Australian Dental Journal
The official journal of the Australian Dental Association
Australian Dental Journal 2014; 59: 187–192 doi: 10.1111/adj.12162
A decade of experience evolving visiting dental services in partnership with rural remote Aboriginal communities K Dyson,* E Kruger,* M Tennant* *International Research Collaborative–Oral Health and Equity, The University of Western Australia.
ABSTRACT Background: Embedding research capabilities and workforce development activities with clinical service entities promotes the development of sustainable, innovative, quality-focused oral health care services. Clinical and strategic governance is an important area of consideration for rural and remote dental services, posing particular challenges for smaller service structures. Sustaining remote area dental services has some significant complexities beyond those involved in urban service models. Methods: This study describes the sustaining structure of a remote area dental service with a decade of history. Results: In the current climate, chief among these challenges may be those associated with dental workforce shortages as these impact most heavily in the public sector, and most particularly, in remote areas. As sustained workforce solutions come from developing a future workforce, an essential element of the workforce governance framework for remote dental service provision should be the inclusion of a student participation programme. Collaborative partnership approaches with Aboriginal health services promote the development and maintenance of effective, culturally sensitive dental services within rural and remote Aboriginal communities. Having sustained care for 10 years, this collaborative model of integrated research, education and service has demonstrated its effectiveness as a service model for Aboriginal communities in Western Australia. Conclusions: This descriptive study finds the core values for this success have been communication, clinical leadership, mentorship within effective governance systems all linked to an integrated education and research agenda. Keywords: Governance, remote areas, services. (Accepted for publication 20 August 2013.)
INTRODUCTION Over the last 15 years, Australia has experienced an increasing oral health workforce shortage with some projections indicating a significant workforce maldistribution will continue for at least the next 10 years.1 Workforce shortage, most acutely experienced in many areas of rural and remote Australia, is exacerbated by the pooling of dentists in capital cities,2 resulting in a significant lack of access to oral health care in many remote areas.3 Although the shortage is most acute among public sector services (providing care for schoolchildren and disadvantaged people), the private sector in rural areas has also been struggling with shortages for a long time. The establishment of Australia’s three newest dental schools in regional areas, as well as growing rural interest among existing dental schools, is expected to help strengthen the focus of this country’s oral health workforce on rural and remote areas.4 However, © 2014 Australian Dental Association
despite these and other remote workforce development strategies, dental service provision challenges in rural and remote areas are expected to continue well into the future. It is well known that dental disease is strongly linked to socio-economic deprivation, with people from lower socio-economic backgrounds suffering greater disease burdens than more advantaged people.5,6 Indigenous Australians (Aboriginal and Torres Strait Islander people) are reported to suffer even greater dental disease burdens (caries, periodontal disease and more complex conditions) than their similarly disadvantaged non-Indigenous counterparts.5,7 Australia’s rural and remote areas are home to disproportionately large numbers of socio-economically disadvantaged people including relatively large numbers of Indigenous people.8 In fact, approximately half of Australia’s Indigenous population live in rural and remote areas, with a considerable number living in small, disparate and isolated communities. This 187
K Dyson et al. sparse, widespread distribution of people with increased care needs poses challenges for the public oral health service providers charged with responsibility for these regions. It is against this background of high dental disease levels and protracted workforce shortage that new approaches to sustainable service provision for rural and remote areas have begun emerging.9 Involvement in exploring solutions has broadened beyond the traditional domain of public sector oral health services to include the Aboriginal health sector, universities, nongovernment organizations and volunteer groups.10 This study describes a decade of experience in establishing visiting oral health services in partnership with rural and remote Aboriginal communities in Western Australia. An integrated service, education and research model Over 10 years ago, the Centre for Rural and Remote Oral Health was established at The University of Western Australia to provide a leadership focus on rural, remote and Indigenous oral health issues in Western Australia. A cornerstone of the Centre’s foundation was the integration of education and research activities with clinical service provision. This integrated service approach, a unique approach within the Australian dental service context of the time, is seen as pivotal to the successes achieved. Over the first two years of operation, the Centre focused on establishing core student education programmes, initiating foundational research activities and developing clinical approaches and systems at two service centres. Over the following years, clinics were established in a further four communities and recruitment, placement, health worker education programmes and clinical activities were reviewed and refined in concert with expanding research activities. Research-service integration The rigour of ongoing analysis of service activities using scientific methods is acknowledged internationally as adding benefit to services, supporting processes for timely system adaptation and high quality care. It is clear from the recent Strategic Review of Health and Medical Research, that the decoupling of research from health care service is becoming more widely recognized as a significant flaw in the wider Australian health care landscape. This has led to calls for the development of much stronger research-service nexus driven health care improvement systems.11 Research and population health expertise was seen as essential in providing the scientific grounding to support many of the Centre’s clinical and educational activities. In addition to supporting the collection, collation and 188
