APPROACH TO SUSTAINABLE PRIMARY HEALTH CARE SERVICE DELIVERY FOR RURAL AND REMOTE SOUTH AUSTRALIA

Aust. J. Rural Health

(2001)

9

, 304–310

Blackwell Science Asia54 University Street, PO Box 378, Carlton South, Victoria 3053 AustraliaAJRThe Australian Journal of Rural Health1038-5282© 2001 National Rural Health Alliance Inc.96December 2001387SUSTAINABLE PRIMARY HEALTH CARE SERVICE DELIVERY: J. TAYLOR ET AL.AUSTRALIAN JOURNAL OF RURAL HEALTH10.1046/j.1038-5282.2001.00387.x

Original Article

10Graphicraft Limited, Hong Kong

APPROACH TO SUSTAINABLE PRIMARY HEALTH CARE SERVICE DELIVERY FOR RURAL AND REMOTE SOUTH AUSTRALIA

Judy Taylor, Ian Blue and Gary Misan

South Australian Centre for Rural and Remote Health (SACRRH), Nicholson Avenue, Whyalla Norrie, South Australia, Australia

ABSTRACT:

We describe the operation of four University Teaching Practices established by the South AustralianCentre for Rural and Remote Health (SACRRH) and the Adelaide University Department of General Practice. Thesepractices were established in response to the acknowledged difficulty in recruiting and retaining GPs in rural SouthAustralia. The practices are co-located with a hospital or accident and emergency service and community basednurses and allied health professionals. They provide integrated health care and multidisciplinary health care studentplacements in a learning environment where students experience rural multidisciplinary practice and country life.The study found that although the sites differed in significant ways, they all provided integrated care and effectiveplacements for students. This style of health care delivery is flexible and broadly applicable. Sustainability isachieved through financially viability, attracting and retaining health care professionals and the development ofelectronic information systems, to support integrated practice.

KEY WORDS:

multiprofessional, rural primary health care, student teaching.

INTRODUCTION

The South Australian Centre for Rural and Remote Health(SACRRH) and the Adelaide University Department ofGeneral Practice have developed a style of primary healthcare delivery that is innovative and applicable to rural Aus-tralia. The approach is different to other primary healthcare models in South Australia (SA) in that it combinesthree elements; University involvement in running a generalmedical practice, placements for undergraduate health carestudents (primarily medical students) and multidisciplinaryhealth care provided by interdependent components. Theconcept is that of collaboration between health care compo-nents, in order to provide integrated health care and stu-dent placements in a multidisciplinary environment.

The approach was reviewed at four sites operatedjointly by SACRRH and the Adelaide University Depart-ment of General Practice, in rural, remote and regionalSA.

1

The practices had been operating between 6 monthsand 4 years. Operationally, the model generally consistsof a family medical practice, staffed by academicallyorientated GPs. Generally one or more of the GPs holdsa fractional academic appointment and the practice is co-located with an allied health team, or hospital or accidentand emergency service. These components collaboratein the provision of primary health care at an accessible‘one-stop shop’ and clinical placements for health carestudents. We use the term multiprofessional healthteaching practice (MHTP) to describe this style of healthcare organisation.

BACKGROUND TO THE DEVELOPMENT OF THE MHTP

Health provision was restructured and regionalised inSA throughout the 1990s with seven rural regional health

Correspondence:

Judy Taylor, South Australian Centre forRural and Remote Health (SACRRH), Nicholson Avenue, WhyallaNorrie, SA 5608, Australia. Email: [email protected]

Accepted for publication February 2001.

AJR387.fm Page 304 Thursday, November 29, 2001 10:31 AM

SUSTAINABLE PRIMARY HEALTH CARE SERVICE DELIVERY: J. TAYLOR

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boards established by 1995. During this period, somesmall hospitals were closed and other services wereamalgamated or scaled down. As a result, GPs in solopractices in country areas were faced with increasedworkloads, professional isolation and insufficient locumrelief to enable them access to professional develop-ment.

2,3

Subsequently, small towns experienced difficultyrecruiting GPs to replace those who had left, wished toretire, or to reduce their workload.

At the request of the communities involved, SACRRHand the Adelaide University developed a UniversityTeaching Practice (UTP) to address the difficulties. Themodel was developed from an existing medical practicewhere the incumbent wished to leave. The model fosteredinterdisciplinary collaboration between the UTP and theallied health team and hospital.

