Improving Rural Health Services Through Integration: What are the Barriers?

• Introduction
• Part I Components of a "Quality" Rural Health Service
• Part II Wairoa, Experience from Current Health Care Providers and Services in Hawke’s Bay
• Part III Barriers to Integration
• References

Introduction

"Improving rural health is a key part" of the National Government’s "overarching health policy"   ⁴  . Despite this recent interest, rural health services, historically, have been managed more by "benign neglect"   ⁵   than by any planned, co-ordinated policy. This has meant that New Zealand rural health services have been left to evolve in their own haphazard manner. While in some instances this has allowed innovative local situations to evolve in most cases it has meant multiple independent poorly integrated providers, unaware of both gaps and overlaps in their services. Until recently, it has also meant that the aspirations of Maori, of nurses and of others wanting to play more significant roles in health service delivery have been prevented by the inertia of the status quo.

This article will discuss the components of a "quality" rural health service, then contrast this with a typical New Zealand rural area (Wairoa) with which two of the authors are associated (RJ, JT), and finally examine the barriers to improving rural health services through better integration of providers.

Part I – Components of a "Quality" Rural Health Service

A "quality" rural health service will be structured differently in different areas in order to meet local needs. How one defines quality depends greatly on the starting viewpoint: Funders seek cost-effective services that will achieve specific health outcomes purchased from a limited budget; large organisations like Hospital and Health Services (HHS) need to fulfil contract obligations while staying within their budget; health providers strive to meet the needs of individual patients while trying to earn a living. In this paper a community viewpoint is taken, but with the clear understanding that there are limited financial resources and a shortage of rural health providers.

We define ’quality’ as "The correct service provided to the correct person, in the correct location, by the correct provider, with the correct equipment, in the correct manner, within the correct timeframe, at the correct cost, with the correct outcome." This definition of quality provides a framework for the various elements that need to be considered.

• "To the correct person" : the needs of the individual as well as the needs of the population
  • Many rural areas in New Zealand are defined by relative geographic isolation that facilitates a population approach to identifying the important health needs of an area. Having responsibility for the health of a defined population includes identifying individuals with high health care needs. The most vulnerable members of a community (eg, children, the elderly, the poor, the mentally ill) are the ones least able to access health care, for a variety of reasons, and may need to be actively assisted with their health care needs. A reactive approach (ie, waiting for individuals to access services) may mean they present late for help, if at all, because of the barriers of cost, distance and health attitudes/beliefs. A proactive, population approach by a team of health providers, using a computer database of all individuals for which the team is responsible, ensures that no one falls through the cracks and allows meaningful audits to be done on health improvements within a community.
    
    
• "By the correct provider" : adequate numbers of skilled providers working as a team
  • In order of priority, Australian rural communities perceive general practitioner (GP), hospital and chemist services to be the three most essential   ⁶  , while recognising the importance of other allied health services (ambulance, nurses, allied health practitioners). This perception will, of course, differ for smaller rural populations unable to support GP, hospital and/or chemist services, where rural nurses may be working in advanced roles   ⁷  .
    
    Currently, in many rural New Zealand areas there are insufficient numbers of GPs. For these communities, the first priority is, therefore, to recruit anyone with a qualification that enables them to practice. Only after solving the problem of an inadequate workforce, can priorities shift to the retention and up-skilling of health care providers on the team. Rural communities only seem to get involved with rural health issues when resource problems reach a crisis point, such as when the hospital is threatened with closure or all the GPs have left.
    
    
    Once the issue of obtaining adequate numbers of health care providers is has been dealt with, the next issue must be the skill levels of the providers and how they work together. A co-ordinated well functioning team will ensure that the skills of its members are complementary, wide-ranging, appropriate to the population served, and has sufficient overlap of skills to provide for individuals having time off. A well functioning team will quickly triage the person requiring care to the most appropriate provider.
    
    
• "The correct service" : evidenced-based care and community input
  • Health providers competing for consumer dollars is not conducive to evidenced-based care but rather to just giving the punter what they want, be it unnecessary investigations or antibiotics for virus infections. Rural health care teams are in a better position than urban teams are to avoid unhealthy competition. This is mainly because they don’t suffer from the problems of too many providers competing for patients, and, frequently, they are interdependent of each other for time off and support.
    
    Evidence-based care is now the standard for which rural health care teams strive, however, the best evidence is from randomised, controlled, clinical trials which must still be interpreted for the individual patient’s specific circumstances. Furthermore, randomised, controlled, clinical trials will not establish health priorities for a rural community where funding for services is limited. Local community input will be needed to decide on where limited resources should be focussed.
    