analysis of the key burden of disease data, research capabilities enabled the publication of findings, broadening opportunities for national and international interpretation, and thereby adding value to the wider community.12 Research capacity can also enhance a service provider’s ability to attract and retain high quality clinicians to participate in service provision.13 Many research initiatives from the Centre were generated through clinical questions developed within the research-service nexus. Among these is a study exploring Western Australian hospitalizations for the treatment of oral malignancy14 and an investigation of rural preschooler oral health revealing significant dental pain and unmet care needs, particularly among Indigenous children.15 A review of Western Australia’s rural oral health workforce provides information to inform workforce development strategies and identify a potential untapped rural workforce among underemployed rural dental therapists.16 Education-service integration The introduction of Indigenous cross-cultural education and rural and remote placements to dental undergraduate training in Western Australia are two leading education initiatives arising from the Centre.17 These pioneering steps have been introduced by dental schools Australia-wide and have become pillars of national rural and Indigenous dental workforce development strategies. The international literature acknowledges two fundamental tenets of developing rural and remote workforce: firstly, students from a rural background are more likely to return to rural practice. Secondly, and of more importance to this discussion, the more exposure students have to rural practice, the more likely they are to practice in a rural area at some stage in their career and the greater their empathy for the complex nature of care provision in these areas.17 It is clear from our experience that student participation and engagement does provide return workforce, and therefore an essential element of the workforce governance framework for remote service provision should be the inclusion of a student participation programme. It is evident that vertically integrated participation of students in rural service provision activities provides workforce sustainability.10 Clinical service in partnership with Aboriginal health services Recognition of the importance of cultural security in Aboriginal health care was central to the decision to partner with Aboriginal health services in service provision. Six dental services were developed within community-controlled Aboriginal health services in © 2014 Australian Dental Association
Remote visiting dental services outer regional, remote and very remote areas (according to the Australian Standard Geographical Classification – Remoteness Area). Such a strongly collaborative approach to state-funded Aboriginal oral health service introduced a new paradigm to Western Australia (and much of Australia). Aboriginal health services present a non-threatening, culturally secure environment that Indigenous people are comfortable attending. This environment supports the maintenance of close service-community relationships and fosters cultural exchange and shared learning, all of which are crucial for the success of visiting remote services Equally important are the enormous logistical supports that community-run services can offer as these immeasurably strengthen visiting service capabilities. Among these supports are intimate community knowledge and community liaison, patient transport, reception and health worker support, the ability for opportunistic and integrated health care provision, access to accurate and comprehensive medical and social history information (with appropriate consent processes). Visiting services need close relationships with the community-based health services as this facilitates effective and integrated health care provision and also provides an important source of professional and social support for visiting practitioners. Local and Indigenous capacity building in oral health Consideration of issues related to local capacity building in oral health are important for visiting remote service providers and rural and remote communities alike. Remote health service staff are required to manage acute dental issues between clinical visits. By virtue of their in-depth community knowledge and continuous presence, they may also be best positioned to implement oral health promotion activities. The establishment of close relationships with community health services facilitates the identification and development of opportunities for integrating oral health promotion with local primary health care health programmes such as diabetes programmes, maternal and early childhood programmes, and others. However, it is important for visiting service providers to appreciate that rural and remote health services may be limited in their capacity to participate in oral health capacity enhancing activities,18 particularly in the more remote areas where skilled workforce shortages are often most acute. The Centre’s educational expertise assisted the development of oral health education resources in collaboration with Indigenous communities and was also instrumental in the establishment of Aboriginal health worker capacity building programmes in oral health education19 and dental assisting. Flexible, tailored learning structures in dental assisting were created © 2014 Australian Dental Association
ranging from short on the job training modalities to more comprehensive certificate-level programmes incorporating online learning packages. On the job training was undertaken within the visiting clinical programme achieving highly successful outcomes in all health services where it was established. Embedding dental clinics within Aboriginal health services also provides a pathway for the development of Indigenous capacity in oral health service governance, building foundations for future transition to sustainable community-run services. Service design The service design involved the establishment of fixed dental clinics in community-run Aboriginal health services providing primary oral health services within an environment of enhanced local preventive oral health capability. The current climate of relatively low and decreasing dental capital equipment cost has created new opportunities for multiple, fixed services approaches to the challenge of service provision for disparate, remote populations. A dental van approach, popularized in the 1970s and 1980s, was avoided for many reasons, chief amongst these being the implications of the changed landscape