Specialist medical clinics were established for Aboriginal people with chronic disease who live in rural and remote areas of Hunter New England Local Health District (HNELHD).
Aim
To improve access to specialist medical care for Aboriginal people with chronic disease living in rural and remote areas of HNELHD.
Benefits
- Contributes to Closing the Gap for Aboriginal people in NSW.
- Improves management and treatment of chronic disease in the community.
- Increases access to specialist medical care for people in rural and remote areas.
- Reduces the travel time and costs associated with visiting a teaching hospital.
- Enhances collaboration with Aboriginal health workers and Aboriginal Medical Services (AMSs).
- Provides physician trainees with training and experience in rural health.
- Provides medical education to rural practitioners.
Background
The burden of illness in Aboriginal people is high, with an average life expectancy 10 years less than non-Aboriginal people. There is also a high incidence of chronic disease in Aboriginal people, including cardiovascular disease, stroke, diabetes, renal disease, respiratory disease and obesity1. The 2011 Australian Bureau of Statistics Census reported that 40 per cent of Aboriginal people have type 2 diabetes by the age of 55, compared to 12 per cent of non-Aboriginal people. It also suggested that six per cent of Aboriginal people over the age of 45 have renal disease and more than double the number of Aboriginal people have chronic lung disease than non-Aboriginal people1.
HNELHD has one of the largest populations of Aboriginal people in NSW, spread across a vast geographical distance. The majority of communities in HNELHD are in regional, rural and remote locations, with teaching hospitals few and far between. While access to specialist medical services is poor in rural and remote locations, teaching hospitals are well endowed with consultants and trainees. However, many Aboriginal people are reluctant to go to a medical institution for historical and cultural reasons.
In addition, the lack of public transport and costs associated with travelling to a teaching hospital meant that prior to the project, many Aboriginal people living in rural and remote areas of HNELHD did not have access to a medical specialist that could treat, manage and even prevent many of the chronic diseases that were prevalent in these areas. It was determined that establishing a specialist clinic for Aboriginal people with chronic disease would improve access to safe and culturally-appropriate care in the community, reduce the burden of chronic disease and reduce the need for people to travel long distances to a teaching hospital.
Implementation
Two models of specialist medical clinics were established as an extension of John Hunter Hospital – clinics run by HNELHD and those based within existing AMSs. Both clinics involved specialists travelling to the clinic and reviewing complex medical cases that were identified by local staff. Engaging local general practitioners (GPs) was critical to establishing both clinic models.
HNELHD clinics are run by HNELHD Aboriginal health workers and clinical nurse coordinators specialising in chronic disease. Clinics are held one day a month. Specialists from John Hunter Hospital travel to clinics via the Royal Flying Doctors Service, to reduce travel time. Specialists in training with John Hunter Hospital also attend clinics as part of their training, to ensure they are sustainable over the long term. More recently, clinical nurse consultants have been employed to organise and schedule clinics.
Clinics based in AMSs benefit from existing relationships with the local community, reducing the need to invest time and resources in engagement activities. As medical and allied health staff are already on site, they can easily talk to the patient’s GP and other healthcare providers, to ensure treatment is tailored to their needs. While pathology results are sourced from private providers, specialists at John Hunter Hospital have access to results and review these in collaboration with AMS staff. However, the success of the clinic is tied to the success of the AMS.
Status
Sustained – The project has been implemented and is sustained in standard business.
Key dates
- 2007: First clinic established at Armajun AMS
- 2008: Clinics established at Tamworth, Biripi (Taree) and Awabakal (Newcastle) AMS
- 2009: Clinic established at Cessnock Hospital, HNELHD
- 2014: Clinics established at Muswellbrook and Glen Innes Hospitals, HNELHD
- 2018: Clinic established at Coledale Community Health Centre, Tamworth
Implementation sites
- Armajun AMS, Inverell
- Tamworth AMS
- Coledale Community Health Clinic, Tamworth
- Biripi AMS, Taree
- Awabakal AMS, Newcastle
- Glen Innes Hospital, HNELHD
- Cessnock District Hospital, HNELHD
- Muswellbrook District Hospital, HNELHD
Partnerships
- Royal Flying Doctors Service
- Aboriginal Medical Services
Results
Clinic staff expected to see patients with cardiovascular disease, renal disease and diabetes. While these chronic diseases were common, there were also a high number of patients with complex medical problems, such as sleep apnoea (falling asleep in the middle of the day). Some clinics revealed an alarming incidence of thyroid, goitre and respiratory disease. Other presentations included neurology, rheumatology, hepatology and gastroenterology. The popularity of the clinics increased over time, with more sites involved and 29 advanced physicians trained over an eight-year period.
In November 2012, the position of Senior Staff Specialist in Aboriginal Chronic Care (0.5 FTE) was created. This role spends half the time travelling to clinics and the other half at John Hunter Hospital. An advanced trainee in general medicine and resident medical officer in clinical governance were also allocated to the project, to ensure sustainability as well as regular correspondence with GPs and nursing staff in local communities. Telehealth consultations were also offered for urgent consultations, however it was deemed not as effective as face-to-face consultations. Each site continues to receive six clinics and around 50-80 consultations per year.
Moving forward, the project team will continue to assess the needs of Aboriginal people in HNELHD and identify where additional clinics or sub-speciality clinics should be located. This assessment includes measuring the burden of illness beyond HNELHD facilities, supporting new facilities in the district, or changing the model of care if required. It is important to engage Aboriginal people who have a chronic disease but aren’t in contact with a hospital or AMS. There is also a need to conduct research to support the unexpected incidence of chronic disease revealed in Aboriginal people attending clinics, such as goitre and stroke.
Lessons learnt
- Sending specialists from teaching hospitals to rural and remote communities is an effective way to improve access to healthcare.
- It is important to understand that each community is unique and as such, each clinic must be tailored to the needs of the local community.
- Support from John Hunter Hospital staff and executive was critical to the success of the project.
- It is important to have a dedicated specialist involved in the clinics for at least half of their allocated hours.
- Integrating clinician training into the model of care allows doctors to broaden and improve their scope of practice, and encourages them to work in rural health.
References
- Australian Bureau of Statistics. Australian Aboriginal and Torres Strait Islander Health Survey: First Results, Australia 2012-13 [Internet]. ABS cat. no. 4727.0.55.001. Available from http://www.abs.gov.au/ausstats/abs@.nsf/mf/4727.0.55.001
Further reading
Watch a presentation from the 2017 Rural Innovations Changing Healthcare Forum
Contact
Patrick Oakley
Senior Staff Specialist
John Hunter Hospital
Hunter New England Local Health District
Phone: 0408 400 497
Patrick.Oakley@hnehealth.nsw.gov.au
