Adoption, implementation and prioritization of specialist outreach policy in Australia: a national perspective

Bull World Health Organ 2014;92:512–519 | doi: http://dx.doi.org/10.2471/BLT.13.130385 Policy & practice 512 Adoption, implementation and prioritization of specialist outreach policy in Australia: a national perspective Belinda G O’Sullivan,a Catherine M Joyceb & Matthew R McGrailc Introduction The World Health Organization (WHO) recognizes the need for policies designed to overcome the chronic undersupply of health workers in rural areas in both developed and devel- oping countries.1 In February 2009, following international calls for action, WHO launched a programme that aimed to increase access to health workers in rural and remote areas by improving staff retention.2 The programme involved an evidence-based appraisal of policies that could influence retention through education, regulation, financial incentives or professional support.3 Outreach was endorsed as an effec- tive strategy because it enables: efficient redeployment of the workforce; continuity of care at the local level; and profes- sional support and education for local workers, which could improve retention.1 WHO defines outreach as, “any type of health service that mobilizes health workers to provide ser- vices to the population or to other health workers away from the location where they usually work and live”.1 In Australia, outreach involves planned, regular visits to each community.4 Australia is the only country that has had, since 2000, a sustained, national policy on outreach that subsidizes medical specialist outreach to rural areas. The country has a low popu- lation density, vast stretches of uninhabited land and several urban centres distributed sparsely along the coastal fringe.5 Inequalities in the social determinants of health between met- ropolitan and rural populations influence the need for health care.4,6 Although it is a developed country, Australia continues to have problems addressing the high rate of preventable dis- ease, particularly in remote communities where the proportion of indigenous people is high and where geographical distances are extremely large.4 For example, the rates of trachoma,7 otitis media8 and rheumatic heart disease9 in these communities remain high relative to global expectations. In rural and remote communities, a lack of local services and low utilization of hospitals results in higher mortality than is found in large cities.10 The medical evacuation of patients who require specialist care in a large hospital is important for these communities but a substantial number need to be retrieved and the cost is high.5,11 Thus, more efficient and effective community-based approaches are needed. Access to comprehensive primary health care involving specialists is considered ideal for the early and ongoing management of illness in rural areas.12 However, only 15% of Australian specialists have their main practice outside metropolitan areas, whereas 30% of Australians reside in nonmetropolitan areas.13 Rural specialist outreach services could help overcome complex barriers to service access,4,6 which are mainly due to language and cultural differences,5,14 and help avoid the cost and effort of seeking care away from home.15 Visiting specialists can meet many of the health service needs of rural areas16 and, since they are less exposed to some of the negative effects of full-time rural specialist practice, it may be easier to recruit them.17,18 In addition, visiting specialists can also provide periodic procedural support for rural generalists, thereby increasing their confidence clinically and reducing their professional isolation.19,20 All medical specialists in Australia must complete ad- vanced medical training and become fellows of a specialist college. Specialist care is normally accessed by referral from a general practitioner and is partly or wholly subsidized by a universal health insurance scheme – the Medicare Benefits Schedule21 – which is funded by the Commonwealth of Aus- tralia (i.e. the national or federal government). Self-employed Abstract The World Health Organization has endorsed the use of outreach to promote: efficient redeployment of the health-care workforce; continuity of care at the local level; and professional support for local, rural, health-care workers. Australia is the only country that has had, since 2000, a sustained national policy on outreach for subsidizing medical specialist outreach to rural areas. This paper describes the adoption, implementation and prioritization of a national specialist outreach policy in Australia. Adoption of the national policy followed a long history of successful outreach, largely driven by the professional interest and personal commitment of the workforce. Initially the policy supported only new outreach services but concerns about the sustainability of existing services resulted in eligibility for funding being extended to all specialist services. The costs of travel, travel time, accommodation, professional support, staff relief at specialists’ primary practices and equipment hire were subsidized. Over time, a national political commitment to the equitable treatment of indigenous people resulted in more targeted support for outreach in remote areas. Current priorities are: (i) establishing team-based outreach services; (ii) improving local staff’s skills; (iii) achieving local coordination; and (iv) conducting a nationally consistent needs assessment. The absence of subsidies for specialists’ clinical work can discourage private specialists from providing services in remote areas where clinical throughput is low. To be successful, outreach policy must harmonize with the interests of the workforce and support professional autonomy. Internationally, the development of outreach policy must take account of the local pay and practice conditions of health workers. a School of Rural Health, Monash University, 26 Mercy Street (Level 3), PO Box 666, Bendigo, Victoria, 3550, Australia. b Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia. c Monash University Gippsland Medical School, Churchill, Australia. Correspondence to Belinda G O’Sullivan (email: Belinda.osullivan@monash.edu). (Submitted: 15 September 