of contemporary occupational health and safety on the viability of this approach. This, coupled with a generational shift in work environment culture among new graduates, accessibility limitations due to remote road surfaces and weather conditions and the known challenges with high maintenance issues in remote areas (electric dental equipment is highly susceptible to vibration damage in remote transit), favoured a fixed clinic approach. Visiting service logistics were designed with a focus on workforce sustainability considerations, together with issues of cost-efficiency and community need. A capital city based model was developed, providing communities with regular service access and continuity of care provider whilst enabling clinicians to spend most weekends at home. The large travel distances involved with service locations in outer regional, remote and very remote areas called for a fly-in approach on cost-effective grounds and safety concerns of long distance country driving. The model was refined over time to provide a robust, systematic approach with cost-effective management of a visiting service model applicable to dentists from a range of backgrounds, including new graduates and more experienced clinicians.7 Workforce sustainability In times of dental workforce shortage, sustainable recruitment and retention of suitable dental professionals is among the most significant challenges faced by the 189
K Dyson et al. rural and remote public oral health sector. The Centre found developing a vertically integrated approach to workforce development to be instrumental in sustaining workforce over the decade. Offering rural and remote clinical placements and a rural graduate training programme created opportunities for students and graduates to expand their knowledge and experience by building on interest stimulated in earlier years. By closely integrating research and education activities with its clinical service models, the Centre was able to offer undergraduates and newly graduated an experience that was at the forefront of internship models in dentistry in Australia and thereby attract high achieving graduates in excess of available positions. The success of early placements quickly led to students becoming integral visiting team members (supported by appropriate orientation and mentoring processes). This was a winning situation affording students highly valued learning opportunities with exposure to Indigenous oral health issues whilst creating enjoyable mentoring opportunities for clinicians and reducing the Centre’s remote auxiliary staffing requirements. Attending to workforce retention is as important as addressing recruitment issues. Creating a positive culture and working experience is integral to maintaining a flow of high quality clinicians, which is vital to the future of the service. As many clinicians are out of their comfort zone when participating in remote dental services, the service provider needs to provide systems of appropriate clinical and social support. Essential requirements include suitably comprehensive and responsive orientation and mentoring processes and ensuring that a clear pathway exists to enable practitioners to address concerns promptly. The Centre found that the social, logistical and professional supports that flow from establishing dental services within a broader health setting to be of immeasurable benefit in sustaining remote services. Governance frameworks Clinical governance It is widely acknowledged that clinical care provision in remote environments brings a heightened level of clinical risk.20 This risk is magnified in situations where clinicians change regularly and may have minimal experience (or experiences limited to city based practice). It is against this backdrop that a strong clinical risk framework needs to be in place to support high quality remote dental service. Clinicians participating in remote visiting services require orientation to the social and cultural circumstances involved in remote practice as well as the 190
clinical environment, including the clinical care framework and quality assurance and improvement processes. The service provider needs a robust boundary setting approach to care, ensuring that care provided is consistent with patient needs, but at the same time does not extend beyond an envelope of risk that is safe for the particular setting. Appropriateness of practice scope is influenced by clinical experience and expertise as well as environmental factors such as equipment, access to backup support and follow-up care among other factors. Most remote service clinicians acknowledge that significant gains in sustainability and quality are achieved from the inclusion of experienced mentoring for newer participants, regardless of clinical experience and expertise. A strong systematic approach to the collection, collation, evaluation and feedback of clinical data, is an essential part of sustaining good clinical quality measures in any setting, with remote visiting services no exception.21 Systems are also needed for prioritizing care according to clinical need and ensuring equitable service access in situations where demand exceeds service capacity, as is frequently the case in remote areas. The increased vulnerability of remote communities associated with unequal power relationships calls for heightened quality assurance processes among health service providers which must include feedback systems for evaluating how well the service is meeting the community’s needs and expectations. Strategic governance One of the keys to providing sustained high quality visiting dental services in remote areas is a clear centralized governance framework. Small remote organizations with limited dental experience put themselves and their community at risk by ‘going it alone’ in service provision. Although the drivers for them to act independently may be strong (longstanding inadequacy of services), the governance frameworks that are essential to providing timely and sustained high quality services are relatively complex and have discipline-specific nuances that are often not inherently evident to health service managers and/or small community organizations. The development and maintenance of a small, nimble, highly experienced central governance organizational structure that supports services in remote areas can ensure the quality of care as well as provide solutions to sustainability. The key considerations are size, experience, linkage with dental students and the wider dental community, ability to provide access to clinical mentoring and support, familiarity with public health principles and ability for rigourous data capture and evaluation. One of the important components of ensuring the success of these styles of service is the long-term © 2014 Australian Dental Association
