Study objective: To examine the role of specialist outreach in supporting primary health care and overcoming the barriers to health care faced by the indigenous population in remote areas of Australia, and to examine issues affecting its sustainability.
Design: A process evaluation of a specialist outreach service, using health service utilisation data and interviews with health professionals and patients.
Setting: The Top End of Australia's Northern Territory, where Darwin is the capital city and the major base for hospital and specialist services. In the rural and remote areas outside Darwin there are many small, predominantly indigenous communities, which are greatly disadvantaged by a severe burden of disease and limited access to medical care.
Participants: Seventeen remote health practitioners, five specialists undertaking outreach, five regional health administrators, and three patients from remote communities.
Main results: The barriers faced by many remote indigenous people in accessing specialist and hospital care are substantial. Outreach delivery of specialist services has overcome some of the barriers relating to distance, communication, and cultural inappropriateness of services and has enabled an over fourfold increase in the number of consultations with people from remote communities. Key issues affecting sustainability include: an adequate specialist base; an unmet demand from primary care; integration with, accountability to and capacity building for a multidisciplinary framework centred in primary care; good communication; visits that are regular and predictable; funding and coordination that recognises responsibilities to both hospitals and the primary care sector; and regular evaluation.
Conclusions: In a setting where there is a disadvantaged population with inadequate access to medical care, specialist outreach from a regional centre can provide a more equitable means of service delivery than hospital based services alone. A sustainable outreach service that is organised appropriately, responsive to local community needs, and has an adequate regional specialist base can effectively integrate with and support primary health care processes. Poorly planned and conducted outreach, however, can draw resources away and detract from primary health care.
- specialist outreach
- equity of access
- indigenous health
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↵* Forty eight people attended the Cottrell Conference by invitation from the Royal Australasian College of Physicians, nominated by their peers and professional colleges because of their experience working with indigenous communities in rural and remote Australia. The vast majority were practising medical specialists across a range of disciplines, but a small number of primary care practitioners, nurse practitioners, and Aboriginal health workers were also invited. (People involved only from a policy or academic viewpoint were not invited.) This was a unique gathering of such specialist expertise, and while not strictly “representative” of all specialists working in rural and remote Australia, was certainly the largest such gathering ever held to discuss specifically the delivery of specialist services to Indigenous communities.
Funding: Dr Gruen was supported in this work by (1) a Medical Postgraduate Award from the National Health and Medical Research Council, and (2) a Surgeon Scientist Award from the Royal Australasian College of Surgeons Foundation. Additional funding for the programme evaluation on which this paper is based was provided by the Steering Committee of the Specialist Outreach Service in Top End of the Northern Territory.
Conflicts of interest: There are no conflicts of interest in the publication of this work for any of the authors. In particular, Dr Gruen and Dr Bailie were involved as independent evaluators. None of the authors are employed by the Specialist Outreach Service and none stand to personally gain from its continuation or otherwise.