The UTP also incorporated a teaching element. Ruralplacements for medical students have been shown toenable students to experience a broader range of conditionsand perform more procedures than city based students.

4

These placements effectively expose health care students topositive role models and present rural careers as a viableoption with the aim being to provide clinical experi-ence.

5,6

Thus the UTP established clinical placementsfor medical and other health care students at the sites,intending to better inform students about rural practiceand stimulate interest in a rural career after graduation.

Certainly the communities which supported studentplacements anticipated that this might contribute to morehealth care practitioners, including doctors who would bewilling to come to the country in the years after graduation.

Showing medical students life in the country takes thefear out of the country for the student doctor. Havingmedical students is fantastic. We will know whether wehave been effective in these placements in about10 years when we see if there are any doctors who weremedical students here coming to practice in the country.(Community board member, rural site).

It was also intended that the connection between theUniversity and the health centres would maximise oppor-tunities for research into clinical practice in primaryhealth care practice and would provide a rich source ofdata to contribute to a greater understanding rural healthissues.

In two cases, the development of the UTP was fullysupported and argued for by the community, and in onecase managed by it. It was intended that these new stylehealth services would gain acceptance in their commu-nities, and become sustainable from a financial and service

delivery perspective adding to the infrastructure in thecommunity.

Aim of the study

The aim of this study was to describe the structure andoperation of the style of service delivery and answer threemajor questions about it:1. What was the nature of multidisciplinary practice and

the model of health care?2. Were the student placements providing effective

learning opportunities?3. Would the approach be sustainable into the future?

METHOD

A case study design was chosen as the best method toprovide a snapshot of what was happening at each of thefour sites. The study sites were chosen because they hada UTP; used a multiprofessional approach to health care;were located in a rural, regional or remote town and hadplacements of medical students.

Each UTP was located in a very different environ-ment. Each of the towns had a different socio-economicprofile and each practice had a different patient /clientprofile, structure, financial base and staff profile. TwoUTPs were located in small rural towns in agriculturalregions, one was in a remote, relatively new mining com-munity and one was in a large regional centre.

The research team applied for and obtained ethicsclearance from the University of South Australia HumanResearch Ethics Committee. Information was obtainedfrom structured interviews of 73 staff across all four sites.Included were GPs, allied health practitioners, registerednurses and administration staff. In addition to interviewsof key community stakeholders, a document search wasconducted. Eighty consumers of the services and 17 of29 health care students (primarily medical students) onplacement in 1999 completed an anonymous survey inNovember 1999.

Information gained from each of the sites was ana-lysed separately. Quantitative data about the incidenceof multidisciplinary practice was obtained from the struc-tured interviews during which clinical staff membersidentified to whom they referred in the course of theirpractice. These data were entered on a spreadsheet andwere analysed using descriptive statistics. Quantitativedata from the student questionnaire and that from theclient /patient survey were analysed in the same way.Qualitative data from the structured interview aboutthe benefits, limitations and the factors affecting


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AUSTRALIAN JOURNAL OF RURAL HEALTH

multiprofessional practice were organised into themesand compared across sites. The consistencies anddifferences in the results are presented.

Client /patient views about students on placementat the sites were examined by using a non-probabilitysample of consumers from each site. A questionnairewas left in the waiting room of the MHTP during the timethe investigator was at the site and completed by thoseconsumers who wished to.

The strength of the case study approach is that each ofthe sites could be studied in depth, looking at manyaspects of the organisation of the health care componentsand using various sources of data. However, this is also alimitation because comparisons between sites can onlybe made at a high order. The material obtained from theresearch design enabled a description of the activitiesat the sites; it was not intended to provide evaluativematerial.

RESULTS

Structure and operation of the style of health care delivery

At each of the sites, up to three co-located independentcomponents collaborated in providing health care, witheach participating organisation remaining independent,using agreements to define organisational roles and finan-cial responsibilities. There was a high degree of inform-ality in developing collaborative relationships. Therewas no common overall formal structure at any of the sites.This approach differs from the multipurpose health centremodel where funds are pooled to provide more flexibleallocation to health service areas.

7

At each site a community-controlled board or aproprietary company managed the UTP. At three sites theUTP was co-located with the local hospital or alliedhealth team. At one site there was an accident and emer-gency service contracted to the UTP. The GPs acted asprivate practitioners contributing a proportion of theirfee for service income to practice management. Registerednurses were employed at the hospitals and at the accidentand emergency service. Each site had a team of alliedhealth professionals employed by the relevant regionalhealth authority. The composition of each team differed interms of the professions represented and roles performed.Other health care professionals employed by differentorganisations were also located with the allied health team.Private allied health practitioners delivered services attwo of the sites.

