Issues Magazine

Quality and Continuity in Remote Medical Services

By Carmen Morgan

A trial primary health care service to a remote Western Australian community showed positive outcomes for both patients and other remote health teams.

Shark Bay is a community spanning some 25,000 square kilometres. It is located on a peninsula midway along the Western Australian coast and is aptly named Shark Bay due to the prolific presence of a number of shark species. It also has World Heritage status and is a tourism mecca for recreational fishermen and dolphin lovers.

In June 2006 an agreement between Silver Chain’s Shark Bay remote health centre (see box, p.29), Midwest Aero Medical Service (MAMS) and the Shire of Shark Bay was initiated to trial an alternative medical service to the small, isolated community.

For about 25 years, clinics funded by the Royal Flying Doctor Service’s (RFDS) Western Operations have been visiting the area on a twice-weekly basis, providing a 6-hour doctor clinic with human resources from the pool of salaried doctors at the Carnarvon Regional Hospital 300 km north of Shark Bay.

This service, by remote access standards, has been very satisfactory but, increasingly of late, the service has been buckling under the strain of doctor workforce shortages, an ever-increasing demand for services at the Carnarvon hospital and other outlying communities and the heavy reliance on overseas-trained doctors with varying levels of English language proficiency.

In 2005 the community at Shark Bay launched a petition urging the relevant health service, Gascoyne Health Service, to improve the visiting service by at the very least providing one particular doctor to service the area so that continuity and consistency of care could be established.

The reported evidence of dissatisfaction with the state-funded service was continually being reflected in Silver Chain’s client satisfaction surveys. Many Shark Bay survey respondents utilised our 6-monthly surveys to highlight issues about the lack of continuity in their doctor–patient relationships. The effect of this dissatisfaction understandably evoked feelings of mistrust and confusion throughout the community about its medical service and the lack of options available. The dilemma for Silver Chain, contracted to provide an isolated nursing service, was that it has no power to alter the structure and arrangements of the state medical services that support many of its sites. This is correctly the domain of the WA Country Health Service.

Over the years, Silver Chain in Shark Bay fielded complaints about the never-ending stream of changing faces, cultural differences and level of skill and experience of the visiting doctors from Carnarvon. Our loyal Silver Chain Nurses have been unyielding in their support of the visiting doctors, always stressing to the community how fortunate the community is to have a regular medical service while many other remote, isolated communities are lucky to see a doctor once or twice per year, if at all. The nursing staff were privately concerned about the merry-go-round of investigation, diagnosis and treatment that many unwell patients were experiencing under a very stressed regional medical service.

In the meantime, an energetic and entrepreneurial doctor by the name of Stuart Adamson, having gained a commercial pilot’s licence, introduced a very welcome weekly visiting service, supporting Silver Chain’s Abrolhos Islands service, 70 km off the coast of Geraldton, the mid-west’s regional centre.

Stuart and his practice nurse, Di Walton, operating as MAMS, worked their way into the hearts and minds of this isolated cray fishing community, which comes together for 4 months each year during the frenzy of the cray fishing season. Stu and Di soon became part of the community and patients, on returning to the mainland at the conclusion of the cray fishing season, transferred to Stu’s practice within the grounds of the Geraldton Airport.

It doesn’t take long to recognise that Stu’s passion for people and medicine is what underpins the trust and belief that patients develop very quickly in the doctor–patient relationship with him. When you work around Stu it’s very hard not to get swept up in his enthusiasm for helping people and his “can do” attitude to life.

When Stu approached me during the 2005 Abrolhos season to ask whether or not I thought his services might be a welcome change for the folks in Shark Bay and a relief for the Carnarvon Hospital’s medical team, I was a little sceptical on several fronts. How could this Geraldton GP, in private practice, deliver a more regular service than the State-funded service already in place? How could he sustain a practice bulk billing in Shark Bay? How could he guarantee a continuing service if he got sick or was called away to war (in his spare time he is a reservist doctor in the RAAF)? Would his passion for doing good survive the tyranny of distance and aviation fuel costs?

I knew Stu was providing similar services to inland communities in the mid-west region at Cue, Mt Magnet, Kirkalocka Mine, Northampton and Morawa, but how did he propose to take his service across the border into the Gascoyne region – a completely different health region? Furthermore, how would the Gascoyne Health Service respond?

Of course, Stu had done his homework and responded to my scepticism with ideas and solutions that reflected a sound strategy.

Impressed by this, or maybe just swept up in his enthusiasm, I agreed to sit down with him and plan a trial for such a service. My main objective was to ensure nothing we did jeopardised the relationships and support of the state-funded service from Carnarvon. To do so would bring pressure from the Shire about the management of Shark Bay’s resident health service by Silver Chain. I was well aware that the Shire was extremely sceptical of this private GP and his flashy ideas to improve a service that they truly believe is “as good as it gets”. They were going to take some convincing!