    
• "Within the correct timeframe" : the "golden hour, day, week and month"
  • Even the best service can be made inaccessible. For example: your hip is to be replaced by the most skilled orthopaedic surgeon in the country, but you will be at least five years on the waiting list before the operation can take place or; your town’s after-hours GP service is provided by a brand new Accident and Medical clinic, but that is located a 45-minute drive away in a larger centre and is thus inaccessible. A quality service must provide care within a reasonable timeframe: emergency care within minutes to hours; acute illness care within hours to days; non-urgent surgical care within weeks to months.
    
    
• "At the correct location" : one-stop shop that brings the service to the people
  • Both in New Zealand   ⁵   and internationally   ^{6  ,   8}  , it has been recommended that, for the benefit of both providers and patients, rural health services should be located under one roof. This would improve patient access (eg, through longer service hours), facilitate information sharing among providers, and avoid stigmatisation associated with attending certain services (eg, STD clinics). This frequently means renovating the down-sized local hospital (if it still exists) into a " one stop health shop". This also allows "economy of scale" savings by sharing expensive equipment and other overheads. The community and visitors have one obvious access point for both routine and emergency health care.
    
    Rural communities in New Zealand have complained loudly when services have been lost through "centralisation" to larger centres. In amalgamating local services, the rural hinterland must not suffer a similar reduction in their services from ’centralisation’. In fact the opposite should occur. A well co-ordinated "one stop shop" in town will be in a better position to offer rural clinics and services.
    
    
• "In the correct manner" : respect and value
  • Providing health services in a bicultural nation with a multicultural population requires not only knowledge and skills, but also attitudes that respect and value the people served. Cultural safety   ⁹   and patient-centredness   ¹⁰   are key aspects of this respect for individuals.
    
    
• "With the correct equipment" : modern and maintained
  • The list of equipment used in primary care continues to grow rapidly. Computers, printers, faxes and modems are now required for communication in addition to the simple telephone. Spirometers, glucometers, otic thermometers and tympanometers are just some of the "meters" that are playing an increasing role in primary care. Costs do not relate simply to the capital cost of the technology, but also to the ongoing operating costs and the need to regularly upgrade old equipment once it becomes essential for routine care.
    
    
• "At the correct cost" : but who decides?
  • The correct cost will be different for the health care consumer, provider and funder because of their conflicting viewpoints. From a community perspective, the consumer would prefer a "free" quality health care service, even though they ultimately pay for it through higher taxes. The New Zealand National Government over its last two terms in office (1994-9) have introduced reforms to make health care much more market driven and open to competition. This unfortunate experiment has shown that health care doesn’t fit into the commodity model very well, as competing providers waste resources on such things as advertising and needless investigations to please the consumer. It also hasn’t benefited poor rural areas, which struggle to retain sufficient providers to provide a service, let alone compete. If a NZ Government is serious about addressing health inequalities between Maori and non-Maori, "this must logically mean that effective interventions, and associated resources, are targeted at deprived populations who have the greatest morbidity and mortality"   ¹¹  .
    
    
• "With the correct outcome" : documenting improvements in health outcomes
  • Quality must be measurable, otherwise it is simply anecdotal. A rural health team will want to prove to themselves and to others that their service is improving the health of the community. Furthermore, funders, with their limited budgets, now tend to put health outcomes in service contracts so that funding will go only to teams making a positive difference.
    
    It is obvious that the elements of a quality rural health service discussed above are interlinked and that no one profession can meet all the care requirements of patients, therefore rural health providers need to work together   ¹²  ,  ¹³  . The "one stop shop" approach facilitates teamwork by bringing providers together for better communication. It also enables a population perspective to be taken and makes the purchasing of expensive equipment needed for care and data collection more affordable. This in turn provides an attractive working environment that assists in retaining staff, attracts locums and makes recruiting new staff easier and, hopefully, with less frequency. Savings made from efficiencies and economies of scale can then be reinvested to further improve local health services.
    
    "Team" can be defined as a group of people who make different contributions towards the achievement of a common goal   ¹⁴  . "Teamwork" has been described as follows   ¹⁵  :
    1. The members of the team share a common purpose that binds them together and guides their actions.
    2. Each member of the team has a clear understanding of their own functions (appreciates and understands the contributions of other health professionals and recognises common interests).
    3. The team works by pooling knowledge, skills and resources and all members share responsibility (both positive and negative) for outcomes.
    4. The effectiveness of the team is related to its capacity to carry its work, and its ability to manage itself as an independent group of people.
       
       

International studies have suggested there may be potential benefits in having interdisciplinary collaboration between community-based primary health care professionals   ¹⁶  ,  ¹⁷  ,  ¹⁸  ,  ¹⁹  . New Zealand data also suggest that there may be effectiveness and efficiency gains when teams of health professionals from different disciplines work together within a defined population to improve services and reduce fragmentation   ²⁰  .

Remarkably, the evidence to prove that teamwork has a significant positive effect is scarce:

• One study of 68 UK primary health care teams found a positive relationship between multidisciplinary teamwork and effectiveness   ¹⁸  .
  