There was an extensive range of health and com-munity services provided at each of the sites. At one rural

site GPs, nursing and allied health staff worked togetherwith the local Division of General Practice to providea range of services including a regular general medicalclinic at an Aboriginal community. The other rural siteprovided a men’s health group, farm safe days, a sexualabuse response and training group, domestic violencenetworking, children’s health promotion and communityeducation and screening for asthma. The remote site providedgeneral family medicine as well as counselling, a needleexchange program, health promotion activities, antenataland postnatal education classes. These services were pro-vided in an integrated manner.

Hospital inpatient services are provided at two ofthe sites with the GPs providing inpatient acute care, andobstetrics and minor surgery services. In addition, anout-of-hours and an emergency medical service is provided.

Until several years ago I was a solo worker with nodirect support. The structure has changed now and I ampart of a team: It is much better now. It is the best thingthat could have happened. More space, more clientsand more support (Aboriginal Health Worker).

Table 1 provides demographic information about thetowns where the sites are located.

Integrated primary health care

At each of the four sites studied, integrated care hasevolved, building on multidisciplinary practice. The UTP,hospital and allied health practitioners share patients /clients and involve and refer to each other when appropriate.

There are benefits for the patient from the model ofhealth care we have here. There is less compartmental-isation of health care, there can be a consistency ofapproach, and the approach can be supported if otherprofessionals are involved. This makes care holistic,different areas of health and wellbeing can be inte-grated (GP Rural site).

Table 2 shows the extent and frequency of multidisci-plinary practices, measured by the self-reporting of theoccurrence of activities such as referrals between healthprofessionals, jointly run clinics, case conferences, careplans utilising more than one discipline, planning for col-laborative practice and sharing case notes and research.

There was effective consultation, communication, col-laboration and sharing of case notes to support integratedcare at each of these sites. All clinics where this occurredwere multiprofessional. The referral patterns amonghealth professionals were a strong indicator of the exist-ence of an integrated practice.



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Referral patterns across the four sites are representedin Table 3 and show a consistently high referral ratebetween professions at each site. It also shows a highpercentage of referrals by other health professionals toGPs ranging from 50% to nearly 60%. Referral rates by GPsto other health professionals averaged close to 50% acrossall four sites and in one site were close to 64%.

Community health nurses and the Aboriginal healthworkers (where they were employed) were also consist-ently referred to and consistently referred to othersregardless of the patient/client profile or the informalrelationships operating at each site. This may have been

because of their broad health care roles and their avail-ability at the site.

Rural general practice teaching sites

Undergraduate health care students are placed with eachof the organisations involved. However, this study focusedon students placed at the four UTP. There were 25 med-ical students and four allied health students placed in1999. Seventeen medical students, predominantly in theirsixth year and one allied health student returned thequestionnaire. Table 4 shows students were uniformlypositive about their experiences in achieving universityset placement objectives.

All the sites were providing placements that exposedstudents to a broad range of clinical and community activ-ities undertaken by health care professionals in a ruralmultidisciplinary environment. This exposure positivelyinfluenced medical students’ views about rural generalpractice as a future career option. This study demon-strates that positive placement experiences in the UTPtranslated into statements about undertaking a career inrural practice at some stage in the future with mostrespondents indicating they were considerably influencedto return. Further studies are required to confirm that thistrend results in actual return to rural service. This isbecause of the long time lapse between the completion ofa medical degree and the necessary postgraduate trainingrequirements for rural practice.

When asked how seriously students who have experi-enced a positive rural placement would consider enteringrural practice at some stage in the future, two-thirds saidthey were unlikely to return or considered there was only

TABLE 1: Socio-demograpic summary of sites

Site 1 Rural Site 2 Rural Site 3 Regional Site 4 Remote

Socio-demographic information

Population of town 1066 733 23 644 2814

Population of LGA 4500 2220 23 644 2814

Percentage of population of region 25% 30% 14% 2%

60 years or over

Economic base Agriculture Agriculture Mining, heavy industry

and service industries

Mining

Distance from capital city 148 km 192 km 393 km 584 km

Staff profile of sites

No. of GPs 4 3 1 (additional sessional staff ) 3

Total available allied health professions 26 17 15 11

Allied health professionals available on site 7 8 15 4

TABLE 2: Health professionals self reported multiprofessional

activities combined across all sites (n = 63)

Activity

Staff at site

who engage in activity (%)

Referral 93%

Joint clinics/outreach 54%

Case conferences† 79%

Care plans‡ 57%

Sharing case notes 68%

Planning for practice 57%

Research 13%

Health promotion

groups/education

40%

†Case conferences are formal and informal.

