dietitian Educator

 

 

 

Endocrinologist (MSOAP supported)

4

 

11

Optometrist (VOS Supported)

3

2

20

Ophthalmologist (Plus visit to Weipa for eye surgeries)

1

2

20

HACC Assessment Clinical Nurse

 

 

 

Qld Health Occupational Therapist

 

 

 

Qld Education Occupational Therapist, Speech Pathology

3

 

 



Note:  This table represents information collected through MSOAP national data and data collected during the site visit to Aurukun.  It may not capture all visiting services.


The specialist physician visits around eight times a year together with a physician registrar, a paediatrician and post graduate medical students on an outreach rotation. The specialist physician (Dr Clive Hadfield) and paediatrician (Dr Richard Haezlewood) have been regularly visiting Aurukun for over 20 years. Both doctors are based at Cairns Hospital. Both visit a range of communities across the Cape, Torres Strait and Cairns Hinterland. They initially established the visiting service in response to needs identified in these communities and through their clinical practice in Cairns. Dr Hadfield provides a visiting service for two days every fortnight with an overnight stay. Every other fortnight he makes a day trip to Cooktown. Two other general physicians in the Division of Medicine at Cairns Hospital also make outreach trips from Cairns. Together, the three general physicians cover the communities of Aurukun, Napranum, Weipa, Bamaga, Thursday Island, Hopevale, Wujal Wujal, Lockhart River, Cohen, Pormpraaw, Kowanyama, Cooktown, Mapoon, Laura. Eight visits were scheduled for Aurukun in 2011. Visits to all communities are scheduled approximately four months prior to the commencement of the calendar year, and changes to the schedule are relatively rare. Clinic staff commented about the reliability of the outreach service.

Dr Hadfield also holds a commercial pilot’s licence and has been the pilot for the visiting team over this period of time. The flight to Aurukun is a charter flight and will typically take Dr Hadfield, Dr Haezlewood, a registrar, post graduate medical students and other visiting services (e.g. allied health services). The team leaves Cairns around 7 am and gets into Aurukun around 9 am. The team then flies on to Weipa where they stay overnight, and typically will provide other outreach services to Napranum (which is near Weipa), before returning to Cairns on the evening of the second day.

As mentioned above, both Dr Hadfield and Dr Haezlewood have been visiting Aurukun for more than 20 years. They are known by most members of the community. The continuity of their involvement with the community was considered to be a key factor in their effectiveness in working with people in the community.

The visit we attended was Dr Haezlewood’s last visit to the community supported through MSOAP. In future, the outreach service for paediatrics will be provided by a Community Paediatrician, who has recently been employed by Apunipima.

On the day we visited the community, an outreach eye team involving Dr Mark Loan (an ophthalmologist) and Rowan Churchill (an optometrist) was also visiting. The team also involved the Regional Eye Health Coordinator (Noel Rofe) who is employed by the Cairns based Wuchopperen Health Service. The team has been operating since 1998, supported by Wuchopperen Health Service, created following the recommendations of the Taylor report that established Regional Eye Health programs with separately funded Eye Health Co-ordinator positions. The outreach team is also supported through funding from Queensland Health, which has a Memorandum of Understanding with Wuchopperen Health Service. The outreach service built on a service originally developed in 1995 under the auspice of the Fred Hollows Foundation (Brian 1997). The arrangements for the Cape for eye health services have been described by Turner et al. (2011).

Dr Loane generally makes two visits to the Cape each year. The first visit, accompanied by the optometrist, involves general eye examinations, providing laser treatment for patients with diabetic retinopathy (using portable equipment), prescribing glasses, advising on basic eye care, identifying and preparing patients requiring surgery, and undertaking other follow up. Aurukun and several other communities are visited over the period of the week. The optometrist travels with the Regional Eye Health Coordinator three times per year to each community to assess all patients and to create a list of patients with pathology that need to see the ophthalmologist, who travels with the team on one of these visits (the mid-year one). Surgery is performed after the mid-year trip and at the end of the year, the optometrist trip serves as the surgical aftercare visit. Through this system the patient only requires one trip away for cataract surgery and no trips for most other procedures as they are treated in the community, unless they require acute care. The system was worked out during the early stages with the Fred Hollows Foundation and remains effective today. Generally, four days of optometry are required for every one day of ophthalmology.

