Issue 37 / 24 September 2012

IN August, the Australian Senate belatedly released a much-anticipated report — The factors affecting the supply of health services and medical professionals in rural areas.

Politicians established an inquiry because of concerns about poorer health outcomes and life expectancy in rural and remote communities compared with their metropolitan counterparts, as evidenced in the Australian Institute of Health and Welfare’s first report on rural health in 1998 — Health in rural and remote Australia — and subsequent updates.

Those of us in rural and remote practice received the Senate report with some scepticism — not because of the findings, but because we have heard it all before with little result.

In 1999, Dr Jack Best AM was commissioned by the Department of Health to conduct The Rural Health Stocktake, released in June 2000. Dr Best’s report was far-reaching, addressing needs of rural communities, recruiting and retention of health professionals, classification of rurality and coordination of government policy.

About 4 years later, the Rural Doctors Association of Australia released a report on viable models in rural and remote practice. This very comprehensive report was impressive because it was composed by rural doctors, rather adopting a top-down approach.

Now here we are in 2012 with the Australian Senate recommending, amongst other things, the need for better data collection, an expanded role for generalists, expanded incentives for nurses and allied health workers, strengthening definitions of rural students to only include those who spent most of secondary school in a rural area, revised workforce incentive schemes, and better financial incentives for rural and remote doctors who provide education to medical students.

We have heard this all before — and are still awaiting action. The conclusions are nothing but a re-hash of previous reports and inquiries.

Generalism is the only way forward for rural communities and it is encouraging to see state governments, especially Queensland, embrace generalist training. Geography and scarcity of resources, in particular personnel, dictates the need for multiskilled, flexible professionals who can sort out diverse clinical issues without needing to transfer everyone to cities and regional centres.

It may surprise some readers, but often things are more efficient in smaller rural hospitals than in the large hospitals, as we are not bogged down waiting for consultants from other specialties to come and make fairly straightforward decisions.

Political inaction and recurrent consultations and reviews are not the only impediments to sorting out rural health. The other enemy is that silent killer of clinical autonomy — dogmatic protocols.

Friday, September 13th (scary, huh?) was World Sepsis Day. The NSW Clinical Excellence Commission has been doing some excellent work on the detection and management of sepsis in hospitals, and in the lead-up to Sepsis Day our hospital managers handed down some sepsis protocols to clinical staff in our district.

Now, while these sepsis protocols work well in large hospitals, smaller hospitals do not have any hope of complying as many do not have the staff, monitoring or pathology equipment and even the drugs available to manage the protocols, which provide no concessions or recommendations that take this into account.

When I raised this concern with local management, the best reply I got was that “standardising treatment is safest for patients”. This convenient political mantra fails to take into account the dislocation it causes patients’ families when a loved one has to be transferred to a hospital hundreds of kilometres away from home.

And one can argue that travelling in an ambulance at night on a country road with tired ambulance officers ain’t necessarily safe when the only reason for the transfer is a tick-a-box protocol.

This dogmatic protocol mentality has already resulted in the inability of many NSW country hospitals to provide paediatric admissions. Rather than promote paediatric services, it has been easier to declare the smaller hospitals unfit to meet protocols and so ban kids from being admitted.

Protocols such as that for sepsis run the risk of setting up rural hospitals for further failure and the resultant cutting back of further services.

Or is this perhaps the real, but silent, agenda?

Dr Aniello Iannuzzi is a GP practising in Coonabarabran, NSW.

Posted 24 September 2012

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6 thoughts on “Aniello Iannuzzi: Rural repetition

  1. D.Freeman says:

    I have little doubt that government policy is to eliminate smaller country hospitals. My partner and I used to perform some 300 procedures under GA yearly, as well as 50-60 confinements. Nowadays there are no operations under GA and no confinements. This represents a blow to the local economy,costs patients, their families and the Ambulance service a lot of money due to transport costs, and tends to lower the quality of medical care.

  2. Peter McInerney says:

    Well said Aniello. You are absolutely correct. ASGC-RA will not change anytime soon even though everyone knows it is a farce.
    Protocol based medicine is for use by those who haven’t learnt clinical method and if you take it to its logical conclusion will make small rural hospital redundant.

  3. Tony Burrell says:

    Severe sepsis is an increasing problem particularly in the elderly. Failure to recognise sepsis and administer timely antibiotics is associated with increased mortality.

    The CEC Sepsis Program is aimed at encouraging every clinician to consider sepsis, and give sepsis the same priority as trauma, AMI and stroke. This is possible in all hospitals no matter what their location or size. We have been working closely with the Rural Critical Care Taskforce around issues such as POC lactate testing. Antibiotic availability in rural hospitals has also been a major focus. Lastly the Rural CNC group have developed a severe sepsis guideline as part of the FLEC guidelines which has been well received by rural clinicians.

    The only agenda here is best patient care which must always be open and transparent.

  4. Sue Page says:

    Part of the difficulty is when protocols are devised in metro areas primarily to regulate the behaviours of junior doctors in training, and are then applied to rural hospitals with words like “must”. One example was a requirement for all children with fevers to be reviewed by a paediatrician before discharge. Fine if you have one, but led to 5 air retrievals in 24 hours at one centre before it was varied to say doctors (usually highly experienced GPs) at rural sites could simply ring a paed if they had concerns.

  5. Max Kamien says:

    There is a good case to review previous reviews and see if their recommendations have been carried out before embarking on new and expensive surveys. But politicians are rarely well informed and their knee-jerk response to any political difficulty is to call for an inquiry. It is a form of fiddling aimed at hoping the interest in the problem will go away.

  6. Dr. Raj Patankar says:

    Excellent article which has come from someone like Dr. Aniello having extensive wide experience of working rural health and who feels the pain of rural community . Hope his vies / efforts to improve rural health are noticed and rewarded.

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