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Aust. J. Rural Health (2013) 21, 297–298
Editorial Integrating rural health services Discussions of rural health services often adopt the language of shortage. This may mean shortage of staff, facilities, funds or similar factors that impede access to or efficiency of services. Record funds are being spent on rural health services but it is not clear that they are being used to best effect. At the recent World Congress of Integrated Care participants were presented with international evidence of a few health systems that have moved from a reactive, fragmented service model designed to treat infectious diseases and simple acute presentations to new models built on a ‘bio-psycho-social’ health and recovery philosophy that fits the needs of the community served. Of particular interest are the developments in the Canterbury district of New Zealand that has made extraordinary progress in urban and rural services alongside dealing with the short and long-term challenges of the recent earthquakes. One unresolved question is whether such models can work, and whether integration of health, medical and social services is easier, in rural and remote communities. Rural communities experience the same range of health problems as urban populations but in smaller numbers and they are often unable to support resident specialist services. Rural services can appear equally fragmented with state hospital and community services, general practitioners, Superclinics, Aboriginal Medical Services, local government, voluntary and aged care providers all competing for patients and resources. Information systems are usually designed for the needs of individual providers and there are few examples of real time shared clinical records. Institutional policies and solutions seem to focus on attracting clinicians to rural or remote areas either as residents or as regular visitors to buttress traditional services and organisations. Some have argued that it should be easier to integrate services in rural areas. Smaller resident populations and fewer providers mean that potential service partners are known and joint working should be easier. Resident staff may work in more than one agency or move between agencies over a period of years as opportunities for advancement appear or a job change seems attractive. Such arrangements should facilitate the development of ‘boundary spanners’ who can promote joint planning and collaborative working. On the other hand, rural health service providers usually have separate governance procedures and work
to different priorities. Financing mechanisms are aligned to organisational objectives whether program funding, fee for service, or activity-based funding. These mechanisms act to reward some activities and discourage others. Frequently, increased occasions of service are rewarded while collaborative activities are undervalued or excluded. We have yet to see much evidence of valuebased financing in which providers are rewarded for health improvement, disease management, or evidence of recovery. Sharing of information is often limited by immature information systems and justified with reference to privacy concerns. The most successful systems seem to have adopted opt-out rather than opt-in provisions for electronic medical records. This failure to share information may result in health risks to patients treated without appropriate information, unnecessary costs to patients and families as they repeat their stories, discomfort as diagnostic tests are repeated, and increased costs to patients, citizens and service providers. These problems are not insurmountable as has been shown in small rural communities with Multipurpose Services that share staff, buildings, information services, and in some cases have single sets of performance measures negotiated with and provided to the relevant funding agencies. In larger rural centres fragmentation is alive and well and may be on the increase as nongovernmental providers are funded to address specific health challenges. Movement towards integrated services that better fit community and patient needs requires a number of drivers. The first is a focus on population health including all life stages and the full range of government, private and voluntary services. Secondly, consistent local leadership is required from those with a commitment to the community. Such positions should not be seen as temporary stepping-stones on the way to promotion and metropolitan glory. These leaders will require skills in change management and the development of receptive and responsive organisational cultures. Thirdly, rural health service leaders need to be spared the micro-management endemic in health service systems in which control of inputs becomes the first and most important priority. Permission to experiment carefully, measure outcomes, learn and share lessons is vital. Fourthly, Rural managers are often expected to ‘fly blind’ as information and communications systems lag behind. Provision of expert assistance in developing and
© 2013 The Author Australian Journal of Rural Health © National Rural Health Alliance Inc.
doi: 10.1111/ajr.12083
298
EDITORIAL
maintaining such systems will require support by skilled specialists from larger communities working in extended partnerships, not short consultancies addressing single problems. Is the development of integrated services easier in rural areas? The answer is probably no but it is clear that continuing to do the same thing is likely to have the same results and that rural communities deserve better.
The AJRH welcomes research and evaluation papers that provide insights into the development of integrated rural health services so that learning can be shared and we can work together to improve the health of rural populations. David Perkins Editor-in-chief
© 2013 The Author Australian Journal of Rural Health © National Rural Health Alliance Inc.