In a second visit to Weipa, cataract and other procedures will be undertaken, with patients from Aurukun and other communities assisted to travel there. A charter flight will be arranged and patients will be ferried to Weipa in groups of four to five on the morning of the surgery. They will be admitted to Weipa hospital, have the surgery, and stay overnight prior to being transported back the following day. Surgeries will be undertaken over a week at Weipa hospital, with around 70-80 surgeries performed in the period. It is interesting to compare the current arrangements with those that applied prior to the outreach service as described by Brian (1997 p 128): “The Queensland Trachoma and Eye Health Program (QTEHP) provided the bulk of ophthalmic service to the Cape. Generally, this involved a community visit every second year, although some communities were reportedly seen less frequently, Typically visits consisted of ocular examination and refraction for spectacles. The latter formed the bulk of the work. Patients requiring cataract surgery and ocular laser for diabetic retinopathy were added to southern, usually Townsville, public waiting lists. …Most of these patients required at least three trips south, one for investigation and addition to the waiting list, one for surgery, and another for post operation follow up. Travel required patient escorts. The approach was not meeting the caseload. It was not uncommon for the QTEHP ophthalmologist to examine Cape patients who had been added to a southern waiting list at a previous QTEHP visit.” A follow up outreach visit to Aurukun is undertaken by the optometrist one to two months after the surgery week.

Both the visiting ophthalmologist and visiting optometrist bulk bill patients to Medicare, or if details cannot be obtained, provide the service free of charge. They both work in private practice and Medicare billing is the principal source of income for the outreach service along with the dispensing of glasses, which is mainly through public funded spectacles scheme operated by Queensland Health and also some private spectacles. The outreach ophthalmology service has not been supported under MSOAP, except for assistance with equipment, which is provided through IRIS. Support for travel is provided by Queensland Health. The outreach service provided by the optometrist is supported under VOS, although under a specific arrangement. The optometrist works exclusively through providing outreach services to localities in Queensland remote regions, and does not have a base practice. He has been providing this service to remote Queensland since the mid-1990s.

An endocrinologist has visited twice a year, but this recently increased to four times a year. For the next clinic, this service will be provided as a telehealth arrangement. The specialist physician who visits more regularly also provides consultations for many of the patients with diabetes.

An ENT surgeon visits Aurukun and provides minor surgery in Weipa. The clinic staff coordinate a list of children requiring ENT surgery, liaising with parents and the school. The clinic organises a charter flight with groups of patients (of about 10) to Weipa to receive the required procedures and flies them back the same day.

Other visiting services supported under MSOAP include an obstetrician/gynaecologist (every two months), an adult psychiatrist (every three months), a child psychiatrist (every six months) who travels with a child mental health team and a dermatologist (every six months). Follow-up surgical services are provided in Weipa, which avoids patients having to travel to Cairns. These may also be supported under MSOAP.Top of page

Other visiting services

A diabetes team, including a podiatrist, a GP and a diabetes educator, visits two days per fortnight from Weipa. The team is funded under the Healthy Lifestyle Program and is run by Apunipima. The GP and podiatrist see a relatively large number of patients. However, the service relies on the CNC to coordinate referrals and reminders.
Other visiting services include dentists from Weipa (one week every month) and Cairns (one day every month). A family health team based in Weipa and Cairns visits regularly. The team includes a CNC (a midwife), an advanced Indigenous Health Worker and a School Youth Indigenous Health Worker. The visit to Aurukun from Weipa occurs two days a week. A social worker/early intervention/child protection liaison officer visits Aurukun monthly. There is also a visiting sexual health service from Weipa.

