Delivery of Nephrology Services to Remote Areas of Australia

Background

Australia has some of the widest variation in health care status and delivery in the world. These range from the high doctor:patient ratios, excellent cardiovascular health statistics and superb medical facilities available in most metropolitan and predominantly Caucasian communities, to the excessive infant and adult mortality & morbidity rates of remote Aboriginal communities. Basic facilities such as water, sewerage and electricity are often lacking in these communities, let alone access to dialysis. However, the prevalence of end-stage renal failure in Aboriginal communities is rising and currently 4-15 fold greater than the age-matched Australian mean (approximating 1-5/1000 population), with a marked excess of presumed or proven diabetic nephropathy. This trend is likely to continue, as the recent prevalence of proteinuria in asymptomatic Aboriginal adults is 40-60% in several studies.

Any plan to improve delivery of nephrology services to remote areas and particularly to Aboriginal and Torres Strait Islander communities, must take into account:

This document attempts to set minimum achievable nephrology service standards, and to maximise cost-efficient access. The document is based on principles enunciated in the Darwin Declaration, arising from the RACP Cottrell Conference (RACP 1997), as well as techniques evaluated in the Tiwi Islanders of the Northern Territory and remote areas of WA (Hoy 1998, Thomas 1998, Couzos 1999).

Recommendations

Periodic Health Examination

Intervention and CRF management

End-stage renal failure management


Mark Thomas 1999

References

Hoy W. Screening for renal disease and other chronic diseases in Aboriginal adults, and preliminary experience of a medical intervention program. Nephrology 4:S90-S95,1998.

Thomas MAB. Kidney disease in Australian aboriginals: time for decisive action. MJA 1998,168:532-533.

Couzos S, Murray RB. Aboriginal Primary Health Care: An Evidence-based Approach. Oxford University Press, Melbourne, 1999.

Appendix

Communiqué of the 1997 Cottrell Conference hosted by the Royal Australasian College of Physicians: Statement on the Delivery of Specialist Services to Remote and Rural Aboriginal and Torres Strait Islander Communities

Shorthand title: The Darwin Declaration 1997

In November 1997, the Royal Australasian College of Physicians held the biennial Cottrell Conference in Darwin. The subject of the conference was 'The Delivery of Specialist Services to Remote and Rural Aboriginal and Torres Strait Islander Communities.' 48 people attended the conference by invitation.

They were predominantly specialists, but primary care medical practitioners, nurse practitioners and Aboriginal health workers were also invited. There were specialist representatives from Australia, New Zealand and Canada.

The conference communiqué has been agreed on by people who have extensive experience with service delivery issues in rural and remote Australia. Many of the principles and problems outlined are applicable to the health of Aboriginal and Torres Strait Islander Australians living, in urban areas.

It was accepted that the health of Aboriginal and Torres Strait Islander Australians is disastrously poor compared to other Australians, and that the fundamental cause is disempowerment, due to various factors including continued dispossession from land, cultural dislocation, poverty, poor education and unemployment.

PART ONE - PRINCIPLES

1. THE ROLE OF HEALTH SERVICES

The provision of appropriate high quality health services is a necessary but partial step in redressing the poor health outcomes of Aboriginal and Torres Strait Islander people.

2. EQUITY OF ACCESS

All Australians, including Aboriginal and Torres Strait Islander people living in rural and remote areas, have a right of access to primary care and specialist medical services, on the basis of need.

3. PRIMARY CARE SERVICES

Medical specialists can only deliver appropriate, effective, high quality care if primary care services are adequately funded and running well.

4. COMMUNICATION AND CULTURE

Good two-way communication between specialists and patients is a prerequisite to safe and effective care, to patient satisfaction, and to informed consent. Individual practitioners must show respect for cultural differences and models of health service delivery must be culturally informed.

5. ORGANISATIONAL, PLANNING AND WORKFORCE ISSUES

The delivery of specialist services needs to be integrated and coordinated within the health system to ensure good continuity of care for clients. Specialist services should be planned, monitored and evaluated accordingly. Accountability needs to be clear at each level of decision making government and the specialist colleges. A skilled workforce needs to be recruited and supported.

PART 2 - BACKGROUND TO THE PRINCIPLES

The role of health services

Specialist providers undertake a variety of roles including clinical care, support for the primary cre team, procedures, skills-transfer, teaching (including Aboriginal and Torres Strait Islander health workers), applied research, quality assurance and advocacy.