2013 – Revised version received: 16 January 2014 – Accepted: 4 February 2014 – Published online: 13 March 2014 ) P licy & practice Bull World Health Organ 2014;92:512–519| doi: http://dx.doi.org/10.2471/BLT.13.130385 513 Policy & practice Specialist outreach policy in AustraliaBelinda G O’Sullivan et al. and hospital specialists with a right to private practice, who together account for 73% of all Australian specialists,21 have the discretion to set their fees at or above the Medicare funding level, which has an effect on the level of co-payment, if any, required from patients. Overall, 47% of specialists work in mixed public and private practice, 33% work in public practice only and 20% work in private practice only.22 Furthermore, 49% of those working only in public practice have a right to a private practice.22 Globally there is a lack of informa- tion on outreach strategies that can help guide policy.1 The aim of this paper, therefore, was to describe the adoption, implementation and prioritization of a national specialist outreach policy in Australia to provide a reference for other countries. Specialist outreach The early history of specialist outreach in Australia includes many examples of individual “champions” who, despite various barriers and logistical chal- lenges, pioneered outreach services at a local and national level.23–25 There are numerous examples of specialists whose practice was adapted to complement lo- cal health services, which highlights the importance of professional autonomy and local design.9,14,26 The provision of specialist outreach through a “bottom- up” approach has continued to result in accessible, safe and relatively sustained (i.e. for more than 5 years) services in different parts of the nation and across a range of specialties.6,8,27 Evaluations have shown that specialist outreach in remote settings improves early inter- ventions and the coordination of care and reduces the hospitalization rate.6 Moreover, integrated services have a higher clinic throughput and lower costs.28 However, such services require time and patience to develop and must be based on local relationships and re- spect for local culture.9,14 In Australia, specialist outreach has been fostered by the interest and investment of state and territory governments.4,27 The funding arrangements for lo- cally initiated outreach services tend to be patchy: funding has often developed relatively opportunistically and its distribution may be inequitable. Some specialists do not receive subsidies for travel associated with outreach,27 whereas others are subsidized by mixed funding – for example, by short-term Commonwealth funding coupled to longer-term state funding – or directly through the health services. Neverthe- less, inequitable funding does not nec- essarily deter professionals from being interested in or having a commitment to outreach. However, with “self-funded” services, in which specialists indepen- dently fund their own transport and accommodation, outreach is likely to be restricted to easily reached locations and the time dedicated to professional support is likely to be limited.27 Although the proportion of spe- cialists providing outreach services to rural areas in Australia is unknown, it appears to be substantial and is increas- ing. Surveys carried out in the late 1990s indicated that 29% of otolaryngologists and 41% of dermatologists based in metropolitan areas provided outreach to rural communities.29,30 The factors that motivated specialists to participate in outreach were the variety of the work professionally, the needs of the rural community and loyalty to rural staff.29,30 Although specialists were willing to provide outreach services for a smaller financial reward than they would receive in metropolitan areas,31 adequate remu- neration for clinical services (at least at the level provided by Medicare) was considered important for sustainabil- ity.27 Bridging the gap in remuneration between specialists’ main practices and their outreach work is vital, particularly for outreach to remote areas.32 A national outreach policy In 1998, following the establishment of national structures for providing policy advice on medical workforce planning three years earlier,33 a discussion paper on sustainable specialist services in Aus- tralia was submitted to the Australian Health Minister’s Advisory Council.34 It advocated outreach as the only means through which many rural communities could obtain access to regular specialist care. The estimated size of the catch- ment area population that was large enough to ensure that outreach work was viable varied from 14 000 to 30 000 people, smaller than that necessary for residential practice (i.e. 20 000 to over 80 000). Moreover, the desirable popu- lation size was similar for different spe- cialties. The main barriers to outreach identified were: (i) the specialist’s travel and accommodation costs and the time needed; (ii) the local clinical infrastruc- ture; and (iii) the availability of staff.34 In May 2000, the Medical Spe- cialist Outreach Assistance Program (MSOAP-Core), a national initiative of the Commonwealth Government, com- menced with an allocated annual budget of approximately 20 million Australian dollars (Aus$), which was equivalent to 12 million United States dollars (US$) at the exchange rate on 3 July 2000. The initial aim was to promote the supply of new rural outreach services by sub- sidizing costs.31 Initially, services that were operating before 2000 – includ- ing those that were already receiving funding from, for example, individual specialists or state or territory govern- ments – were not eligible for funding. In practice, MSOAP-Core complemented other Commonwealth Government pro- grammes. For example, it helped ensure that ophthalmologists were available for the new Eye Health Program.35 In addi- tion, MSOAP-Core provided systematic support for travel, the travel time needed by non-salaried specialists, accommoda- tion and the hire of equipment and fa- cilities. It was well received by specialists contemplating rural service.36 Proposals for new outreach services usually origi- nated at the local level and MSOAP-Core ensured that service delivery was flex- ible. Table 1 gives a broad outline