Organisational factors impacting on visiting specialist services

Specialist services are delivered through a combination of public hospital staff specialists, largely based in Cairns, and private practitioners. Where possible patients are bulk billed under Medicare, but this is often very difficult to achieve.
A white board in the clinic is used to record all visiting services. In addition, the RFDS maintains an electronic calendar/database (http://www.rhsd.com.au/). This was not completely up to date. As mentioned previously, some of the long standing visiting services (e.g. by Dr Hadfield) are scheduled around four to five months prior to the beginning of the calendar year. Other visiting services are usually scheduled in advance, but generally closer to the time of the visit. The health service manager generally accommodates all requests, but at times there will be significant pressures on available space. On some occasions visiting services arrive without prior warning.

Within the community, accommodation options for visiting and local staff are very limited and in high demand.

The clinic has six rooms for consultants, which are often under pressure when several outreach services are visiting at the same time. For example, on the day Health Policy Analysis visited there was an ophthalmologist, an optometrist, a paediatrician, a general physician, a physician registrar, two medical students, the RFDS GP, an RFDS child nurse, an occupational therapist, a rheumatic heart disease registered nurse undertaking an audit, three members of the family health team from Weipa/Cairns and others. The local and visiting staff are generally flexible and will ensure visiting specialists can be accommodated in some way.

Referrals to specialists are managed through both the Queensland Health electronic patient management system (Ferret) and an appointment book through which patients identified for follow-up or referral are recorded.

Prior to a visit, patient lists will be identified and sometimes discussed/communicated to the visiting specialists. Paper invitations are prepared in the days prior to the visit, often by the CNC. These are distributed on the morning of the visit, usually by the driver of the health service. During the day a large number of patients will be transported to the clinic, particularly where a visiting doctor, GP or nurse indicates it is important for someone to be seen.

Of the people identified on a patient list, typically around 50% will attend.

Effectiveness of visiting services

Local and visiting staff were asked about their views of the effectiveness of the visiting services. Issues highlighted were:
    • That vast majority of visiting services are highly valued.
    • The continuity of visiting staff has a very significant impact on the effectiveness of service delivery. Visiting staff get to know the community and its challenges and customs, the issues with particular patients, local staff, and the systems used by the local primary care service. The community and patients are also able to develop a rapport with the visiting service providers, which impacts on their willingness to change behaviours and accept treatment. It was noted that often it is the specialist providing continuity in service delivery, with a high turnover of other staff.
    • The continuity of remote area nurses was noted as an important issue for visiting specialists. Remote area nurses who have been in the community for a longer period of time were much more able to understand and work with the community and patients, similar to the issues identified above. New staff often find working in remote communities difficult and confronting. The visiting specialists believed that better approaches were needed to attract and keep people in these roles.
    • Aboriginal health workers were seen as being extremely valuable in helping visiting services working with patients and their families. In Aurukun there were only a small number of Aboriginal health workers, although there are several vacancies.
    • Coordination of services on the ground remains a challenge. As mentioned above, on some days there are many visiting services in the clinic. This puts pressure on the local service, including the driver. Often clinical staff (such as the chronic disease CNCs) are spending considerable time involved with coordinating matters prior to and after a visit.

Assessment of need and gaps in specialist services

Local staff commented on a number issues related to assessing needs for visiting services in Aurukun. They did not believe they had been consulted on needs previously, and that input on these issues had typically been handled by others in the health service. They were not aware of and had not participated in a regional advisory forum for MSOAP.
Particular priorities identified included:
    • expansion of paediatrics and ENT.
    • extend GP coverage to five days a week.
    • more focus on chronic disease through extending relevant specialties.
It was commented that chronic illness prevalence seems to have increased in the community, but only because issues are now being picked up. Previously they were not being diagnosed.

Local staff and the paediatrician commented that the clinical issues in child and adolescent health were changing. Overall, health in children in the community had improved with the introduction of alcohol management and the welfare reforms which had significantly improved school attendance. However, a range of behavioural and mental health issues were beginning to emerge. They felt there were gaps in the outreach child and adolescent mental health services that needed to be considered.Top of page