However, there is a lack of evidence as to which of these roles contributes most to improving health outcomes for Aboriginal and Torres Strait Islander people, and a dearth of evaluation as to the most appropriate and effective models of service delivery.

The provision of specialist services in the community decreases the social disruption and immediate costs associated with travel, for clients who would otherwise have had to attend urban centres for review. Improving specialist services may also lead to an increase in subsequent costs as people are appropriately hospitalised for investigation and management of conditions which were previously undiagnosed. With time, if these conditions are managed effectively, there will be a reduction in the ensuing complications and a corresponding improvement in outcomes and reduction in long term costs. Experienced specialists who visit rural and remote Aboriginal or Torres Strait Islander communities strive to use hospitalisation only as needed and encourage community-based care.

There are currently dedicated specialists running innovative high standard service delivery programmes in rural and remote Australia. Such programs provide a basis on which to strengthen referral and management systems.

Most specialist services in rural and remote areas are still delivered from and in regional hospitals. These hospitals need to be supported in order to develop their referral role and expand their training opportunities.

We support the role of community-controlled health services in the provision of primary health care to indigenous Australians, since these services ease the access of Aboriginal and Torres Strait Islander people into the health sector.

The advent of telemedicine will not replace the need for specialists in rural and remote areas.

Telemedicine is not a substitute for specialist services, but it can, when used well, supplement local services.

Equity of access

There are considerable differences in the histories, current circumstances, size and resources of Aboriginal and Torres Strait Islander communities across Australia. This heterogeneity must be taken into account in the planning of health services.

Notwithstanding the large number of specialists resident in urban areas, many Aboriginal people living in urban areas also have problems accessing mainstream services.

The lack of doctors and pharmacists in rural and remote areas results in an undersupply of Medicare and Pharmaceutical Benefits Scheme (PBS) funds to those areas and a consequent underfunding of health care services on a per capita basis, let alone on a needs basis.

Primary care services

Primary care services to rural and remote Aboriginal and Torres Strait Islander communities are significantly underfunded and are inadequate to meet the needs of the resident population. Improving specialist services without improving. primary care services could worsen, rather than improve, health outcomes.

Medical specialists form part of a multi-disciplinary health care team, primarily with primary care doctors, Aboriginal or Torres Strait Islander health workers, nurse practitioners and allied health professionals.

The better the organisation, structure and staffing at the primary health care level, the better the utilisation of specialist services.

Specialist providers should aim to provide a service that is responsive to local needs and should be accountable initially to their individual patients and the referring primary care practitioners, and ultimately to the local Aboriginal or Torres Strait Islander community.

Communication and Culture

For many Aboriginal and Torres Strait Islander people, English is not their first language. The contribution of specialists, like other predominantly non-Aboriginal health staff, is hampered greatly by a virtual absence of funded positions for translators and 'cultural educators'. The result is poor history-taking, constant miscommunication, client misunderstanding, suboptimal compliance, a lack of informed consent and ineffective service delivery.

Specialist providers should have input into the setting of best practice guidelines, standards and protocols, and abide by local guidelines, standards and protocols whenever possible, providing a justification where deviation is necessary.

Organisational, planning and workforce issues

The work of specialist medical practitioners in rural and remote Aboriginal and Torres Strait Islander communities is important, challenging and satisfying. The potential of such experience to inform other innovative service delivery initiatives at a national level should be recognised.

The current workforce situation is characterised by an undersupply of specialists in rural and remote areas of Australia, and this impacts particularly on the large number of Aboriginal Australians with poor health status who live in those areas. There is also an imbalance of specialist skills in particular areas.

Given the high number of discrete but coexisting medical problems experienced by many Aboriginal and Torres Strait Islander people, there is a particular need for specialists with 'generalist' skills.

Different specialty services (for example ENT and paediatrics) lend themselves to different methods of organisation for the delivery of services.

Overall, the current provision of specialist medical services is more often ad hoc than planned and current models of service delivery are neither equitable, sufficiently planned nor properly evaluated.

Explicit models of service delivery and transparent organisational methods will allow the system to be monitored, evaluated and improved.