of the administrative steps involved in imple- menting national specialist outreach policy. Subsidies were also provided for meals, cultural training for specialists, back-filling for the specialist’s primary practice (i.e. short-term staff relief for salaried specialists) and improvement of skills (i.e. sharing knowledge with or providing educational support for local staff).37 However, clinical services were not subsidized, which provided an incentive for specialists to achieve a reasonable clinical load. Specialists had the discretion to set charges for services. After the first four years of MSOAP- Core, the Commonwealth Government commissioned an evaluation of the sustainability of outreach services that were not eligible for MSOAP-Core funding in 2000. Despite the lack of Commonwealth Government funding, outreach services had been operating for more than five years in six of eight case studies, principally because of personal investment by specialists and the clear willingness of the community to pay.27 To ensure that these services would be sustainable, the Commonwealth Bull World Health Organ 2014;92:512–519| doi: http://dx.doi.org/10.2471/BLT.13.130385514 Policy & practice Specialist outreach policy in Australia Belinda G O’Sullivan et al. Government expanded eligibility for MSOAP-Core funding to existing ser- vices in May 2004 with the hope that state and territory governments would continue their current levels of invest- ment in outreach services.31 In 2008, after an incoming gov- ernment renewed its commitment to improve the health of indigenous people as a political commitment to equity, a National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes was signed between the Com- monwealth Government and State and Territory Governments. As part of this Agreement, the Commonwealth Gov- ernment provided an additional stream of funding for outreach in 2009 and 2010 through the MSOAP Indigenous Chronic Disease (MSOAP-ICD) pro- gramme. This programme had the same annual budget as MSOAP-Core (i.e. US$ 16 million at the Aus$ exchange rate on 1 July 2009) and targeted remote communities or communities with a high proportion of Aboriginal people, who have high rates of diabetes, car- diovascular disease, chronic respiratory disease, chronic renal disease and can- cer. It funded outreach services based on multidisciplinary teams that included specialists, general practitioners and allied health workers;39 placed a greater emphasis on collaborative and sustained care; supported the local workforce and encouraged improvements in their skills; and encouraged self-management by patients. Subsequently, two further streams of MSOAP funding were intro- duced: one for ophthalmology in 2011 (MSOAP-Ophthalmology) and one for maternity services in 2012 (MSOAP- Maternity). In 2011, an independent national evaluation of all streams of MSOAP funding was commissioned because it was not possible to judge the value of the programme using only self-reported data submitted in bimonthly specialist service reports (Table 1). The evaluation showed that MSOAP was strongly sup- ported by policy-makers, fund-holders, service providers and local staff. In addi- tion, the evaluation identified the need for improvements in: (i) the national framework for assessing the local need for specialists; (ii) the systematic provi- sion of local outreach coordinators; and (iii) national monitoring of specialist outreach.31 Although improving local staff ’s skills was also considered im- portant, it may not have occurred in practice because of competing demands on specialists’ time during short visits.31 The relative effect of MSOAP on improving access to specialist services was assessed using Medicare data and estimates of billing practices in remote areas based on consultations with stake- holders. It was estimated that MSOAP contributed 0.7% to 3.0% of specialist services in inner and outer regional areas, 4.2% in remote areas and 28.7% in very remote areas.31 Geographical areas were defined according to the Australian Standard Geographical Clas- sification Remoteness Structure as either metropolitan, inner regional, outer regional, remote or very remote.40 Case studies in seven local areas showed that, whereas most visiting specialist services in remote areas were provided through MSOAP, a large number in regional areas operated independently.41 This Table 1. Administration of national specialist outreach policy, Australia, 2000–present37,38 Administrative step Associated action A specialist or a rural health organization submits a proposal to the fund holder (i.e. the operational agency in the state or territory government responsible for national specialist outreach policy). The specialist or rural health organization: • proposes a location and commencement date for the service; • describes how the proposed service meets needs; • estimates the size of the visiting team, including students; • describes the proposed clinical services and the actions that will be taken to improve skills; • describes how cultural awareness training will be carried out; • confirms worker registration and indemnity insurance have been arranged; and • proposes a billing method and reports funding from other sources. The fund holder reviews the submission in the context of a regional needs assessment and the regional service plan. The fund holder: • verifies there is a substantial need in the community for the care provided by the specialist; • ensures the proposal is consistent with national policy priorities; • ensures the local workforce and facilities can support and integrate with the proposed service; and • verifies that the proposed service provides value for money. The State or Territory Advisory Forum, which is an impartial representative of the state or territory government, endorses the proposal. The State or Territory Advisory Forum holds regular meetings with the fund holder. The Commonwealth Government approves the proposal and contracts a specialist provider via the fund holder. • A deed of agreement is signed by the Commonwealth Government and the specialist or rural health organization. The fund holder pays the specialist on submission of a bimonthly service report. The specialist reports: • the number of