Remote visiting dental services continuity in relationships with each community. This is particularly because of the high turnover of remote staff with the consequential loss of local corporate history. Therefore, it is beholden on the visiting service provider to establish and maintain a strong continuity base. It is the ongoing relationships with the community and health services that ameliorate the problems that surface regularly in recurrent visiting services. It was our experience that establishing a long-term, relatively stable leadership team able to provide continuity, is important for success. In reflecting on some of the challenges encountered by the Centre over the decade, it is interesting to consider that perhaps the most significant challenge was to deepen our understanding and appreciation of differing approaches to health, well-being and care provision. It was our experience that rural and remote Aboriginal health services approach health care in quite different ways from public (and private) dental services. This offers great learning opportunities for dental service providers with a willingness to examine their established views about oral health care provision. A good service is one that the community wants rather than one that dental service providers may consider to be good and appropriate. CONCLUSIONS Sustaining remote area recurrent visiting services has some significant complexities beyond urban public dental service models. Perhaps chief among these are the challenges associated with dental workforce shortages which impact most heavily in the public sector, and most particularly in remote areas. An essential element of the workforce governance framework for remote service provision should be the inclusion of a student participation programme as sustained solutions come from developing a future workforce. It is clear from our experience that student participation and engagement does provide return workforce (and can also provide immediate workforce with appropriate mentoring and support systems). Clinical and strategic governance is an important area of consideration for rural and remote services, and poses particular challenges for smaller service structures. Embedding of research capabilities and workforce development activities with clinical service entities promotes the development of sustainable, innovative, qualityfocused oral health care services. The establishment of significant collaborative partnerships with Aboriginal health services promotes the development and maintenance of culturally sensitive dental services within rural and remote Indigenous communities. It also creates an environment supportive of transition to increasingly community-run services. The development © 2014 Australian Dental Association
of a small nimble central governance structure that has provided leadership to community-based remote services has been successful for nearly a decade in Western Australia. The core values for this success have been communication, clinical leadership, mentorship and service monitoring all linked to an integrated education and research agenda. It is evident that after 10 years the evidence of sustainability of such a model has been proven effective. ACKNOWLEDGEMENTS We would like to particularly acknowledge the support and generosity of our Aboriginal health service partners and the communities they serve in Carnarvon, Geraldton, Kalgoorlie, Roebourne, Wiluna, Warburton and the Ngaanyatjarra Lands. The authors would like to thank the Brocher Foundation for the opportunity of the author (MT) to be a residential Fellow during the study finalization. REFERENCES 1. Teusner DN, Chrisopoulos S, Spencer AJ. Projected demand and supply for dental visits in Australia: analysis of the impact of changes in key inputs. Dental Statistics and Research Series no. 38. Cat. no. DEN 171. Canberra: AIHW, 2008. 2. Tennant M, Kruger E. A national audit of Australian dental practice distribution: do all Australians get a fair deal? Int Dent J 2013;63:177–182. 3. Kruger E, Tennant M, George R. Application of geographic information systems to the analysis of private dental practices distribution in Western Australia. Rural and Remote Health 2011;11:1736 [online]. 4. Kruger E, Tennant M. Short-stay rural and remote placements in dental education, an effective model for rural exposure: a review of eight-year experience in Western Australia. Aust J Rural Health 2010;18:148–152. 5. Australian Institute of Health and Welfare, Dental Statistics and Research Unit; Jamieson LM, Armfield JM, Roberts-Thomson KF. Oral health of Aboriginal and Torres Strait Islander children. AIHW cat. no. DEN 167. Canberra: Australian Institute of Health and Welfare (Dental Statistics and Research Series No. 35), 2007. 6. Kruger E, Smith K, Atkinson D, Tennant M. The oral health status and treatment needs of Indigenous adults in the Kimberley region of Western Australia. Aust J Rural Health 2008;16:283–289. 7. Dyson K, Kruger E, Tennant M. Networked remote area dental services: a viable, sustainable approach to oral health care in challenging environments. Aust J Rural Health 2012;20:334– 338. 8. Australian Bureau of Statistics. Information Paper. An Introduction to Socio-Economic Indexes for Areas (SEIFA), 2006. URL: ‘http://www.abs.gov.au/AUSSTATS/[email protected]/Lookup/2039.0Main+ Features12006?OpenDocument’. Accessed August 2013. 9. Kruger E, Jacobs A, Tennant M. Sustaining oral health services in remote and Indigenous communities: a review of 10 years experience in Western Australia. Int Dent J 2010;60: 129–134. 10. Kruger E, Perera I, Tennant M. Primary oral health service provision in Aboriginal Medical Services-based dental clinics in Western Australia. Aust J Prim Health 2010;16:291–295. 191
K Dyson et al. 11. Strategic Review of Health and Medical Research in Australia – Better Health Through Research. ISBN: 978-0-9872039-5-3. Commonwealth of Australia, 2013. URL: ‘http://www.mckeonreview.org.au/’. Accessed May 2013.
18. Walker D, Tennant M, Short S. Listening to indigenous health workers: helping to explain the disconnect between policy and practice in oral health role development in remote Australia. Health Education Journal 2011;70:400–406.
12. Smith K, Kruger E, Dyson K, Tennant M. Oral health in rural and remote Western Australian Aboriginal communities: a twoyear retrospective analysis of 999 people. Int Dent J 2007;57:93–99.
19. Pacza T, Steele L, Tennant M. The development of oral health training for rural and remote Aboriginal health workers. Aust J Rural Health 2001;9:105–110.