‡There are different definitions of care plans; most refer to the

case management approach.


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‘some possibility’ of returning. This reflects the forward-looking nature of the question with all of the uncertaintyof predicting the future. Also, the reality for most medicalstudents is that unless they undertake training as a GP inthe country, it is likely they would not return to ruralpractice for some years after graduation.

Community acceptance of the approach

In the communities where the sites are located, there is anacceptance that there is a benefit from the development ofthe UTP. The major benefit is that residents are able totake advantage of primary health care including consist-ently available and accessible GPs. Secondary benefitsinclude the addition to community infrastructure, employ-ment opportunities, the potential of attracting health careprofessionals to the community after training and enablingresidents to access other allied health services attractedto the site because of the critical mass of services. Someof these factors are highlighted in Table 7.

It can be seen from Table 5 that there are vari-ations across each of the sites about the reasons whyclients /patients chose to use the service. This reflectsthe unique nature of each of the sites. For example thereare alternative GP services available at three of thesites but not at the remote site. A convenient locationwas a reason for the choice of practice at each of therural sites, but less so at the regional and remotesites.

To maintain the UTP sites as teaching and researchcentres requires patients /clients to be willing to seestudents. Fifty-one percent of the patients who answereda questionnaire (

n

= 80) had seen a medical student at theUTP and 98% of these patients were satisfied with theexperience. Ninety-two percent of the patients who hadnot seen a student would be willing to. All patientsshared a view that students needed ‘hands-on’ experienceand the great majority were willing to assist in thestudents’ education.

TABLE 3: Referrals patterns at each site

Site 1 Rural

(n = 22)

Site 2 Rural

(n = 18)

Site 3 Regional

(n = 19)

Site 4 Remote

(n = 14)

% Staff referring to five or more disciplines 55 47 50 36

% Staff referring to GPs 50 59 52 55

% Staff referring to aboriginal health workers 55 not available 30 not available

% Staff referring to community health nurses 61 31 41 64

TABLE 4: Medical student rating of placement opportunities according to university placement objective (n = 17)

Placement objective Excellent Good Adequate Poor

Patient management 9 8 0 0

Practical procedures and skills 10 7 0 0

Knowledge of and contact with related health services 8 8 1 0

Exposure to rural general practice 12 4 1 0

TABLE 5: Reasons why patients of the university teaching practice use the practice (n = 80)

Factors responsible for choice of health centre Site 1 Rural Site 2 Rural Site 3 Regional Site 4 Remote

Convenient location 69% 93% 37% 50%

Range of services provided 72% 63% 50% 40%

Confidence in health care staff 91% 70% 91% 20%

No alternative 0% 0% 0% 60%

Other 28% 17% 37% 10%



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SUSTAINABILITY OF THE APPROACH

Financial viability

The UTP functions as a typical family practice to gener-ate income, cover operating costs and sustain studentplacements. This requires increasing service delivery atthe site and/or providing services on an outreach basis toother locations.

To remain financially viable and retain staff, the sitesshould continue to provide a broad range of health care. AQueensland study found that rural GPs mentioned workvariety as both an initial attraction to rural practice andalso a positive feature of continued practice there.

1

Workvariety also encourages students and is advantageousfor the community. However, if GPs change their workpatterns and/or reduce service provision (perhaps becauseof the cost of maintaining it) then the viability of the practicemay be an issue.

Recruiting and retaining staff

Sustainable medical and allied health services in ruralareas require attention to workforce recruitment and reten-tion. This may be assisted by providing academic/researchand professional opportunities, and a means of collabora-tion for health professionals. This would avoid the dis-advantages of solo practice, a factor that is associatedwith staff retention issues in rural locations.

2

Staff members said that professional isolation wasreduced and learning enhanced by sharing knowledge andskills across professions. GPs noted that multidisciplinarypractice shared the workload and the responsibility forpatient care among relevant professionals with whom theyhad a close working relationship.

There is a great opportunity to do more here and learnfrom other health professionals. Everyone supports andassists everyone else and it broadens my professionalexperience to see how other disciplines operate and Ican use skills I learn to assist clients/patients in otherareas (community nurse rural site).

