One of the main communication issues is the coordination of care across long distances. Coordination of care across long distances involves different types of facilities and health professionals having to share information. Coordination of care across long distances is necessary because rural patients access a variety of services, and these services need not be co-located. For this reason, services need to network about care delivery: communicate with one another about how to deliver care to rural patients in ways that create continuity and maintain access.

Practice example 4.1 presents a case study of one rural patient’s journey through the health system. It highlights the vulnerability of patients in rural areas. Practice example 4.2 demonstrates access issues often faced by rural patients. It asks you to reflect on how new and emerging telehealth and information technology initiatives are seeking to address some of these communication challenges.

Introduction

Those providing health care to rural patients face a number of challenges depending on the degree of ‘rurality’ involved. ‘Rurality’ is defined according to the Australian Standard Geographical Classification – Remoteness Areas system (ASGC-RA). The ASGC-RA is explained as ‘a geographic classification system that was introduced on 1 July 2010. It was developed by the Australian Bureau of Statistics (ABS). The ASGC-RA allows quantitative comparisons between ‘city’ and ‘country’ Australia’ (ABS, 2010 cited in Commonwealth of Australia, 2012, p. 6). According to the ABS, ‘as at June 2009, 68.6% of the population resided in Australia’s major cities. Of the total population, 29.1% resided in regional areas and just 2.3% lived in remote or very remote Australia’ (ABS, 2010 cited in Commonwealth of Australia, 2012, p. 5).The National Strategic Framework for Rural and Remote Health states:

The RA categories are defined in terms of the physical distance of a location from the nearest urban centre based on population size. The five RA categories under the ASGC system are:

• RA1 – Major Cities of Australia;
  
• RA2 – Inner Regional Australia (rural);
  
• RA3 – Outer Regional Australia (rural);
  
• RA4 – Remote Australia (remote), and
  
• RA5 – Very Remote Australia (remote). (Commonwealth of Australia, 2012, p. 6)

According to the National Strategic Framework for Rural and Remote Health ‘the terms “rural” and “remote” are used to encompass all areas outside Australia’s major cities. This includes areas that are classified as inner and outer regional (RA2 and RA3) and remote or very remote (RA4 and RA5)’ (Commonwealth of Australia 2012, p. 5). The different categories are set out in Figure 4.1.

Figure 4.1 Remoteness area boundaries of Australia (ABS, 2011)

As Figure 4.1 demonstrates, the largest remoteness category is ‘very remote’ or RA5 – over 5.5 million square kilometres (72.5% of the Australian land area). Next in size is the ‘remote’ (RA4) category at 1.02 million square kilometres (13.2%); and finally the ‘outer regional’ (RA3) and ‘inner regional’ (RA2) categories cover 10.8% and 3.2% of Australia’s land area, respectively (Commonwealth of Australia, 2012, p. 5). Approximately seven million people, about one-third of Australia’s total population – live outside major cities (Commonwealth of Australia, 2012, p. 5). According to the Australian Institute of Health and Welfare:

[t]he relationship of remoteness to health is particularly important for Indigenous Australians, as they are more likely to live outside metropolitan areas than non-Indigenous Australians. In 2011, just over one-third of Indigenous Australians lived in Major cities (34.8%), compared with over 70% of non-Indigenous Australians. Only 1.7% of non-Indigenous Australians lived in Remote or Very remote areas, compared with about one-fifth of Indigenous Australians (7.7% in Remote and 13.7% in Very remote areas). Indigenous Australians represent 16% and 45% of all people living in Remote and Very remote areas respectively. (AIHW, 2014, 7.7)

The population distribution for each remoteness area is set out in Table 4.1.

The Australian Government Department of Health Doctor Connect website (http://www.doctorconnect.gov.au/internet/otd/publishing.nsf/Content/locator, retrieved October 20, 2014) enables individuals to insert a town or street address name to identify the correct RA classification for that location.

The challenges facing rural and remote health care

When it comes to the health of a population, remoteness, or rurality, has several consequences. The Australian Institute of Health and Welfare’s (AIHW) report, Australia’s Health 2014, states for example that ‘Australians in regional and remote areas tend to have shorter lives and higher rates of disease and injury than people in major cities’ (AIHW, 2014, 5.6). The main reasons for the difference are a lack of ‘educational and employment opportunities, income, and access to goods and services’ (AIHW, 2014, 5.6). Further reasons include rural patients’ need for more long distance travel, access to fresh foods, and access to health services (Commonwealth of Australia, 2012).

Another consequence of rurality is increased disease risk factors and increased levels of illness (Commonwealth of Australia, 2012). In addition, death rates increase with remoteness (AIHW, 2014). One of the reasons for the increased disease factors and levels of illness is the higher rate of poverty experienced by residents of rural, regional and remote areas compared to those in metropolitan areas. In their report, entitled A Snapshot of Poverty in Rural and Regional Australia, the National Rural Health Alliance (NRHA) and the Australian Council of Social Services (ACOSS) state: ‘Allowing for the costs of housing, poverty is slightly worse in rural, regional and remote areas (13.1 per cent “outside capital cities”) than in capital cities (12.6 per cent). When housing costs (which are higher in capital cities) are not taken into account, that divide becomes starker.’ (NRHA & ACOSS, 2013, p. 3).