Governments have a responsibility to fund, organise and deliver health services to all Australians on the basis of need, and to be involved in medical workforce supply, distribution, education, training and financing.

Governments also have a role in adequately funding the transfer of patients and escorts from rural and remote areas to regional and tertiary centres for assessment and care. The provision of escorts is an important mechanism that allows appropriate family support.

The specialist medical colleges have a responsibility to advocate for rural and remote practice in general, and to actively support the development of a skilled specialist workforce in rural and remote Australia. A number of the specialist colleges have made concerted efforts in recent years to set up accredited rural training schemes, but other colleges have not done enough in this area up to now.

The specialist colleges also need to ensure that an adequate number of training positions are available nationally, so that the demand for such specialists in capital city areas is not so great that the cost of attracting them to rural and remote areas is prohibitive.

PART 3 RECOMMENDATIONS

To the specialist medical colleges

That each specialist college prepare a position paper on strategies to improve specialist services to rural and remote Aboriginal communities, including an implementation plan with mechanisms outlined for monitoring. and reporting outcomes. These position papers should be developed by working parties with a majority of remote area practitioners and with indigenous input. Each college could report to the Committee of Presidents of Medical Colleges or to the Australian Academy of Medicine when established. The Royal Australasian College of Physicians would be an appropriate 'sponsoring college' for such a proposal, given its role in organising and funding the 1997 Cottrell Conference, and its initiative in setting up a Health Policy Unit.

The position papers should include strategies to:


To the federal state and territory governments

Ale exact financial contribution of the federal, state and territory governments would be a matter of negotiation, based on cooperation, goodwill and a shared commitment to improving Aboriginal health outcomes.

  1. Establish state and/or regional positions, administrative centres, or planning groups to:
    1. assess service needs in conjunction with primary care practitioners and Aboriginal and Torres Strait Islander communities;
    2. identify gaps in specialist services;
    3. negotiate new services where needed; and
    4. plan, organise and coordinate the delivery of specialist services.

    These positions, centres or planning groups would benefit all people living in rural and remote areas, both Aboriginal and non-Aboriginal. The positions, centres or planning groups could also organise suitable orientation for specialist providers working with Aboriginal and Torres Strait Islander people. The positions, centres or planning groups could be based at regional hospitals or in academic centres of rural health, and could be established either under the auspices of the specialist colleges or the federal, state or territory health service.

  2. Initiate innovative demonstration or pilot projects where specialist service programs would be integrated into a comprehensive health care delivery system, and the effectiveness and outcomes of specialist services could be evaluated.

  3. Address the disadvantage and inequity Aboriginal and Torres Strait Islander people suffer in access to Commonwealth health funds by a number of mechanisms. We support the cashing, out of MBS and PBS funds on a per capita basis, with multiplicative factors based on need (e.g. increased morbidity and mortality) and the costs of delivering health care to rural and remote Aboriginal communities. The Commonwealth government also needs to explore the cashing out of MBS funds for specialist services, with similar multiplicative factors.
  4. Establish Language Centres in areas where English is a second or even less commonly spoken language for the local indigenous population. Such centres would develop: a team of competent translators and interpreters; a set of bridging terms and concepts, around contemporary medical terms and concepts, from the indigenous languages of the region to English; and word dictionaries and other resources for health professionals, including medical specialists. We note that there has been little response nationally to Recommendation 249 of the Royal Commission into Aboriginal Deaths in Custody: 'that the non-Aboriginal health professionals who have to serve Aboriginal people who have limited skills in communicating with them in the English language should have access to skilled interpreters'.
  5. Establish Community Education teams, either on their own in areas where English is the common first language, or in conjunction with the Language Centres mentioned above. Community Education team members would have competency in medical knowledge and skills in community education methods. The team would work to develop a variety of health education resources for community members and work with the clinical staff to integrate the preventive and curative aspects of care.
  6. Ensure appropriate resourcing for the Patient Assistance Travel Scheme(PATS) to ensure appropriate family support during times of crisis.
  7. Ensure sufficient hospital-based positions are created to establish at least per capita state-average specialist numbers in centres which care for substantial Aboriginal and Torres Strait Islander populations.
  8. Support retraining of specialists after time spent in rural and remote areas of Australia. Such support could be in the form of contracts with set amounts of retraining time allocated per year of rural and remote practice (so-called retraining salary).