Rural outreach by specialist doctors in Australia

Outreach healthcare is an important strategy to increase access to specialist medical services in rural and remote Australia. However, most research evidence about rural outreach work by specialist doctors is in the form of small-scale reports describing and validating outreach services for different specialties and contexts. No research systematically describes such outreach at a state/territory or national level. As such there is poor information to understand the level of workforce participation, where rural outreach services are delivered and the factors that influence rural outreach work. This thesis aims to systematically describe rural outreach work by specialist doctors in Australia to improve the basis of information for policy development and planning. It includes multiple studies to describe the extent of rural outreach work and the factors influencing participation and patterns of service provision, including service distribution and continuity. The thesis uses data collected between 2008 and 2014 as part of the Medicine in Australia: Balancing Employment and Life (MABEL) study, a large national longitudinal panel survey of Australian doctors. The findings suggest that rural outreach work is relatively common, involving one in five Australian specialists, mostly males, who participate for a range of reasons. Only 16% of outreach providers worked in remote locations, however as a proportion of all services, 42% were provided in outer regional or remote as opposed to inner regional locations. Outreach services were continued to the same town around half the time and the median length of continuing the main outreach service was six years. Increasing age did not influence participation but was correlated with remote outreach work. Additionally, mid-career specialists were more likely to continue rural outreach services, as opposed to those in early career or nearing retirement. A range of specialist types participated, however, generalists and otolaryngologists more commonly provided rural outreach services, worked in remote locations and sustained service provision. Specialists based in rural areas more commonly participated in rural outreach but three-quarters of all providers were metropolitan-based. Location also influences service distribution. Inner regionally-based specialists were less likely than metropolitan-based specialists to provide remote outreach services. Instead, remote outreach work was mainly undertaken by a combination of specialists living nearby or in metropolitan areas. Metropolitan specialists, whether working in the public or private sector, were more likely to travel to distant locations. Their outreach services were just as stable as those by rural specialists. Specialists working in private consulting rooms were more likely to participate in rural outreach and private specialists commonly participated to provide complex healthcare in challenging situations. However specialists in private consulting rooms tended to be less likely to work in remote locations. Private rural specialists restricted their travel distance to <300km. Working only privately, as opposed to in mixed or public practice, also reduced the stability of rural outreach services. Around half of all specialist outreach providers received subsidies for rural outreach work. Subsidies either from the Australian Government’s Rural Health Outreach Fund (ROHF) (19%), or another source (27%), were related to longer travel and the provision of services into more remote locations. Additionally, compared with non-subsidised specialists, RHOF subsidies supported specialists working in priority areas, who provided regular services they intended to continue, despite visiting more remote locations. This thesis addresses an important gap in systematic knowledge and understanding of rural outreach work. Such work is relatively common, by a range of specialists, mainly based in metropolitan areas and working in different practice sectors. However, complex drivers influence participation and patterns of rural outreach work, which broadly operate at individual, organisational and economic levels. Instead of a simple response, rural outreach work is likely to require multilevel policy and planning. Further, based on the extent and range of rural outreach services provided via different models in both regional and more remote locations, systems are likely to be needed to ensure outreach services are appropriately targeted, integrated and coordinated.