The National Strategic Framework for Rural and Remote Health (Commonwealth of Australia, 2012) summarises the consequences of rurality as follows:

[h]igher mortality rates and lower life expectancy; higher road injury and fatality rates; higher reported rates of high blood pressure, diabetes, and obesity; higher death rates from chronic disease; higher prevalence of mental health problems; higher rates of alcohol abuse and smoking; poorer dental health; higher incidence of poor antenatal and post-natal health; and higher incidence of babies born with low birth weight to mothers in very remote areas. (Commonwealth of Australia, 2012, p. 13)

Service delivery in rural and remote areas is very different to that in the city (Commonwealth of Australia, 2012). Some of the reasons for this are the increased costs incurred in providing health services in remote locations due in part to the lack of existing infrastructure that can be utilised and the lack of trained and skilled workers. In addition there is greater dependence on primary healthcare providers such as general practitioners (GPs). While there is a higher use of emergency departments in rural areas, these emergency departments are usually serviced by visiting medical officers (VMOs), who are often GPs. Facilities are smaller, yet they must provide a broader range of services such as aged and community care to a more geographically dispersed population (AIHW, 2014).

In addition, prevailing service models and models of care are often better suited to metropolitan settings than to rural and remote settings. The reason for this, according to the National Strategic Framework for Rural and Remote Health (Commonwealth of Australia, 2012), is that most health service education and planning take place in metropolitan settings, with little regard for the differences that rurality brings. Despite a number of more recent incentive programs and rural clinical placements:

traditional training approaches and funding mechanisms have led to the uneven distribution of healthcare professionals across the country. This can be seen in the disparity in the number of healthcare professionals between metropolitan and the most remote parts of the country. For example, in 2006 very remote areas had:

• 58 generalist medical practitioners per 100 000 population (compared to 196 per 100 000 in capital cities);
  
• 589 registered nurses per 100 000 population (compared to 978 per 100 000 in major cities); and;
  
• 64 allied health workers per 100 000 population (compared to 354 per 100 000 in major cities). (Commonwealth of Australia, 2012, p. 9)

This uneven distribution of the health workforce, together with workforce shortages, often results in heavy workloads for rural clinicians. As a consequence of limited resources and time, rural health professionals often become generalist practitioners with broad knowledge and flexible work practices. According to McNeil et al. (2014) there exists the expectation that rural health practitioners ‘will provide a wider range of services [than their metropolitan counterparts]. Flexibility in role boundaries and overlapping knowledge and skills’ is therefore necessary between health professionals (McNeil, Mitchell & Parker, 2014, p. 2).

Given these complexities, careful communication and ongoing cooperation between rural health professionals and with the community is essential in order to meet the health needs of rural communities. This means that rural clinicians are often closely associated with non-health agencies and community groups that provide social services. Being members of a small community, health professionals are often well known to their patients. This may pose a number of challenges in relation to personal and professional boundaries around issues such as confidentiality and incident management, for example.

The National Strategic Framework for Rural and Remote Health states there are:

further complexities for planning, managing and delivering public hospital services in rural and remote locations as they:

• are generally smaller than metropolitan centres;
  
• have high fixed costs of operation;
  
• are less able to achieve the economies of scale experienced in large hospitals; and
  
• are often the default service provider in the absence of private sector options, adequate primary health and aged care services provision. (Commonwealth of Australia, 2012, p. 11)

Furthermore:

[P]eople in rural and remote areas needing to access health services are often influenced by:

• travel distance to relevant health services, including the availability of transport and the cost of travel;
  
• uncertainty about how to use and access services, including the availability of emergency care and retrieval services;
  
• cultural and language barriers; and
  
• poorer understanding of health issues and how to access health services. (Commonwealth of Australia, 2012, p. 29)

There can be cultural and language barriers (particularly for Aboriginal and Torres Strait Islander peoples and for people from culturally and linguistically diverse backgrounds) and poorer understanding of health issues, or poor health literacy (Commonwealth of Australia, 2012, p. 30).

Past experience also has an influence on whether or not people access care. Lack of support for travel from rural and remote areas to metropolitan centres for specialist care is often viewed by patients as difficult to coordinate and disruptive to family and professional life. Accordingly, such appointments may be delayed or cancelled. This can mean that people prefer to live with their condition rather than access treatment far from home (Commonwealth of Australia, 2012, p. 30).

These challenges create specific communication issues for patient safety. Practice example 4.1 highlights the challenges and vulnerability faced by patients who live in rural communities. Practice example 4.2 highlights the challenges of access to specialty services. The second example will also touch on the changes brought about by new and emerging telehealth initiatives.

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