13. Tennant M. Rural, remote and Indigenous oral health: the past, the present and the future, a Western Australia perspective. Ann Roy Australas Coll Dent Surg 2004;17:93–97. 14. Subramaniam S, Smith KL, Kruger E, Tennant M. Hospital admissions for oral malignancies in Western Australia: a fouryear retrospective analysis. Asia Pac J Clin Oncol 2005;1:151– 157. 15. Kruger E, Dyson K, Tennant M. Pre-school child dental health in Western Australia. Aust Dent J 2005;50:258–262. 16. Kruger E, Smith K, Tennant M. Non-working dental therapists: opportunities to ameliorate workforce shortages. Aust Dent J 2007;52:22–25. 17. Bazen JJ, Kruger E, Dyson K, Tennant M. An innovation in Australian dental education: rural, remote and Indigenous pre-graduation placements. Rural Remote Health 2007;7: 703.
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20. McConnel FB, Pashen D, McLean R. The ARTS of risk management in rural and remote medicine. Can J Rural Med 2007;12:231–238. 21. Australian Commission on Safety and Quality in Health Care. Safety and Quality Improvement Guide Standard 1: Governance for Safety and Quality in Health Service Organisations (October 2012). Sydney: ACSQHC, 2012.
Address for correspondence: Professor Estie Kruger International Research Collaborative–Oral Health and Equity The University of Western Australia 35 Stirling Highway Nedlands WA 6009 Email: [email protected]
© 2014 Australian Dental Association
The official journal of the Australian Dental Association
Australian Dental Journal 2014; 59: 187–192 doi: 10.1111/adj.12162
A decade of experience evolving visiting dental services in partnership with rural remote Aboriginal communities K Dyson,* E Kruger,* M Tennant* *International Research Collaborative–Oral Health and Equity, The University of Western Australia.
ABSTRACT Background: Embedding research capabilities and workforce development activities with clinical service entities promotes the development of sustainable, innovative, quality-focused oral health care services. Clinical and strategic governance is an important area of consideration for rural and remote dental services, posing particular challenges for smaller service structures. Sustaining remote area dental services has some significant complexities beyond those involved in urban service models. Methods: This study describes the sustaining structure of a remote area dental service with a decade of history. Results: In the current climate, chief among these challenges may be those associated with dental workforce shortages as these impact most heavily in the public sector, and most particularly, in remote areas. As sustained workforce solutions come from developing a future workforce, an essential element of the workforce governance framework for remote dental service provision should be the inclusion of a student participation programme. Collaborative partnership approaches with Aboriginal health services promote the development and maintenance of effective, culturally sensitive dental services within rural and remote Aboriginal communities. Having sustained care for 10 years, this collaborative model of integrated research, education and service has demonstrated its effectiveness as a service model for Aboriginal communities in Western Australia. Conclusions: This descriptive study finds the core values for this success have been communication, clinical leadership, mentorship within effective governance systems all linked to an integrated education and research agenda. Keywords: Governance, remote areas, services. (Accepted for publication 20 August 2013.)
INTRODUCTION Over the last 15 years, Australia has experienced an increasing oral health workforce shortage with some projections indicating a significant workforce maldistribution will continue for at least the next 10 years.1 Workforce shortage, most acutely experienced in many areas of rural and remote Australia, is exacerbated by the pooling of dentists in capital cities,2 resulting in a significant lack of access to oral health care in many remote areas.3 Although the shortage is most acute among public sector services (providing care for schoolchildren and disadvantaged people), the private sector in rural areas has also been struggling with shortages for a long time. The establishment of Australia’s three newest dental schools in regional areas, as well as growing rural interest among existing dental schools, is expected to help strengthen the focus of this country’s oral health workforce on rural and remote areas.4 However, © 2014 Australian Dental Association
despite these and other remote workforce development strategies, dental service provision challenges in rural and remote areas are expected to continue well into the future. It is well known that dental disease is strongly linked to socio-economic deprivation, with people from lower socio-economic backgrounds suffering greater disease burdens than more advantaged people.5,6 Indigenous Australians (Aboriginal and Torres Strait Islander people) are reported to suffer even greater dental disease burdens (caries, periodontal disease and more complex conditions) than their similarly disadvantaged non-Indigenous counterparts.5,7 Australia’s rural and remote areas are home to disproportionately large numbers of socio-economically disadvantaged people including relatively large numbers of Indigenous people.8 In fact, approximately half of Australia’s Indigenous population live in rural and remote areas, with a considerable number living in small, disparate and isolated communities. This 187
K Dyson et al. sparse, widespread distribution of people with increased care needs poses challenges for the public oral health service providers charged with responsibility for these regions. It is against this background of high dental disease levels and protracted workforce shortage that new approaches to sustainable service provision for rural and remote areas have begun emerging.9 Involvement in exploring solutions has broadened beyond the traditional domain of public sector oral health services to include the Aboriginal health sector, universities, nongovernment organizations and volunteer groups.10 This study describes a decade of experience in establishing visiting oral health services in partnership with rural and remote Aboriginal communities in Western Australia. An integrated service, education and research model Over 10 years ago, the Centre for Rural and Remote Oral Health was established at The University of Western Australia to provide a leadership focus on rural, remote and Indigenous oral health issues in Western Australia. A cornerstone of the Centre’s foundation was the integration of education and research activities with clinical service provision. This integrated service approach, a unique approach within the Australian dental service context of the time, is seen as pivotal to the successes achieved. Over the first two years of