specialist visits completed; • the number of patients seen; • the proportion of patients from indigenous communities; and • the skills improved and the personnel involved. The fund holder reports annually to the Commonwealth Government. The fund holder: • submits an annual report; and • renews contracts for services that were performed well. Bull World Health Organ 2014;92:512–519| doi: http://dx.doi.org/10.2471/BLT.13.130385 515 Policy & practice Specialist outreach policy in AustraliaBelinda G O’Sullivan et al. highlighted the need for strong local coordination of outreach services sup- ported by MSOAP and of those operat- ing independently of national policy, principally in regional centres. The evaluation of MSOAP included a provider survey of 233 specialists. It showed that 59% intended to provide outreach for an additional five years or more. Moreover, 57% of specialists involved in MSOAP normally worked in the private sector: 42% had mixed public and private practices and 15% had private practices only. In addition, 41% were from public hospitals and had a right to private practice in 67% of the cases.42 The estimated annual cost of ad- ministration in 2010 and 2011 for state and territory governments was US$ 1.8 million (at the Aus$ exchange rate valid on 1 July 2010) for MSOAP- Core and US$ 1.3 million (at the Aus$ exchange rate valid on 1 July 2010) for MSOAP-ICD. The total annual cost to the Commonwealth Government was around US$ 0.84 million (at the Aus$ exchange rate valid on 1 July 2010).31 Most costs were staff costs. In July 2012, as a result of the MSOAP evaluation, a streamlined Rural Health Outreach Fund was created to consolidate the funding for outreach provided by MSOAP-Core, MSOAP- Ophthalmology and MSOAP-Maternity. The fund had a value of US$ 28 million per year (at the Aus$ exchange rate valid on 2 January 2014) and funding was separate from that for MSOAP-ICD. However, as with MSOAP-ICD, the priorities of the Rural Health Outreach Fund were aligned with other health- care priorities (e.g. on chronic disease, maternal and paediatric health, mental health and ophthalmology) and a team- based approach to outreach, which included a service coordinator, was adopted.38 The principles underlying the administration of the Rural Health Outreach Fund are similar to those listed in Table 1 but place greater emphasis on performing nationally consistent assess- ments of needs via fund holders. In 2012 and 2013, in response to the growth of fly-in-fly-out work practices in the mining industry in Australia, a national parliamentary inquiry was conducted into the fly-in-fly-out work- force.43 The findings confirmed that out- reach services were important for rural health care in Australia, particularly as a complement to residential services in primary health care. The inquiry con- cluded that a comprehensive national public health policy on outreach was required to tackle the need for: (i) infra- structure, such as staff accommodation and clinical facilities; (ii) streamlined and supported local coordination; (iii) realistic funding that takes into ac- count the true cost of service provision; and (iv) explicit regional planning that incorporates the outreach workforce. Discussion The two broad aims of national special- ist outreach policy in Australia are to support the provision of outreach and to ensure its sustainability. The specific policy aims are: (i) to counter strong market forces that reinforce the central- ization of specialists; (ii) to ensure that remote areas are equitably served by out- reach; (iii) to sustain outreach practice by ensuring its financial viability; and (iv) to influence practice by providing incentives that support the integration of specialist outreach services with lo- cal health services and the provision of professional assistance for local workers. The policy affects specialists who would otherwise fund outreach themselves and who would encounter financial disincentives to providing outreach in remote areas and to improving the skills of local workers. Back-filling support for salaried specialists also fosters outreach by hospital-based specialists. The extent to which specialist outreach services can be provided independently of national policy – for example, by specialists or rural health organizations – has not been explored systematically. Consequently, the influ- ence of national policy on the distribu- tion and practice of outreach has not been evaluated in comparative studies. It is likely that the professional autonomy and personal investment of specialists will remain important for initiating and ensuring the continuity of outreach services. Current national policy, by default, encourages the supply of outreach to areas where there is a legitimate clinical demand because it does not subsidise payment for clinical services. However, although fee-for-service billing arrange- ments improve the efficiency of outreach services, providing specialists with a regular salary or a fixed payment for clinical services in remote and sparsely populated areas might help counterbal- ance any loss of income due to poor attendance or low throughput at clinics in these areas.28 Funding for outreach services is based on proposals from specialists or health organizations and a strong assessment framework is needed to ensure that these proposals address legitimate needs. The establishment of a national outreach service register might help identify where there is an oversup- ply or undersupply of services. Local outreach service coordinators can help reduce costs and improve the efficiency of services by organizing what can be a complex array of interrelated outreach services.28 In addition, coordinators can act as cultural intermediaries who en- sure that outreach services are accessed according to need.44 Outreach has been described as a low-cost, health-care option for resource-constrained countries45 but has also been seen as essential for en- suring universal access to health care.44 International attempts to replicate Aus- tralia’s experience with adaptable and regular outreach have highlighted the need to take into account local patterns of illness, the characteristics of the lo- cal community and the capacity of the local workforce.46 In