Sustaining integrated care

Integrated care will need to continue to be developed ateach site to provide cost benefits or efficiencies and qual-ity health care. Health care collaboration may produceefficiencies if it enables the most appropriate staff toprovide services to consumers in the most effective andefficient manner.

8

This style of practice requires a high degree of col-laboration to sustain it. Co-location, amount of time spentat the site, the degree of understanding of the health

professional’s role, trust and respect of each professional,and an ability to share patients /clients were consistentlymentioned as factors necessary to sustain multidisciplinarypractice at the sites. These factors are consistent withthose referred to in the literature.

8,9

However, multi-disciplinary practice was not an end in itself. It was seenas an appropriate means to provide the best care for thepatient /client. In addition, it is a very useful approachfor students to experience, as it moves towards improvinginterdisciplinary boundaries that need to be less obviousin rural practice.

The process of establishing a vision and commongoals is made more difficult because of the mix of privateand public (salaried) practitioners. This mix was men-tioned by some staff at all centres as a barrier to multi-disciplinary practice because of differences in the timeavailable for clients /patients, fee charging practices anddiffering responsibilities. Open discussion in the processof developing common goals is required to effectivelymanage the differences.

While there was shared understanding regardingintegrated patient /client care, there were few systems inplace to support this approach. Staff members were wellaware of the need to develop overall information systems,policies and integrated plans. Long-term health care ser-vice delivery will require strategic planning involvingeach component.

Maintaining acceptance and connection within the community

Some sites had a more central role in their communitythan others. The presence of a community board involvedcommunity members in management and fundraisingfunctions. It also enabled local ownership of the servicesresulting in an attempt to provide local solutions to healthissues.

Where there was a close health centre/communityconnection, students had an opportunity to be exposed tothe situations that affect the health of their patients /clients and the role that the health centre plays in primaryhealth care.

FURTHER APPLICATION OF THE APPROACH

The strength of this approach is in its broadapplicability. It requires no formal structure in its ownright, apart from agreements or memoranda of under-standing to cover roles and financial responsibilities.Independent organisations can collaborate in the provi-sion of integrated health care if they see mutual benefits.


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The approach can be operationalised wherever thereis a general practice, hospital or some allied healthprofessionals who are willing to work together to build ateam. The general practice acts as a nucleus and at all ofthe sites studied, the other components are co-located.

It would be interesting to trial the approach withprofessionals who are not all co-located. At the remotesite 64% of allied health professionals were visiting staffand at the rural case study sites 73% and 53% of staff,respectively, were based elsewhere, often only being ableto visit the site every second month. If health care profes-sionals collaborate across distance, this would requireresources to build teams that will consistently use theintegrated model of care. Communication systems using in-formation technology would be required to support relation-ships and enable sharing of patient /client information.

The other alternative is to use one single employingorganisation; an approach that has been used in Victoriaand SA.

10,11

This alleviates the necessity to developsystems across several organisations and integrate privateand salaried practitioners.

CONCLUSIONS

Despite the fact that each of the sites had a differenthistory, length of establishment, staff profile and man-agement arrangements, the UTP worked well in providingeffective teaching and integrated patient care.

Integrated clinical practice has developed due to theinfluence of key health care professionals, interdependencyand the co-location of services. This has enabled staff tobuild a collaborative team, gain an understanding of eachothers’ roles and develop an ability to share clients /patients.

Medical students were the only students consistentlyplaced at the UTP during the period of study and theplacements for them were particularly effective in enab-ling supervised consultation. Placements were success-ful in giving students a positive view of rural generalpractice and encouraging students to consider ruralgeneral practice as a career option.

The continuation of this approach to health care ser-vice delivery will require an increasing use of informationtechnology, increased access to research and developmentopportunities for all health care staff and the ability toretain academically orientated GPs, registered nurses andallied health staff.

ACKNOWLEDGEMENTS

This study was undertaken with a grant from the Common-wealth Department of Health and Aged Care throughthe rural health support, education and training (RHSET)program.

The authors acknowledge the important contributionsof staff members, board members, students, consumersand community representatives who participated in thisstudy at each of the sites. Dr Brian Symon and DrJonathan Newbury are particularly acknowledged.

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APPROACH TO SUSTAINABLE PRIMARY HEALTH CARE SERVICE DELIVERY FOR RURAL AND REMOTE SOUTH AUSTRALIA