Aust. J. Rural Health (2013) 21, 297–298
Editorial Integrating rural health services Discussions of rural health services often adopt the language of shortage. This may mean shortage of staff, facilities, funds or similar factors that impede access to or efficiency of services. Record funds are being spent on rural health services but it is not clear that they are being used to best effect. At the recent World Congress of Integrated Care participants were presented with international evidence of a few health systems that have moved from a reactive, fragmented service model designed to treat infectious diseases and simple acute presentations to new models built on a ‘bio-psycho-social’ health and recovery philosophy that fits the needs of the community served. Of particular interest are the developments in the Canterbury district of New Zealand that has made extraordinary progress in urban and rural services alongside dealing with the short and long-term challenges of the recent earthquakes. One unresolved question is whether such models can work, and whether integration of health, medical and social services is easier, in rural and remote communities. Rural communities experience the same range of health problems as urban populations but in smaller numbers and they are often unable to support resident specialist services. Rural services can appear equally fragmented with state hospital and community services, general practitioners, Superclinics, Aboriginal Medical Services, local government, voluntary and aged care providers all competing for patients and resources. Information systems are usually designed for the needs of individual providers and there are few examples of real time shared clinical records. Institutional policies and solutions seem to focus on attracting clinicians to rural or remote areas either as residents or as regular visitors to buttress traditional services and organisations. Some have argued that it should be easier to integrate services in rural areas. Smaller resident populations and fewer providers mean that potential service partners are known and joint working should be easier. Resident staff may work in more than one agency or move between agencies over a period of years as opportunities for advancement appear or a job change seems attractive. Such arrangements should facilitate the development of ‘boundary spanners’ who can promote joint planning and collaborative working. On the other hand, rural health service providers usually have separate governance procedures and work
to different priorities. Financing mechanisms are aligned to organisational objectives whether program funding, fee for service, or activity-based funding. These mechanisms act to reward some activities and discourage others. Frequently, increased occasions of service are rewarded while collaborative activities are undervalued or excluded. We have yet to see much evidence of valuebased financing in which providers are rewarded for health improvement, disease management, or evidence of recovery. Sharing of information is often limited by immature information systems and justified with reference to privacy concerns. The most successful systems seem to have adopted opt-out rather than opt-in provisions for electronic medical records. This failure to share information may result in health risks to patients treated without appropriate information, unnecessary costs to patients and families as they repeat their stories, discomfort as diagnostic tests are repeated, and increased costs to patients, citizens and service providers. These problems are not insurmountable as has been shown in small rural communities with Multipurpose Services that share staff, buildings, information services, and in some cases have single sets of performance measures negotiated with and provided to the relevant funding agencies. In larger rural centres fragmentation is alive and well and may be on the increase as nongovernmental providers are funded to address specific health challenges. Movement towards integrated services that better fit community and patient needs requires a number of drivers. The first is a focus on population health including all life stages and the full range of government, private and voluntary services. Secondly, consistent local leadership is required from those with a commitment to the community. Such positions should not be seen as temporary stepping-stones on the way to promotion and metropolitan glory. These leaders will require skills in change management and the development of receptive and responsive organisational cultures. Thirdly, rural health service leaders need to be spared the micro-management endemic in health service systems in which control of inputs becomes the first and most important priority. Permission to experiment carefully, measure outcomes, learn and share lessons is vital. Fourthly, Rural managers are often expected to ‘fly blind’ as information and communications systems lag behind. Provision of expert assistance in developing and
© 2013 The Author Australian Journal of Rural Health © National Rural Health Alliance Inc.
doi: 10.1111/ajr.12083
298
EDITORIAL
maintaining such systems will require support by skilled specialists from larger communities working in extended partnerships, not short consultancies addressing single problems. Is the development of integrated services easier in rural areas? The answer is probably no but it is clear that continuing to do the same thing is likely to have the same results and that rural communities deserve better.
The AJRH welcomes research and evaluation papers that provide insights into the development of integrated rural health services so that learning can be shared and we can work together to improve the health of rural populations. David Perkins Editor-in-chief
© 2013 The Author Australian Journal of Rural Health © National Rural Health Alliance Inc.