addition, national policy must consider: political stabil- ity; the structure and funding of the health system; the size of the health-care workforce; remuneration patterns; local transportation and options for retriev- ing patients; and the level of poverty in the local community. The structure and funding of the health services in a country will influence the autonomy of the workforce and hence the ability of workforce members to participate in outreach and their payment for par- ticipating. Dual-practice health-care systems, like Australia’s, are common internationally.47 However, the cost of the outreach policy in Australia is small relative to the national health budget and outreach is made possible by the ex- istence of Medicare.48 In countries with high levels of poverty and high health- care needs that lack universal health insurance, outreach policy may be based on salaried or volunteer workers, a low level of subsidy or mandatory partici- pation. Moreover, the implementation of outreach in resource-constrained nations may require the support of partner nations for technical knowledge and help with equipment, training and mentorship, monitoring and funding.45 International alliances can work well if Bull World Health Organ 2014;92:512–519| doi: http://dx.doi.org/10.2471/BLT.13.130385516 Policy & practice Specialist outreach policy in Australia Belinda G O’Sullivan et al. صخلم ينطو روظنم :اتهايولوأ ديدتحو اهذيفنتو ايلاترسأ في ينيئاصخلأا لصاوت ةسايس دماتعا ام زيزعتل لصاوتلا مادختسا ةيلماعلا ةحصلا ةمظنم تدمتعا ؛ةءافكب ةيحصلا ةياعرلا لامج في ةلماعلا ىوقلا شرن ةداعإ :ليي ينلماعلل ينهلما معدلاو ؛ليحلما ديعصلا لىع ةياعرلا ةيرارمتساو دعتو .يفيرلاو ليحلما نيديعصلا لىع ةيحصلا ةياعرلا لامج في ةسايس ،2000 ماع ذنم ،هيدل دجوت يذلا ديحولا دلبلا ايلاترسأ ينيئاصخلأا لصاوت معد لىإ فدته لصاوتلا نأشب ةمادتسم ةينطو ةسايس دماتعا ةقرولا هذه فصتو .ةيفيرلا قطانلما عم ينيبطلا .اتهايولوأ ديدتحو اهذيفنتو ايلاترسأ في ينيئاصخلأا لصاوتل ةينطو لصاوتلا نم ليوط خيرات جاتن ةينطولا ةسايسلا دماتعا ناكو مازتللااو ينهلما مماتهلاا نع سييئر لكشب جتن يذلا ،حجانلا تامدخ ةسايسلا تمعد ،ةيادبلا فيو .ةلماعلا ىوقلل صيخشلا تامدلخا ةمادتسا نأشب فواخلما نأ يرغ طقف ةديدلجا لصاوتلا تامدخ عيجم لمشيل ليومتلا ةيلهأ قاطن عيسوت اهنع جتن ةمئاقلا ةماقلإاو رفسلا تقوو رفسلا فيلاكت معد متو .ينيئاصخلأا ةيلولأا ينيئاصخلأا تادايع في ينلماعلا ةحارو ينهلما معدلاو سيايسلا مازتللاا نع جتن ،تقولا رورمبو .تادعلما راجئتساو معدلا ةدايز ينيلصلأا ناكسلا جلاع في فاصنلإا يرحتب ينطولا ةنهارلا تايولولأا لثمتتو .ةيئانلا قطانلما في لصاوتلل فدهتسلما )2( ؛قرفلا لىع ةدنتسلما لصاوتلا تامدخ ءاشنإ )1( :ليي مايف )4( ؛ليحلما قيسنتلا قيقتح )3( ؛ليحلما قيرفلا تاراهم ينستح نكملما نمو .ًاينطو قستم وحن لىع تاجايتحلال مييقت ءارجإ هب موقي يذلا يريسرلا لمعلل ةمدقلما تاناعلإا بايغ يدؤي نأ ميدقت نع صالخا عاطقلا في ينيئاصخلأا ءانثإ لىإ نويئاصخلأا قافنلإا لياجمإ اهيف ضفخني يتلا ةيئانلا قطانلما في تامدلخا عم لصاوتلا ةسايس قستت نأ بيج ،اهحاجن نماضلو .يريسرلا ديعصلا لىعو .ينهلما للاقتسلاا معدو ةلماعلا ىوقلا تامماتها بتاورلا نابسلحا في لصاوتلا ةسايس عضو ذخأي نأ بيج ،ليودلا .ةسرمالما فورظو ينيحصلا ينلماعلل ةيلحلما 摘要 澳大利亚专科医生外展政策的采用、实施和优先落实：国家视角 世界卫生组织一直都支持使用外展以便推进 ：医疗劳 动力的有效调动 ；护理在地方层面上的连续性 ；对地 方、农村卫生医护人员的专业支持。澳大利亚是唯一 自 2000 年以来一直提供可持续外展政策的国家，该政 策为在农村地区开展外展服务的专科医生提供补贴。 本文描述澳大利亚国家专科医生外展政策的采用、实 施和优先落实。采用国家政策之后，外展取得长期的 成功，这在很大程度上是由工作人员的职业兴趣和个 人奉献驱动的。最初，政策只支持新的外展服务，但 因为考虑到现有服务的可持续性，资助资格扩展至所 有专科医生服务。对差旅、差旅时间、住宿、专业支持、 专科医生的主要工作的员工助济和设备租用的费用进 行补贴。久而久之，公平对待原住民的全国性政治承 诺促进了偏远地区更有针对性的外展支持。当前的优 先顺序是 ：(i) 建立基于团队的外展服务 ；(ii) 提高当 地工作人员技能 ；(iii) 实现当地协调 ；(iv) 执行全国一 致的需求评估。如果专科医生临床工作无补贴，则会 打击私人专科医生在临床产出较低的偏远地区提供服 务的积极性。要想取得成功，外展政策必须与工作人 员利益相协调，并对专业自主权提供支持。在国际上， 外展政策的制定必须考虑卫生工作人员的当地工资和 实践条件。 Résumé Adoption, mise en œuvre et priorisation de la politique de proximité spécialisée en Australie: un point de vue national L’Organisation mondiale de la Santé a approuvé l’utilisation de services de proximité pour promouvoir: le redéploiement efficace du personnel des soins de santé; la continuité des soins au niveau local; et le support professionnel au personnel de santé local et rural. L’Australie est le seul pays qui possède, depuis l’an 2000, une politique nationale soutenue de services de proximité afin de subventionner la présence de médecins spécialistes dans les zones rurales. Cet article décrit l’adoption, la mise en œuvre et la priorisation d’une politique nationale de proximité spécialisée en Australie. L’adoption de cette politique nationale a fait suite à une longue histoire de services de proximité dont la réussite est largement attribuable à l’intérêt professionnel et à l’engagement personnel des professionnels de santé. À l’origine, cette politique soutenait seulement les nouveaux services de proximité, mais les préoccupations concernant la durabilité des services existants ont abouti à l’extension de l’admissibilité au financement à tous les services spécialisés. Les coûts des déplacements, des temps de déplacement, d’hébergement, du soutien professionnel, de personnel de remplacement dans les cabinets primaires des médecins spécialistes et de la location d’équipement ont été subventionnés. Au fil du temps, l’engagement politique national pour le traitement équitable they address programmes at a systemic level, engage with local staff and are responsive to local circumstances.49 For example, the Fred Hollows Foundation in Australia, a not-for-profit agency, has promoted outreach internationally by offering leadership, providing strong collaboration and focusing on capac- ity building.50 Globally, such alliances often benefit outreach workers, many of whom practice under extremely difficult conditions.45 In Australia, national policy sup- ports the supply of specialist outreach services and helps ensure their sustain- ability while making sure that they are aligned with national health-care priori- ties. The policy’s success is underpinned by interested specialists who, given the right support, may initiate and sustain outreach. It is essential that outreach policy be coupled to the systematic as- sessment of local health-care needs, take into account local health-care organiza- tion and funding, and be implemented in accordance with the interests of the workforce. ■ Competing interests: None declared. Bull World Health Organ 2014;92:512–519| doi: http://dx.doi.org/10.2471/BLT.13.130385 