Health Workforce

The health of individuals and communities is poorer the further the distance from a metropolitan centre; holding positions of trust with patients, rural and remote GPs provide health care to the majority of people in the community in which they reside and have little day-to-day contact with others of their profession which often leads to a feeling of isolation and challenges in maintaining a healthy work-life balance. This is true also for other health professionals including nurses and allied health professionals. Retention of health professionals in rural and remote locations is an ongoing challenge requiring input from the whole community, state and Australian Government to resolve.

Key Points

• Most regions across country SA are nationally designated GP Distribution Priority Areas

• Recruitment and retention of primary health workforce remains a challenge

• Rurality and remoteness impact workforce distribution

Identified Needs

1. Workforce and service sustainability

Service Needs

Regional and rural areas face health workforce challenges related to an ageing workforce, a rise in the number of patients experiencing chronic disease and the complexity of a diverse geographic environment and changing community demographics There is a continued difficulty in attracting, recruiting and retention of health professionals to rural and remote areas.

Community issues of concern are availability of General Practice, Allied Health, and Specialist services; physical access given limited transport options; and affordability

General Practitioners (GPs)

GPs in country SA not only provide primary health care services via general practice, they also provide medical services in local Emergency Departments, and procedural services such as minor surgery and Obstetrics.

Nationally, the Distribution Priority Area classification identifies locations where people don’t have enough access to doctors, based on the needs of the community. Following an updated classification in July 2022, all regions in Country SA are identified as Distribution Priority Areas for GPs, with the exception of two GP catchments in Mount Barker (172)

In 2021, the average GP full-time equivalency (FTE) in SA was 11 8 per 10,000 persons and ranged between 7.2 – 12.9 FTE based on remoteness, as classified by the Modified Monash Model (MMM) Regions with the lowest GP FTE per 10,000 persons were those classified as Modified Monash (MM) categories 2 (regional centres) (7.2 GP FTE) and 7 (very remote communities) (7.5 GP FTE). This was followed by regions classified as MM5 (small rural towns) (9.1 GP FTE) and MM6 (remote communities) (9.9 GP FTE). Whilst MM2 regions had the lowest reported GP FTE per 10,000 persons, it should be noted that these populations may often access GPs in MM1 (metropolitan) regions, which had the highest GP FTE per 10,000 persons (12.4 GP FTE)(173)

Access to available GP services is limited with 38% of adults in the Country SA PHN region reporting that at some point over a 12 month period they could not access their preferred provider, and 28% felt they waited longer than acceptable to get an appointment with a GP (174).

Nurses and Midwives

The Mid North had the greatest number of Nurses and Midwives practicing in the area per 1,000 population (92.6 per 1,000) if the majority of nurses are living within the area, this means just over 9% of the Mid North population are a registered or enrolled nurse. In contrast, Adelaide Hills, Gawler – Two Wells, and Barossa had the lowest ratio per

1,000, but this could be due to the proximity and thus possibility of their primary place of employment being within the metro area (31).

An estimated 97% of General Practices in Country South Australia employ at least one practice nurse (i.e. 1 FTE), exceeding the national average (79)

Allied Health: Podiatry, Physiotherapy, Occupational Therapy

The number of professionals delivering Occupational Therapy (OT), Podiatry, and Physiotherapy services decreases the further travelling away from metro areas, with only 13% of these professions having their primary place of practice in regional, rural and remote areas (MM3 – MM7) of South Australia (175).

Physiotherapists are reasonably well distributed in MM 3 – 4, and MM6 areas (10.5 – 12.9 per 10,000 population) but reduce to 6 per 10,000 population in MM5 areas and down to 2.2 per 10,000 in MM7 areas (175).

Podiatrists are similar in their distribution between MM 1 – MM4 areas but decline in MM5 to 1.5 per 10,000 and further down to 0.6 per 10,000 population in MM7 areas (175)

There are 8.6 OTs per 10,000 population in MM3 (large rural towns) areas compared to 12.4 per 10,000 in MM1 & 2. Numbers of OTs reduce with remoteness, down to 2.2 therapists per 10,000 population in MM7 (175)

Dentists and oral health professionals

The private dental sector is the largest provider of oral health care in South Australia. Fewer dental professionals practice in rural and remote areas, with recognised maldistribution of oral workforce between Adelaide and country SA resulting in insufficient workforce in regional and remote areas, and a reliance on public dental services for regional and remote populations (95)

Pharmacists

Pharmacy services are an important part of the primary health care system, providing vital access to prescription medications, professional advice and other health and wellness supplies and programs. While medications can still be obtained through pharmacy depots or online in some remote locations, the presence of a pharmacist and fullservice pharmacy is an advantage to a community.

The highest ratio of pharmacists to population was in the Mid North, with 4.3 pharmacists per 1,000 population, the lowest was the Barossa with 2.3 per 1,000 (31)

After hours care

The provision of sustainable after hours medical services within rural and remote regions of Australia is an ongoing challenge for providers and coordinating agencies. It is reliant on not only the existence of the workforce, but also the ability of practitioners to participate in on-call, after-hours activity, especially in areas with workforce shortage where the distribution of workload disproportionately falls on very few practitioners.