operation, the Centre focused on establishing core student education programmes, initiating foundational research activities and developing clinical approaches and systems at two service centres. Over the following years, clinics were established in a further four communities and recruitment, placement, health worker education programmes and clinical activities were reviewed and refined in concert with expanding research activities. Research-service integration The rigour of ongoing analysis of service activities using scientific methods is acknowledged internationally as adding benefit to services, supporting processes for timely system adaptation and high quality care. It is clear from the recent Strategic Review of Health and Medical Research, that the decoupling of research from health care service is becoming more widely recognized as a significant flaw in the wider Australian health care landscape. This has led to calls for the development of much stronger research-service nexus driven health care improvement systems.11 Research and population health expertise was seen as essential in providing the scientific grounding to support many of the Centre’s clinical and educational activities. In addition to supporting the collection, collation and 188
analysis of the key burden of disease data, research capabilities enabled the publication of findings, broadening opportunities for national and international interpretation, and thereby adding value to the wider community.12 Research capacity can also enhance a service provider’s ability to attract and retain high quality clinicians to participate in service provision.13 Many research initiatives from the Centre were generated through clinical questions developed within the research-service nexus. Among these is a study exploring Western Australian hospitalizations for the treatment of oral malignancy14 and an investigation of rural preschooler oral health revealing significant dental pain and unmet care needs, particularly among Indigenous children.15 A review of Western Australia’s rural oral health workforce provides information to inform workforce development strategies and identify a potential untapped rural workforce among underemployed rural dental therapists.16 Education-service integration The introduction of Indigenous cross-cultural education and rural and remote placements to dental undergraduate training in Western Australia are two leading education initiatives arising from the Centre.17 These pioneering steps have been introduced by dental schools Australia-wide and have become pillars of national rural and Indigenous dental workforce development strategies. The international literature acknowledges two fundamental tenets of developing rural and remote workforce: firstly, students from a rural background are more likely to return to rural practice. Secondly, and of more importance to this discussion, the more exposure students have to rural practice, the more likely they are to practice in a rural area at some stage in their career and the greater their empathy for the complex nature of care provision in these areas.17 It is clear from our experience that student participation and engagement does provide return workforce, and therefore an essential element of the workforce governance framework for remote service provision should be the inclusion of a student participation programme. It is evident that vertically integrated participation of students in rural service provision activities provides workforce sustainability.10 Clinical service in partnership with Aboriginal health services Recognition of the importance of cultural security in Aboriginal health care was central to the decision to partner with Aboriginal health services in service provision. Six dental services were developed within community-controlled Aboriginal health services in © 2014 Australian Dental Association
Remote visiting dental services outer regional, remote and very remote areas (according to the Australian Standard Geographical Classification – Remoteness Area). Such a strongly collaborative approach to state-funded Aboriginal oral health service introduced a new paradigm to Western Australia (and much of Australia). Aboriginal health services present a non-threatening, culturally secure environment that Indigenous people are comfortable attending. This environment supports the maintenance of close service-community relationships and fosters cultural exchange and shared learning, all of which are crucial for the success of visiting remote services Equally important are the enormous logistical supports that community-run services can offer as these immeasurably strengthen visiting service capabilities. Among these supports are intimate community knowledge and community liaison, patient transport, reception and health worker support, the ability for opportunistic and integrated health care provision, access to accurate and comprehensive medical and social history information (with appropriate consent processes). Visiting services need close relationships with the community-based health services as this facilitates effective and integrated health care provision and also provides an important source of professional and social support for visiting practitioners. Local and Indigenous capacity building in oral health Consideration of issues related to local capacity building in oral health are important for visiting remote service providers and rural and remote communities alike. Remote health service staff are required to manage acute dental issues between clinical visits. By virtue of their in-depth community knowledge and continuous presence, they may also be best positioned to implement oral health promotion activities. The establishment of close relationships with community health services facilitates the identification and development of opportunities for integrating oral health promotion with local primary health care health programmes such as diabetes programmes, maternal and early childhood programmes, and others. However, it is important for visiting service providers to appreciate that rural and remote health services may be limited in their capacity to participate in oral health capacity enhancing activities,18 particularly in the more remote areas where skilled workforce shortages are often most acute. The Centre’s educational expertise assisted the development of oral health education resources in collaboration with Indigenous communities and was also instrumental in the establishment of Aboriginal health worker capacity building programmes in oral health education19 and dental assisting. Flexible, tailored learning structures in dental assisting were created © 2014 Australian Dental Association
