Governments have responded to the range of rural health issues through a variety of programs. This section describes this public policy context within which MSOAP and VOS operate and offers a schema for understanding the general intent and mechanism of delivery of the various programs.
Mainstream programsPublic sector responsibility for health policy and service delivery in Australia is split across Commonwealth and state/territory levels of government. Both levels of government fund and manage a range of ‘mainstream’ programs through which the major components of health services are supported. Mainstream programs include:
- Medicare or the Medical Benefits Scheme (MBS) and the equivalent program for Veterans (RMBS), which is funded by the Commonwealth Government. Through these schemes benefits are paid in relation to services provided by private medical practitioner services and some allied health practitioners including optometrists. MBS and RMBS expenditure accounted for 20.9% of total public sector health funding in Australia in 2008-09.
- The Pharmaceutical Benefits Scheme (PBS) and the equivalent program for Veteran (RPBS), which is also funded by the Commonwealth Government. Through this scheme benefits are paid in relation to pharmaceuticals provided principally by private sector pharmacists. PBS and RPBS expenditure accounted for 10.4% of total public sector health funding in Australia in 2008-09.
- Public hospitals are funded jointly by the Commonwealth Government and state/territory governments. Public hospital expenditure accounted for an estimated 42.3% of total public sector health funding in Australia in 2008-09.
- Community health services are funded partially by the Commonwealth Government (in particular Aboriginal and Torres Strait Islander health services) and state/territory governments. Community health expenditure accounted for an estimated 7.4% of total public sector health funding in Australia in 2008-09.
To address various gaps and issues with mainstream programs, a variety of other programs have been developed at the Commonwealth and state/territory levels and jointly between governments. Many of the programs are targeted at issues related to improving access to services for people living in rural and remote areas. These are described in the following section.
Rural and remote targeted programsIn addition to mainstream services, there are many Commonwealth and state/territory programs targeted at addressing the specific needs of people living in rural and remote Australia. Several of these programs are described in Appendix E. There are many programs that have some focus on issues for rural and remote communities. Table 23 below lists the major Commonwealth programs with a rural/remote focus.
Table 23 – Department of Health and Ageing programs with a rural focus, 2011-12
|Programs:||DoHA outcome area:|
|Rural Pharmacy Maintenance Allowance||x|
|Rural Pharmacy Workforce program||x|
|Visiting Optometrists Scheme||x|
|After Hours Other Medical Practitioners program||x|
|MedicarePlus for Other Medical Practitioners program||x|
|Rural Other Medical Practitioners program||x|
|Temporary Resident Other Medical Practitioners program||x|
|Higher Bulk Billing Incentives for GPs in Regional, Rural and Remote Areas, Tasmania and Metropolitan Areas||x||x|
|Multi-Purpose Services program||x|
|Rural and Remote Building Fund||x|
|Aged Care Adjustment Grants for Small Rural Facilities||x|
|Training for Rural and Remote Aged Care Staff||x|
|Viability Supplement for Community Aged Care in Rural and Remote Areas||x|
|Capital Infrastructure Support (provides funding for the Indigenous Aged Care Plan)||x|
|Practice Incentives program including: Domestic Violence Incentive; Procedural General Practitioner (GP) Payment; Rural Loading; and Rural Practice Nurse Incentive||x|
|Mental Health Services in Rural and Remote Areas (COAG)||x|
|Mental Health Support for Drought Affected Communities initiative||x||x|
|Australian General Practice Training program||x|
|Rural Retention program||x|
|Expansion of Training for Rural and Remote Procedural GPs program||x|
|Remote Vocational Training Scheme||x|
|Rural and Remote General Practice program||x|
|Prevocational GP Placements program||x|
|HECS Reimbursement Scheme||x|
|Rural Registrars Incentive Payments Scheme||x|
|Workforce Support for Rural General Practitioners (Divisions of General Practice)||x|
|Royal Flying Doctor Service program||x|
|Rural Women’s GP Service||x|
|Rural Primary Health Services program||x|
|Medical Specialist Outreach Assistance program||x|
|National Rural and Remote Health Infrastructure program||x|
|Supporting Women in Rural Areas Diagnosed with Breast Cancer||x|
|General Practice Rural Incentives program||x|
|Rural Procedural Grants program||x|
|Rural Locum Relief program||x|
|Rural Health Multidisciplinary Training program, incorporating: Rural Clinical Schools program, Dental Training Expanding Rural Placements program, University Departments of Rural Health program, Rural Undergraduate Support and Coordination program, John Flynn Placement program||x|
|Recruitment, Support, Coordination and Assistance for Overseas Trained Doctors||x|
|Rural Australian Medical Undergraduate Scheme||x|
|Medical Rural Bonded Scholarships Scheme||x|
|Medical Rural Bonded Scholarships Support Scheme||x|
|Bonded Medical Places Scheme||x|