517 Policy & practice Specialist outreach policy in AustraliaBelinda G O’Sullivan et al. des populations autochtones a entraîné un soutien plus ciblé pour acheminer les services de médecine mobile dans les zones reculées. Les priorités actuelles sont: (i) l’établissement de services de proximité en équipe; (ii) l’amélioration des compétences des professionnels locaux; (iii) la réalisation de la coordination locale; et (iv) la conduite d’une évaluation cohérente des besoins à l’échelle nationale. L’absence de subventions pour le travail clinique des médecins spécialistes peut décourager les médecins spécialistes privés de venir soigner dans les zones éloignées où le rendement clinique est faible. Pour qu’elle réussisse, la politique de proximité doit s’harmoniser avec les intérêts des professionnels de santé et soutenir l’autonomie professionnelle. À l’échelle internationale, le développement de politiques de proximité doit tenir compte du salaire local et des conditions d’exercice des professionnels de la santé. Резюме Принятие, осуществление и определение приоритетов политики выездного обслуживания специалистами в Австралии: национальная перспектива Всемирная организация здравоохранения одобрила использование выездного обслуживания для способствования эффективному перераспределению медицинских кадров, преемственности оказания медицинской помощи на местном уровне, а также для профессиональной поддержки местных и сельских медицинских работников. Австралия — это единственная страна, в которой с 2000 года проводится национальная политика выездного обслуживания с целью субсидирования выездного обслуживания медицинскими специалистами сельских районов. В данной статье описывается принятие, осуществление и определение приоритетов в национальной политике выездного обслуживания специалистами в Австралии. Национальная политика была принята после длительного периода осуществления выездного обслуживания, успех которого в значительной степени был обусловлен профессиональным интересом и личной приверженностью работников. Изначально в рамках политики поддержка оказывалась только новым видам выездного обслуживания, но опасения относительно развития существующих услуг привело к распространению права на финансирование всех видов услуг специалистов. Осуществлялось субсидирование затрат на проезд, время в пути, проживание, профессиональное обслуживание, высвобождение персонала в первичных учреждениях практикующих врачей-специалистов и аренду оборудования. Со временем национальная политическая приверженность принципу равного отношения к коренным народам привела к более адресной поддержке выездного обслуживания в отдаленных районах. В настоящее время приоритетами являются: (i) введение услуг выездного обслуживания коллективом специалистов; (ii) повышение квалификации местного персонала; (iii) осуществление координации на местном уровне и (iv) проведение последовательной оценки потребностей на национальном уровне. Отсутствие субсидий для поддержки клинической работы специалистов может препятствовать предоставлению услуг частными специалистами в отдаленных районах с низкой клинической пропускной способностью. Для обеспечения успешности политики выездного обслуживания она должна согласовываться с интересами работников и поддерживать профессиональную автономию. На международном уровне при развитии политики выездного обслуживания необходимо учитывать уровень оплаты труда на местах и условия практической работы медицинского персонала. Resumen La adopción, implementación y prioridad de una política de difusión de especialistas en Australia: una perspectiva nacional La Organización Mundial de la Salud ha aprobado el uso de la difusión con el objetivo de promover la reasignación eficiente del personal sanitario, la continuidad de la atención a nivel local y el apoyo profesional para el personal sanitario a nivel local y rural. Australia es el único país que ha mantenido, desde el año 2000, una política nacional continuada en materia de subvención de la difusión de especialistas médicos en las zonas rurales. Este artículo describe la adopción, implementación y prioridad de la política de difusión de especialistas en dicho país. La adopción de la política nacional obedeció a un largo historial de difusión con buenos resultados, impulsado en gran parte por el interés profesional y el compromiso personal de los trabajadores. En un principio, la política apoyaba únicamente los servicios de difusión nuevos, pero la preocupación acerca de la sostenibilidad de los servicios existentes auspició una ampliación de la financiación a la totalidad de los servicios especializados. Se subvencionaron los costes y el tiempo de viaje, el alojamiento, el apoyo profesional, la asistencia al personal en los consultorios principales de los especialistas y el alquiler de equipos. Con el tiempo, el compromiso político nacional respecto al trato equitativo de los pueblos indígenas se tradujo en un apoyo más específico para la difusión en las áreas más alejadas. Las prioridades actuales son: (i) establecer servicios periféricos por equipos, (ii) mejorar las capacidades del personal local, (iii) lograr la coordinación local y (iv) llevar a cabo una evaluación cohesiva de las necesidades a nivel nacional. La ausencia de subsidios para el trabajo clínico de los especialistas puede disuadir a los especialistas privados de prestar servicios en zonas remotas, en las que el rendimiento clínico es bajo. Para resultar satisfactoria, la política de difusión debe armonizar los intereses del personal y apoyar la autonomía profesional. A nivel internacional, el desarrollo de una política de divulgación debe tener en cuenta los salarios y las condiciones locales de los miembros del personal sanitario. References 1. de Roodenbeke E, Lucas S, Rouzaut A, Bana F. Outreach services as a strategy to increase access to health workers in remote and rural areas (Technical Report No. 2). Geneva: World Health Organization and International Hospital Federation; 2011. Available from: http://whqlibdoc. who.int/publications/2011/9789241501514_eng.pdf [cited 2013 Aug 30]. 2. Increasing access to health workers in remote and rural areas through improved retention: global policy recommendations. Geneva: World Health Organization; 2010. Available from: http://whqlibdoc.who.int/ publications/2010/9789241564014_eng.pdf [cited 2013 Aug 30]. 