After hours (AH) services within the Country SA region are available through hospital emergency departments (EDs) and/or through extended hours offered by GP clinics. In the majority of hospitals in the Country SA region, EDs are serviced by on-call GPs from the area. The highest number of AH GP sites are located the Adelaide Hills, followed by the Eyre Peninsula and South West (see Table 6). However, the Eyre Peninsula and South West region has a very large area and a high number of sites located within the regional cities of Whyalla and Port Lincoln, meaning AH service is sparsely distributed throughout the remainder of the region (161)

The Country SA PHN region has less than half the rate of AH GP attendances than the SA and national average, indicating potential gaps in service provision or challenges with access. SA3 regions with the lowest ratio of AH GP services provided (per 1,000 persons) are the Limestone Coast, Eyre Peninsula and South West, the Yorke Peninsula, Mid North, and Fleurieu - Kangaroo Island (see Table 6)

Lower urgency ED presentations are indicative of health conditions or events that could often be more appropriately managed in the primary care setting (176) A high rate of presentations in the AH period may therefore indicate gaps in use or availability of alternative services. Analysis of restricted SA Health ED data identified Country SA regions with a high proportion and per-capita rate of lower urgency AH presentations, and this was used to inform internal planning.

Health Information and Technology

Over the last 20 years, there have been a number of attempts to lessen the fragmentation within the Australian health system with varied outcomes. As we move further into the technological age, some system boundaries are gradually shifting, but barriers continue to ensure that critical areas remain disconnected impacting integration and the patient journey.

Key Points

• Low use of telehealth by general practice and specialist services

• Electronic referrals limited

• Low uptake of secure messaging

• Limited awareness of required web services transition for Department of Human Services

Priorities

1. Effective uptake of telehealth and secure messaging

2. Supporting web services transition

3. Supporting Real Time Prescription Monitoring

Service Needs

Process for roll out of ‘My Health Record’ impacts on knowledge and understanding of patient history and care. Continued use by GPs and use and uptake by the general public is variable. The core activity for use has been with General Practice and Pharmacy.

Use of the My Health record for cross views is dependent upon allied health, specialists, aged care and hospitals also being able to upload. Registration and use by other provider groups is required in order for effective uptake.

Telehealth

There is a low uptake of uptake of telehealth by providers as an ongoing service delivery model Lack of permanence of relevant MBS item numbers and standards for platforms has contributed to the reticence by general practice to introduce regular and consistent use when appropriate (177)

Electronic referrals

Across Australia electronic referrals and transfer of patient information between health providers is limited, with only 40% of GP and specialist letters or referrals being electronic (79) Faxed transfer of information maintains the continued practice with a high proportion of general practices and allied health providers across country SA using this method to send referrals or clinical reports

Across country SA region:

• Only 46% of general practitioners and 22% of allied health professionals are employing secure messaging software to send information (79)

• No RACFs across Country SA PHN region have secure message facilities (178)

• Discharge summaries faxed from SA Health experience around a 40% failure rate

• Local hospitals do not have secure messaging facilities

In circumstances of shared care such as aged care it has a negative impact upon information being consistent or timely. Allied health providers are less likely than general practice to use electronic patient records (61% vs. 99%)(178). As a result, only about 50% of allied health professionals report that they can easily generate a clinical summary to share with patients or other health care providers, compared with around 90% of GPs (79)

Web Services Transition

From March 2022, all payments to healthcare providers will be processed by a web service connection to Department of Human Services. Verification of the Healthcare provider and location of service will be using a combination of the Australian Business Register, Provider numbers and allocated Facility numbers. The change will impact all My Aged Care, NDIS, PBS, MBS, and private health insurance payments.

Transition impacts general practice, pharmacy, allied health, and dental services, requiring complex business system, software and administrative changes. There are identified delays from software providers with bringing requirement ready updates and products to market to support service providers.

Allied Health service providers have low awareness of transition requirements and an impact on Allied Health business service delivery is anticipated (178).

Real Time Prescription Monitoring (RTPM)

RTPM is a nationally implemented system, to monitor the prescribing and dispensing of controlled medicines. Monitored drugs include all Schedule 8 medicines (drugs of dependence) and Schedule 4 medicines. It is expected that it will become mandatory for SA prescribers to utilise the digital platform ScriptCheckSA before prescribing a monitored drug by April 2022.

Dentists have had limited engagement and support in preparation for required deadlines, and dental software is nonconformant for RTPM (41)

Secure messaging

Secure Messaging is the intentional end-to-end sending of encrypted information in a format which enables data transfer. Although the majority of General Practice is able to use – the value is only fully realised when those with whom they share care such as Allied health and Aged Care are also connected.

The recent transition to Interoperable Secure Messaging allows for differing secure messaging vendors to share directories and communicate between systems.

However, interoperability is built upon the use of the Healthcare Identifier (HI) Service so Allied Health, Residential Aged Care Facilities and Dentists will need to be registered for the HI Service. Registration is a requirement for Real Time Prescription Monitoring.

As at 2021, for registrations for HI Service as at October 2021:

• Allied Health: 65 or 14% of providers

• Residential Aged Care Facilities: 25 or 37% of providers

• Dentists: 1 or 0% of providers (179)

Electronic referrals uptake and implementation by SA Health is another function of Secure Messaging.

Community Voice

Telehealth became a more used mechanism during 2020 with face-to-face access to GPs reduced due to COVID-19 restrictions. 73% of survey respondents accessed telehealth during this period and there was overall support for continued and ongoing use of telehealth for delivery of care to support. Specific consultation identified support for use of telehealth for:

• GP consults for minor or non-clinical needs such as proof of vaccination, confirming details when there has been a change in care, or a prescription

• Specialist follow-up appointments to reduce time off work, costs associated with travel and accommodation for short consults

• Services that can be delivered via video or telephone but otherwise usually require travel (e.g. dietician, mental health services) (99)