|Bonded Medical Places Support Scheme||x|
|National Rural Locum program||x|
|Consolidation of Continuing Education and Training Support for Rural Health incorporating: Rural Health Support, Education and Training program, Rural Health Education Foundation, Rural Advanced Specialist Training Support, Support Scheme for Rural Specialists||x|
|Improving Access to Primary Care Services in Rural and Remote Areas (COAG)||x|
Source: DoHA 2011dTop of page
Commonwealth programs which have a particular relationship with MSOAP and VOS are:
- Rural Women’s GP Services (RWGPS): RWGPS funds the travel of female GPs to rural communities in all states and the Northern Territory. The program is contracted through the Royal Flying Doctor Service (RFDS). The aim of the program is to provide GP services for women where there is not a female GP available as some women prefer to see a female GP to discuss personal health matters. Communities have to apply through the RFDS and meet the requirements that their community/cluster of communities is at least 1,000 people, have reasonable access to a male GP and have no female GP within 50km. Typically the service will provide visits for a location between once a month and once every six months.
- Indigenous Chronic Disease Package - Primary Care (Commonwealth): In addition to MSOAP-ICD, the package includes the Increasing Specialist Follow-up Care Measure and Care Coordination and Supplementary Services (CCSS) Program. These provide care coordination for eligible Aboriginal and Torres Strait Islander patients with a chronic disease, and provide a funding pool to assist patients in accessing specialist and allied health services in accordance with their care plan.
- Maternity Services Reform Package: This program includes the MSOAP Maternity Services expansion and also aims to provide more access to midwives through increased MBS and PBS benefits and indemnity insurance for midwives, provide additional training and support for GPs and midwives to expand maternity workforce, particularly in rural and remote areas and expand and improve the National Pregnancy Telephone Counselling Helpline.
- Mental Health Services in Rural and Remote Areas Program: This program is designed to provide better access to mental health services in rural and remote communities. The program is part of the Australian Governments component of the COAG National Action Plan on Mental Health 2006-2011 and is run by DoHA. The program is meant to work alongside the Better Access to Psychiatrists, Psychologists and General Practitioners through the Medicare Benefits Schedule (MBS) initiative to fund additional services where Medicare funded services are not as readily available. Funds are provided in a flexible manner to organisations such as GP divisions, the RFDS and AMSs to provide mental health services. The service in each location caters to local needs and is designed to be set up in areas of high need for the service.
- Remote Service Delivery for Indigenous Australians: Under the Closing the Gap in the Northern Territory National Partnership Agreement, funding is provided for follow-up ear, nose and throat (ENT) and dental services to Indigenous children under the age of 16 years with outstanding referrals from a child health check. In 2010-11, 329 ENT consultations and 35 occasions of ENT surgery will be funded under the Agreement.
- Royal Flying Doctor Services (RFDS): The RFDS has been funded by the Australian Government for over 75 years. It also receives funding from some state and territory governments. The RFDS provides aero-medical transport and health services to people who live, work or travel in remote regions of Australia. The main services of the RFDS are: 24 hour emergency service for serious or critical illness or injury outside of the normal medical infrastructure, provision of primary and community health care clinics at remote sites and the provision of medical chests to isolated locations. The Australian Government funds the recurrent and capital costs of the RFDS. State and territory governments fund the transfer of patients between hospitals.
Telemedicine items have been included in the MBS for psychiatry from around 2000. In the 2011-12 budget, the Commonwealth government announced a major extension to telemedicine under MBS. From July 2011, Medicare rebates for online consultations across a range of medical specialties will be available. Telehealth facilities located in GPs, aged care facilities, AMSs and certain other, non-medical facilities, will be able to videolink patients in rural, remote and outer metropolitan areas with specialists in cities or major regional centres. The patient may be accompanied by their GP or a nurse practitioner, midwife, Aboriginal and Torres Strait Islander health worker or practice nurse. The telehealth initiative includes:
- New Medicare items that will allow a range of existing consultation services to be provided via video conferencing and additional rebates on top of these items recognise the increased complexity of providing a service to a remote patient. There will be a 50% additional rebate for the specialist service and a 35% additional rebate for the service provided by the practitioner at the patient end. Payments are applicable for both the specialist and the GP, nurse, midwife or Aboriginal health worker assisting the patient during the consultation.