3. Dolea C, Stormont L, Braichet J-M. Evaluated strategies to increase attraction and retention of health workers in remote and rural areas. Bull World Health Organ. 2010;88:379-85. doi: http://dx.doi.org/10.2471/ BLT.09.070607 PMID: 20461133 4. Gruen RL, Weeramanthri TS, Bailie RS. Outreach and improved access Bull World Health Organ 2014;92:512–519| doi: http://dx.doi.org/10.2471/BLT.13.130385518 Policy & practice Specialist outreach policy in Australia Belinda G O’Sullivan et al. to specialist services for indigenous people in remote Australia: the requirements for sustainability. J Epidemiol Community Health. 2002;56:517-21. doi: http://dx.doi.org/10.1136/jech.56.7.517 PMID: 12080159 5. Carson PJ. Providing specialist services in Australia across barriers of distance and culture. World J Surg. 2009;33:1562-7. doi: http://dx.doi.org/10.1007/ s00268-009-0088-1 PMID: 19495863 6. Gruen RL, Bailie RS, Wang Z, Heard S, O’Rourke IC. Specialist outreach to isolated and disadvantaged communities: a population-based study. Lancet. 2006;368:130-8. doi: http://dx.doi.org/10.1016/S0140- 6736(06)68812-0 PMID: 16829297 7. Taylor HR, Fox SS, Xie J, Dunn RA, Arnold AL, Keeffe JE. The prevalence of trachoma in Australia: the National Indigenous Eye Health Survey. Med J Aust. 2010;192:248-53. PMID: 20201757 8. Rothstein J, Heazlewood R, Fraser M; Paediatric Outreach Service. Health of Aboriginal and Torres Strait Islander children in remote far north Queensland: findings of the Paediatric Outreach Service. Med J Aust. 2007;186:519-21. PMID: 17516899 9. Tibby D, Corpus R, Walters DL. Establishment of an innovative specialist cardiac indigenous outreach service in rural and remote Queensland. Heart Lung Circ. 2010;19:361-6. doi: http://dx.doi.org/10.1016/j.hlc.2010.02.023 PMID: 20381420 10. Rural, regional and remote health: indicators of health system performance (Rural Health Series No. 10) [Internet]. Canberra: Australian Institute of Health and Welfare; 2008. Available from: http://www.aihw.gov.au/ WorkArea/DownloadAsset.aspx?id=6442459852 [cited 2013 Aug 30]. 11. Margolis SA, Ypinazar VA. Aeromedical retrieval for critical clinical conditions: 12 years of experience with the Royal Flying Doctor Service, Queensland, Australia. J Emerg Med. 2009;36:363-8. doi: http://dx.doi. org/10.1016/j.jemermed.2008.02.057 PMID: 18814993 12. Garne DL, Perkins DA, Boreland FT, Lyle DM. Frequent users of the Royal Flying Doctor Service primary clinic and aeromedical services in remote New South Wales: a quality study. Med J Aust. 2009;191:602-4. PMID: 20028276 13. Medical workforce 2011 (National Health Workforce Series No. 3) [Internet]. Canberra: Australian Institute of Health and Welfare; 2013. Available from: http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129542629 [cited 2013 Sep 13]. 14. Cord-Udy N. Remote area indigenous psychiatry: not your usual day at the office. Australas Psychiatry. 2006;14:295-9. doi: http://dx.doi.org/10.1080/ j.1440-1665.2006.02288.x PMID: 16923042 15. Rankin SL, Hughes-Anderson W, House AK, Heath DI, Aitken RJ, House J. Costs of accessing surgical specialists by rural and remote residents. ANZ J Surg. 2001;71:544-7. doi: http://dx.doi.org/10.1046/j.1440- 1622.2001.02188.x PMID: 11527266 16. Harris MG. Specialist medical services for rural and remote Australians. Wollongong: University of Wollongong; 1992. 17. Alexander C, Fraser J. Medical specialists servicing the New England Health Area of New South Wales. Aust J Rural Health. 2001;9:34-7. doi: http:// dx.doi.org/10.1046/j.1440-1584.2001.00317.x PMID: 11703265 18. Gorton SM, Buettner PG. Why paediatricians rural out going to the country but support opportunities for change. J Paediatr Child Health. 2001;37:113- 7. doi: http://dx.doi.org/10.1046/j.1440-1754.2001.00655.x PMID: 11328463 19. Robinson M, Slaney GM, Jones GI, Robinson JB. GP proceduralists: ‘the hidden heart’ of rural and regional health in Australia. Rural Remote Health. 2010;10:1402. PMID: 20722462 20. Glazebrook RM, Harrison SL. Obstacles and solutions to maintenance of advanced procedural skills for rural and remote medical practitioners in Australia. Rural Remote Health. 2006;6:502. PMID: 17107272 21. Cheng TC, Scott A, Jeon S-H, Kalb G, Humphreys J, Joyce C. What factors influence the earnings of general practitioners and medical specialists? Evidence from the medicine in Australia: balancing employment and life survey. Health Econ. 2012;21:1300-17. doi: http://dx.doi.org/10.1002/ hec.1791 PMID: 21919116 22. Cheng TC, Joyce CM, Scott A. An empirical analysis of public and private medical practice in Australia. Health Policy. 2013;111:43-51. doi: http:// dx.doi.org/10.1016/j.healthpol.2013.03.011 PMID: 23602546 23. Croser JL. Trauma care systems in Australia. Injury. 2003;34:649-51. doi: http://dx.doi.org/10.1016/S0020-1383(03)00157-8 PMID: 12951287 24. Taylor BL, Biggs WW. Anaesthesia and the flying surgeon service 25 years on. Br Med J (Clin Res Ed). 1987;294:233-5. doi: http://dx.doi.org/10.1136/ bmj.294.6566.233 PMID: 3101824 25. Taylor HR. Trachoma in Australia. Med J Aust. 2001;175:371-2. PMID: 11700815 26. Broadbent A, McKenzie J. Wagga Wagga specialist outreach palliative medicine service: a report on the first 12 months of service. Aust J Rural Health. 2006;14:219-24. doi: http://dx.doi.org/10.1111/j.1440- 1584.2006.00813.x PMID: 17032299 27. Gadiel D, Ridoutt L, Bune A, Cheang C, Cook K, Thiele D. Evaluation of outreach models of medical specialist service delivery. Sydney: Human Capital Alliance International; 2004. Available from: http://www. humancapitalalliance.com.au/downloads/DH28%20Specialist%20 outreach%20model%20evaluation.PDF [cited 2013 Jul 23]. 28. Turner AW, Mulholland WJ, Taylor HR. Coordination of outreach eye services in remote Australia. Clin Experiment Ophthalmol. 2011;39:344-9. doi: http:// dx.doi.org/10.1111/j.1442-9071.2010.02474.x PMID: 21105975 29. The ear, nose and throat surgery workforce in Australia: supply and requirements 1997-2007 (AMWAC Report 1997.6). Sydney: Australian Medical Workforce Advisory Committee; 1997. Available from: http://www. ahwo.gov.au/documents/Publications/1997/The%20ear%20nose%20 and%20throat%20surgery%20workforce%20in%20Australia.pdf [cited 2013 Sep 13]. 