ranging from short on the job training modalities to more comprehensive certificate-level programmes incorporating online learning packages. On the job training was undertaken within the visiting clinical programme achieving highly successful outcomes in all health services where it was established. Embedding dental clinics within Aboriginal health services also provides a pathway for the development of Indigenous capacity in oral health service governance, building foundations for future transition to sustainable community-run services. Service design The service design involved the establishment of fixed dental clinics in community-run Aboriginal health services providing primary oral health services within an environment of enhanced local preventive oral health capability. The current climate of relatively low and decreasing dental capital equipment cost has created new opportunities for multiple, fixed services approaches to the challenge of service provision for disparate, remote populations. A dental van approach, popularized in the 1970s and 1980s, was avoided for many reasons, chief amongst these being the implications of the changed landscape of contemporary occupational health and safety on the viability of this approach. This, coupled with a generational shift in work environment culture among new graduates, accessibility limitations due to remote road surfaces and weather conditions and the known challenges with high maintenance issues in remote areas (electric dental equipment is highly susceptible to vibration damage in remote transit), favoured a fixed clinic approach. Visiting service logistics were designed with a focus on workforce sustainability considerations, together with issues of cost-efficiency and community need. A capital city based model was developed, providing communities with regular service access and continuity of care provider whilst enabling clinicians to spend most weekends at home. The large travel distances involved with service locations in outer regional, remote and very remote areas called for a fly-in approach on cost-effective grounds and safety concerns of long distance country driving. The model was refined over time to provide a robust, systematic approach with cost-effective management of a visiting service model applicable to dentists from a range of backgrounds, including new graduates and more experienced clinicians.7 Workforce sustainability In times of dental workforce shortage, sustainable recruitment and retention of suitable dental professionals is among the most significant challenges faced by the 189
K Dyson et al. rural and remote public oral health sector. The Centre found developing a vertically integrated approach to workforce development to be instrumental in sustaining workforce over the decade. Offering rural and remote clinical placements and a rural graduate training programme created opportunities for students and graduates to expand their knowledge and experience by building on interest stimulated in earlier years. By closely integrating research and education activities with its clinical service models, the Centre was able to offer undergraduates and newly graduated an experience that was at the forefront of internship models in dentistry in Australia and thereby attract high achieving graduates in excess of available positions. The success of early placements quickly led to students becoming integral visiting team members (supported by appropriate orientation and mentoring processes). This was a winning situation affording students highly valued learning opportunities with exposure to Indigenous oral health issues whilst creating enjoyable mentoring opportunities for clinicians and reducing the Centre’s remote auxiliary staffing requirements. Attending to workforce retention is as important as addressing recruitment issues. Creating a positive culture and working experience is integral to maintaining a flow of high quality clinicians, which is vital to the future of the service. As many clinicians are out of their comfort zone when participating in remote dental services, the service provider needs to provide systems of appropriate clinical and social support. Essential requirements include suitably comprehensive and responsive orientation and mentoring processes and ensuring that a clear pathway exists to enable practitioners to address concerns promptly. The Centre found that the social, logistical and professional supports that flow from establishing dental services within a broader health setting to be of immeasurable benefit in sustaining remote services. Governance frameworks Clinical governance It is widely acknowledged that clinical care provision in remote environments brings a heightened level of clinical risk.20 This risk is magnified in situations where clinicians change regularly and may have minimal experience (or experiences limited to city based practice). It is against this backdrop that a strong clinical risk framework needs to be in place to support high quality remote dental service. Clinicians participating in remote visiting services require orientation to the social and cultural circumstances involved in remote practice as well as the 190
clinical environment, including the clinical care framework and quality assurance and improvement processes. The service provider needs a robust boundary setting approach to care, ensuring that care provided is consistent with patient needs, but at the same time does not extend beyond an envelope of risk that is safe for the particular setting. Appropriateness of practice scope is influenced by clinical experience and expertise as well as environmental factors such as equipment, access to backup support and follow-up care among other factors. Most remote service clinicians acknowledge that significant gains in sustainability and quality are achieved from the inclusion of experienced mentoring for newer participants, regardless of clinical experience and expertise. A strong systematic approach to the collection, collation, evaluation and feedback of clinical data, is an essential part of sustaining good clinical quality measures in any setting, with remote visiting services no exception.21 Systems are also needed for prioritizing care according to clinical need and ensuring equitable service access in situations where demand exceeds service capacity, as is frequently the case in remote areas. The increased vulnerability of remote communities associated with unequal power relationships calls for heightened quality assurance processes among health service providers which must include feedback systems for evaluating how well the service is meeting the community’s needs and expectations. Strategic governance One of the keys to providing sustained high quality visiting dental services in remote areas is a clear centralized governance framework. Small remote organizations with limited dental experience put themselves and their community at risk by ‘going it alone’ in service provision. Although the drivers for them to act independently may be strong (longstanding inadequacy of services), the governance frameworks that are essential to providing timely and sustained high quality services are relatively complex and have discipline-specific nuances that are often not inherently evident to health service managers and/or small community organizations. The development and maintenance of a small, nimble, highly experienced central governance organizational structure that supports services in remote areas can ensure the quality of care as well as provide solutions to sustainability. The key considerations are size, experience, linkage with dental students and the wider dental community, ability to provide access to clinical mentoring and support, familiarity with public health principles and ability for rigourous data capture and evaluation. One of the important components of ensuring the success of these styles of service is the long-term © 2014 Australian Dental Association