• A study of teamwork in primary health care in the US showed that families receiving team care had fewer hospitalisations, fewer operations, lower levels of physician visits for illness and more visits for health promotion in controlled families   ¹⁷  .
• Teamwork in primary care has been shown to enhance health care delivery and staff motivation   ¹⁹  .
• Multidisciplinary teamwork has also led to better detection, treatment, follow up and outcomes for a variety of patient conditions such as hypertension   ¹⁶  .
  

In contrast to these studies, others have suggested that teams may perform less effectively than individual members working alone   ²¹  . A recent review of the literature   ²²   found " no rigorous evidence supporting the use or abandonment of strategies to improve interprofessional collaboration, either for its direct effects on collaboration, or for its consequences for patients."

Despite no rigorous evidence either way, most health providers know from experience that teamwork improves patient care. To be able to support the teamwork concept with more than anecdotal evidence, further research about the benefit of primary health care teams is desperately needed.

" Collaboration should not be a panacea, nor an article of faith, nor dependent on haphazard circumstances, but a taught and resourced part of each profession’s repertoire of skills, organisation and culture."   ²³  

Part II – Wairoa, Hawke’s Bay: Current Health Care Providers and Services

The Wairoa district is a typical North Island rural area located in the northern Hawke’s Bay and has a population of 10,000, half living in the town of Wairoa and half in the district. The region is geographically isolated, and many people have to travel significant distances over poor roads to reach Wairoa. The socio-demographic profile   ²⁴   shows high percentages of Maori (57%), children (4-year-olds = 30%) and unemployment (37%); a low median income of $12,298; 49% of adults (15 years old) receive income support; 51% of the population have no educational qualifications; and 18% of the adult female population are single parents. The workforce is mainly employed in agriculture and fishing and related service industries.

Wairoa’s current health providers (Table 1) attempt to meet the high health needs of this poor rural area. The health services have evolved in an ad hoc manner over time, with the recent "health reforms" accelerating change. Significant amounts of money have been invested over the last few years in an effort to improve Wairoa’s poor health statistics. The Wairoa Hospital’s recent refurbishment (at a cost of $1,500,000), in an attempt to become a "one stop shop", has seen inpatient bed numbers reduced to 11 acute care and three "low risk" maternity beds. The hospital now includes a purpose-built medical centre large enough to accommodate all six GPs in town, although only one practice (two GPs) so far has signed a lease and moved in.

Significant investment occurred in community health care following Lynne Lane’s 1994 report   ²⁵   which highlighted Wairoa’s high health needs. There has also been greater community and iwi consultation, with increased funding of Maori health providers. Three rural Maori initiatives are now operating rural clinics, which offer a variety of primary health services (including GP clinics in partnership with local GPs), while two other Maori health services provide a range of health services to the district’s population.

While Wairoa has a poorly integrated health service compared to other areas, there are positive aspects of teamwork within it. Three of the local GPs provide the inpatient medical service, thereby ensuring a high level of integration between primary care and secondary rural hospital services. Two hospital nurses work part-time in other areas; one as a practice nurse, the other as a district nurse. These examples suggest that shortages of rural hospital doctors might be overcome with additional upskilling of local rural GPs, and show that nurses can expand out of rigid traditional roles (public health, district, practice, Plunket) to become multi-skilled rural generalist nurses.

Part III – Barriers to Integration

Despite the general agreement that better teamwork is needed in health care, barriers continue to prevent or hinder this from occurring. Barriers exist because of the differences in knowledge, skills, attitudes, philosophy, culture, expectations, goals and working conditions between potential team members. In addition in New Zealand, primary rural health care has been given conflicting messages from the government. While governmental policies have talked of the importance of integration: " The Government is keen to foster a variety of different approaches that may serve to integrate care in rural communities"   ⁴  , its actions have been to legislate for increased competition in health provision. Table 2 attempts to summarise these barriers for New Zealand rural health care.

While this list of barriers may look formidable, there are a number of examples of rural areas in New Zealand that have overcome enough of them to significantly improve the integration of their health service: Dannevirke, Balclutha, Gore, Ranfurly, Dargaville   ⁴  . Ironically, the main stimulus to change has been a threat to their health service, usually in the form of the historical dominant provider (ie, the HHS) exiting rural health care. This threat has been sufficient to enable local providers to put aside individual and personal issues (Table 2,   ⁵  ) to combine into a new more integrated service, there by ensuring their local community’s level of health service is maintained.

For poor rural areas like Wairoa, integration requires either (a) expert facilitation, combined with additional financial support and buy-in by key providers (ie, HHS, GPs, nurses, Maori) or (b) a crisis (eg, HHS exiting rural health or loss of GPs). Most rural areas that accomplish change seem to need the crisis.

References

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