30. The specialist dermatology workforce in Australia: supply, requirements and projections 1997–2007 (AMWAC Report 1998.1). Sydney: Australian Medical Workforce Advisory Committee; 1998. Available from: http:// www.ahwo.gov.au/documents/Publications/1998/The%20specialist%20 dermatology%20workforce%20in%20Australia.pdf [cited 2013 Sep 13]. 31. Evaluation of the Medical Specialist Outreach Assistance Program and the Visiting Optometrists Scheme – final report. Volume 1 [Internet]. Canberra: Department of Health and Ageing; 2011. Available from: http:// www.ruralhealthaustralia.gov.au/internet/rha/publishing.nsf/Content/ Evaluation_of_the_Medical_Specialist_Outreach_Assistance_Program_ and_the_Visiting_Optometrists_Scheme_Final_Report [cited 2013 Aug 30]. 32. Turner AW, Mulholland W, Taylor HR. Funding models for outreach ophthalmology services. Clin Experiment Ophthalmol. 2011;39:350-7. doi: http://dx.doi.org/10.1111/j.1442-9071.2010.02475.x PMID: 21105976 33. Australian Medical Workforce Advisory Committee. Medical workforce planning in Australia. Aust Health Rev. 2000;23:8-26. PMID: 11256274 34. Sustainable specialist services: a compendium of requirements (AMWAC Report 1998.7). North Sydney: Australian Medical Workforce Advisory Committee; 1998. Available from: http://www.ahwo.gov.au/documents/ Publications/1998/Sustainable%20specialist%20services%20-%20A%20 compendium%20of%20requirements.pdf [cited 2013 Aug 15]. 35. Jones J, Henderson G, Poroch N, Anderson I, Taylor H. A critical history of indigenous eye health policy-making: towards effective system reform. Melbourne: Indigenous Eye Health Unit, Melbourne School of Population Health, University of Melbourne; 2011. Available from: http://iehu.unimelb. edu.au/?a=459851 [cited 2013 Aug 30]. 36. Cord-Udy N. The Medical Specialist Outreach Assistance Programme in South Australia. Australas Psychiatry. 2003;11:189-94. doi: http://dx.doi. org/10.1046/j.1039-8562.2003.00532.x PMID: 15715762 37. Medical Specialist Outreach Assistance Program. Guidelines. Canberra: Department of Health and Ageing; 2007. Available from: http://www. dhhs.tas.gov.au/__data/assets/pdf_file/0020/8606/MSOAP_Guidelines_ February_2007.pdf [cited 2013 Aug 19]. 38. Rural Health Outreach Fund. Service delivery standards: rural and regional health Australia. Canberra: Department of Health and Ageing; 2012. Available from: http://www.checkup.org.au/icms_docs/162955_ STANDARDS_RHOF_Service_Delivery_Standards.pdf [cited 2013 Sep 14]. 39. Medical Specialist Outreach Assistance Program. Indigenous chronic disease 2009–2013: guidelines. Canberra: Department of Health and Ageing; 2010. Available from: http://www.health.gov.au/internet/ctg/ publishing.nsf/AttachmentsByTitle/MSOAP-ICD-guidelines.pdf/$FILE/ MSOAP-ICD-guidelines.pdf [cited 2013 Aug 14]. 40. The Australian Statistical Geography Standard (ASGS) Remoteness Structure [Internet]. Canberra: Australian Bureau of Statistics; 2011. Available from: http://www.abs.gov.au/websitedbs/d3310114.nsf/home/ remoteness+structure [cited 2013 Aug 29]. 41. Health Policy Analysis. Evaluation of the Medical Specialist Outreach Assistance Program and the Visiting Optometrists Scheme. Final report, volume 2 (Community Case Studies V0.2). Canberra: Department of Health and Ageing; 2011. Available from: http://www.ruralhealthaustralia.gov. au/internet/rha/publishing.nsf/Content/CA2578FF004C26B7CA257AA1 001ED300/$File/DoHA-Evaluation_of_MSOAP_and_VOS_final_report_ Volume%202.pdf [cited 2013 Aug 30]. Bull World Health Organ 2014;92:512–519| doi: http://dx.doi.org/10.2471/BLT.13.130385 519 Policy & practice Specialist outreach policy in AustraliaBelinda G O’Sullivan et al. 42. Health Policy Analysis. Evaluation of the Medical Specialist Outreach Assistance Program and the Visiting Optometrists Scheme. Final report, volume 3. Canberra: Department of Health and Ageing; 2011. Available from: http://www.ruralhealthaustralia.gov.au/internet/rha/publishing.nsf/ Content/CA2578FF004C26B7CA257AA1001ED300/$File/DoHA-Evaluation_ of_MSOAP_and_VOS_final_report_Volume%202.pdf [cited 2013 Aug 30]. 43. Cancer of the bush or salvation for our cities? Fly-in, fly-out and drive-in, drive-out workforce practices in regional Australia [Internet]. Canberra: Parliament of Australia; 2013. Available from: http://www.aph.gov. au/parliamentary_business/committees/house_of_representatives_ committees?url=ra/fifodido/report.htm [cited 2013 Aug 15]. 44. Finger RP, Kupitz DG, Holz FG, Chandrasekhar S, Balasubramaniam B, Ramani RV, et al. Regular provision of outreach increases acceptance of cataract surgery in South India. Trop Med Int Health. 2011;16:1268-75. doi: http://dx.doi.org/10.1111/j.1365-3156.2011.02835.x PMID: 21718395 45. Needle RH, Burrows D, Friedman SR, Dorabjee J, Touzé G, Badrieva L, et al. Effectiveness of community-based outreach in preventing HIV/AIDS among injecting drug users. Int J Drug Policy. 2005;16:45-57. doi: http://dx.doi. org/10.1016/j.drugpo.2005.02.009 46. Katz IJ, Hoy WE, Kondalsamy-Chennakesavan S, Gerntholtz T, Scheppingen J, Sharma S, et al. Chronic kidney disease management – what can we learn from South African and Australian efforts? Blood Purif. 2006;24:115-22. doi: http://dx.doi.org/10.1159/000089447 PMID: 16361851 47. García-Prado A, González P. Policy and regulatory responses to dual practice in the health sector. Health Policy. 2007;84:142-52. doi: http://dx.doi. org/10.1016/j.healthpol.2007.03.006 PMID: 17449134 48. The Commonwealth of Australia. Budget: portfolio budget statements 2013–14 (Budget Related Paper No. 1.10). Human services portfolio. Canberra: Australian Government; 2013. Available from: http://www. humanservices.gov.au/spw/corporate/publications-and-resources/ budget/1314/resources/2013-14-dhs-pbs.pdf [cited 2013 Dec 8]. 49. Aveling E-L, Martin G. Realising the transformative potential of healthcare partnerships: insights from divergent literatures and contrasting cases in high- and low-income country contexts. Soc Sci Med. 2013;92:74-82. doi: http://dx.doi.org/10.1016/j.socscimed.2013.05.026 PMID: 23849281 50. Moran D. 20 years of the Fred Hollows Foundation. Med J Aust. 2012;197:244-5.doi: http://dx.doi.org/10.1016/j.socscimed.2013.05.026 PMID: 23849281