Stuart then proposed the provision of in-service education for the nursing staff (he is a WA GP Education and Training supervisor and Regional Training Advisor involved in training the medical workforce for the future). He was also happy to provide telephone support for his patients to the nursing staff on the 5 days per week when he was elsewhere.

The trial, which the Shark Bay Shire had cautiously agreed to, was a huge success. It resulted in many positive health outcomes within a very short time, attributable to:

  • introduction of an enhanced primary care program, with care plans for patients with chronic disease or multiple pathologies;
  • domiciliary mobile medical reviews that included bringing in a pharmacist to review patient stocks of medication;
  • home visits, mainly to a small number of palliative care patients;
  • regular lectures on topics such as diabetes; and
  • weekly public lectures on issues such as heart disease and skin cancer.

None of this was ever possible through the visiting service from Carnarvon, which was strapped for time on the ground and resources.

By the end of the trial period, improvement in primary health care arising from MAMS presence was noticeable. The trialled service made some noticeable improvements in several key areas:

  • improved symptom control and monitoring of chronic conditions;
  • personalised and person-centred GP care for palliative care clients, and all clients generally;
  • improved antenatal, confinement and post-natal outcomes;
  • continuity of care; and
  • better overall access to medical services for this remote community.

We have every reason to believe that these improvements would continue and grow with full implementation of a funded MAMS service.

Stu self-funded the service’s transport costs throughout the 6-month trial, understanding that he needed to demonstrate the benefits of his service to a wide range of stakeholders before anyone would commit financial support.

The community became extremely anxious about the delays Stu encountered in securing Commonwealth funding support to carry on his visiting service. The community understood that Stu could not continue the service post-trial on a self-funded basis, despite his fond relationship with the community. They also accepted that the state-funded service would have to be reinstated while he awaited an outcome of his business case to the Federal health minister.

While we waited for an outcome for many months, some residents of Shark Bay chose to travel 400 km south to Geraldton to see Stu in his Geraldton practice rather than resuming their care under the Carnarvon visiting service. Many others, unable to travel, had no other choice. They eagerly looked forward to the “funded” return of Stu’s service to their community. Little did any of us know that the service would never return.

Stu’s directorship of MAMS based in Geraldton has seen it grow from humble beginnings in 2004. As described earlier, he provides fly-in, fly-out medical services to a growing number of isolated communities and mining towns in the mid-west. His vision is to expand the service to truly open up access to medical services for many more remote communities. He now has five other doctors and three practice nurses working with him.

Stu advertises nationally to recruit like-minded doctors who truly want to see people living in rural and remote areas of Australia get a better deal. The carrot is an opportunity to fly to work, and in some instances fly yourself. This is a young enthusiastic team of dedicated professionals who ostensibly seek adventure in their work environment.

Stu’s interest in Shark Bay presented challenges on many levels. Working across borders (albeit regional borders) within a non-traditional service model proved to be an enlightening and exciting experience, not only for MAMS but for Silver Chain as well. The major spin-off of Silver Chain’s partnership with MAMS was that our nursing staff in this isolated community were well-supported, with regular time off and continuing education, not to mention the positive effect the service promoted in regard to the management of chronic illness and healthy lifestyle change in the resident population.

Most importantly, the outcome for Shark Bay during the trial was a community very satisfied with this medical service and improved health status, with results that could easily be replicated in many other remote communities across the country. The savings and benefits to the health system across the regions – in terms of RFDS outreach clinics, Medical Specialists Outreach Assistance Program transportation, increasing remote access to regular, consistent medical services and the support and camaraderie for the remote health teams encompassed by MAMS, both on the ground and via telephone support – was immeasurable.

The business case passed through the hands of people at many levels of government and many different stakeholders. Ultimately, the proposal was rejected at the highest level of government because Federal funding (less than $60,000) could not be found to support it.

We know it was within our collective powers to make this work – a non-traditional model like this one requires us to think laterally, work together, put aside personal issues and look for solutions – but this innovative solution was just not possible.

Needless to say, the Shark Bay community was very disappointed with the outcome, having embraced the trial so enthusiastically and enjoyed the benefits of a personable, collaborative, primary health care service. Doctor clinics in Shark Bay provided by the Carnarvon medical officers are still oversubscribed; patients are still under the care of several different visiting medical officers from the Carnarvon hospital, and patients still travel long distances to regional centres for specialist care. Although the Carnarvon medical officers do the very best they can, the service is still not a primary health care service by any stretch of the imagination. The sad fact is, we know it truly could have been.

How can we better work together in the future to assess innovative ideas and support the ones that are viable, giving our remote areas of Australia the very best services? How do we ensure that we capture enthusiasm and not wear it away? We can all say “let’s do it”, and a solution may appear to benefit communities for years to come. Or we can keep things as they are and not progress at all.