Remote visiting dental services continuity in relationships with each community. This is particularly because of the high turnover of remote staff with the consequential loss of local corporate history. Therefore, it is beholden on the visiting service provider to establish and maintain a strong continuity base. It is the ongoing relationships with the community and health services that ameliorate the problems that surface regularly in recurrent visiting services. It was our experience that establishing a long-term, relatively stable leadership team able to provide continuity, is important for success. In reflecting on some of the challenges encountered by the Centre over the decade, it is interesting to consider that perhaps the most significant challenge was to deepen our understanding and appreciation of differing approaches to health, well-being and care provision. It was our experience that rural and remote Aboriginal health services approach health care in quite different ways from public (and private) dental services. This offers great learning opportunities for dental service providers with a willingness to examine their established views about oral health care provision. A good service is one that the community wants rather than one that dental service providers may consider to be good and appropriate. CONCLUSIONS Sustaining remote area recurrent visiting services has some significant complexities beyond urban public dental service models. Perhaps chief among these are the challenges associated with dental workforce shortages which impact most heavily in the public sector, and most particularly in remote areas. An essential element of the workforce governance framework for remote service provision should be the inclusion of a student participation programme as sustained solutions come from developing a future workforce. It is clear from our experience that student participation and engagement does provide return workforce (and can also provide immediate workforce with appropriate mentoring and support systems). Clinical and strategic governance is an important area of consideration for rural and remote services, and poses particular challenges for smaller service structures. Embedding of research capabilities and workforce development activities with clinical service entities promotes the development of sustainable, innovative, qualityfocused oral health care services. The establishment of significant collaborative partnerships with Aboriginal health services promotes the development and maintenance of culturally sensitive dental services within rural and remote Indigenous communities. It also creates an environment supportive of transition to increasingly community-run services. The development © 2014 Australian Dental Association
of a small nimble central governance structure that has provided leadership to community-based remote services has been successful for nearly a decade in Western Australia. The core values for this success have been communication, clinical leadership, mentorship and service monitoring all linked to an integrated education and research agenda. It is evident that after 10 years the evidence of sustainability of such a model has been proven effective. ACKNOWLEDGEMENTS We would like to particularly acknowledge the support and generosity of our Aboriginal health service partners and the communities they serve in Carnarvon, Geraldton, Kalgoorlie, Roebourne, Wiluna, Warburton and the Ngaanyatjarra Lands. The authors would like to thank the Brocher Foundation for the opportunity of the author (MT) to be a residential Fellow during the study finalization. REFERENCES 1. Teusner DN, Chrisopoulos S, Spencer AJ. Projected demand and supply for dental visits in Australia: analysis of the impact of changes in key inputs. Dental Statistics and Research Series no. 38. Cat. no. DEN 171. Canberra: AIHW, 2008. 2. Tennant M, Kruger E. A national audit of Australian dental practice distribution: do all Australians get a fair deal? Int Dent J 2013;63:177–182. 3. Kruger E, Tennant M, George R. Application of geographic information systems to the analysis of private dental practices distribution in Western Australia. Rural and Remote Health 2011;11:1736 [online]. 4. Kruger E, Tennant M. Short-stay rural and remote placements in dental education, an effective model for rural exposure: a review of eight-year experience in Western Australia. Aust J Rural Health 2010;18:148–152. 5. Australian Institute of Health and Welfare, Dental Statistics and Research Unit; Jamieson LM, Armfield JM, Roberts-Thomson KF. Oral health of Aboriginal and Torres Strait Islander children. AIHW cat. no. DEN 167. Canberra: Australian Institute of Health and Welfare (Dental Statistics and Research Series No. 35), 2007. 6. Kruger E, Smith K, Atkinson D, Tennant M. The oral health status and treatment needs of Indigenous adults in the Kimberley region of Western Australia. Aust J Rural Health 2008;16:283–289. 7. Dyson K, Kruger E, Tennant M. Networked remote area dental services: a viable, sustainable approach to oral health care in challenging environments. Aust J Rural Health 2012;20:334– 338. 8. Australian Bureau of Statistics. Information Paper. An Introduction to Socio-Economic Indexes for Areas (SEIFA), 2006. URL: ‘http://www.abs.gov.au/AUSSTATS/[email protected]/Lookup/2039.0Main+ Features12006?OpenDocument’. Accessed August 2013. 9. Kruger E, Jacobs A, Tennant M. Sustaining oral health services in remote and Indigenous communities: a review of 10 years experience in Western Australia. Int Dent J 2010;60: 129–134. 10. Kruger E, Perera I, Tennant M. Primary oral health service provision in Aboriginal Medical Services-based dental clinics in Western Australia. Aust J Prim Health 2010;16:291–295. 191
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Address for correspondence: Professor Estie Kruger International Research Collaborative–Oral Health and Equity The University of Western Australia 35 Stirling Highway Nedlands WA 6009 Email: [email protected]
© 2014 Australian Dental Association