- A financial incentive being provided to encourage all health professionals to incorporate telehealth services into their day to day practice by including a $6,000 incentive when a health practitioner provides their first consultation.
- Bulk billing is encouraged with extra telehealth bulk billing incentives to be paid at a rate of $20 each time a practitioner bulk bills a service in the first year.
- $50 million to expand the GP after hours helpline and include the capacity for the helpline to provide online triage and basic medical advice via videoconferencing.
- Training and supervision for health professionals using online technologies.
A range of telemedicine services have also been supported under MSOAP. The new MBS arrangements will not include services such as Tele-Derm, where a request for assistance occurs via email.
States and territories have also implemented a range of telemedicine arrangements. These arrangements include the establishment of infrastructure that can be used by private practitioners as well as hospital/health service employees. There is not clear view of the extent of current telemedicine arrangements across Australia.
At the state and territory level a range of targeted programs exist including:
- State/territory based aeromedical services: States and territories are involved in support or provision of aeromedical services in addition to the RFDS.
- State/territory based outreach programs: States and territories have also established a range of outreach services. Many of these arrangements are established and negotiated by local hospitals. Many of these arrangements are very long standing, and involve public hospital based clinical teams that have been servicing specific communities over many years.
- Patient Assisted Travel Schemes: One of the principal ways in which states and territories assist access is through patient assisted travel schemes (PATS) which go by various names in the different jurisdictions. The first program in Australia to fund patient travel to health care was in 1978 and was managed by the Australian Government, called the Isolated Patient Travel and Accommodation Assistance Program (IPTAAP). From 1987, this program was transferred to state and territory control. Each state and territory currently operates its own program to assist patients in travel to medical services. The programs in each state and territory are similar, but the specific payment levels and eligibility requirements vary. The first requirement is that the patient must be going for an approved type of care; some specialist visits are covered, whereas others are not. Typically, there are also requirements around having a proper referral from a doctor or sometimes another health care professional. Some states also accommodate bulk reimbursement for people with conditions that require regular visits to a specialist, such as for cancer treatment, to make applying for funds simpler. The availability of local services is also a factor in determining eligibility. The closest available service must be a minimum distance from the patient for funding to be provided. Payment levels for travel programs also vary by state and level of need.
- Private health insurance policies can also include patient travel assistance, which can be used to cover the cost of visiting a health care provider.
- Several important criticisms have been raised about these programs, including lack of uniformity, levels of reimbursement, and challenges to accessing funds. The lack of uniformity in programs means that access to care is not equal for all Australians; depending on where you live, you may or may not receive funds or they may be insufficient to cover expenses. The levels of reimbursement also do not reflect current costs of travel and accommodation.
- Other patient transport schemes: Health services and public hospital services provide a range of patient transport arrangements to patients requiring support to attend consultations and hospital services. These services may be operated through the hospital itself, a non-government organisation or in conjunction with an ambulance service. Arrangements vary considerably across health services and communities.
How programs address access issuesThe programs discussed above have five principal mechanisms through which they are intended to improve service delivery for rural and remote populations. These include:
- To strengthen local health service infrastructure and viability. For example, by pooling funds across hospital and aged care, the MPS model seeks to create a more cost effective and hence financially viable business model for both hospital and aged care is small townships.
- To provide support for more appropriate models of service delivery. For example, the Section 100 provisions for the Pharmacy Support Allowance Program have created a much more flexible mechanism through which Indigenous people in remote communities can access pharmaceuticals.
- To create incentives for practitioners to relocate or remain in practice in rural and remote regions. For example, a range of locum initiatives have been implemented to facilitate access to locums for rural and remote practitioners. These schemes address what has been a significant problem for rural practitioners and a disincentive to set up or continue practicing in rural locations. Similarly, a range of financial incentives are available to encourage practitioners in rural settings.
- To support outreach services into rural and remote areas. MSOAP and VOS are both examples of programs that have assisted practitioners based in metropolitan or regional areas to travel to rural and remote communities to provide outreach services.
- To remove access barriers using telecommunications. An alternative to service providers travelling to communities is to allow patients and service providers to communicate by video links. Telemedicine options reduce travel costs involved for service providers and also potentially for patients, although patients may still have to travel to a location at which adequate video conferencing facilities are available. MSOAP is currently supporting a range of Telemedicine arrangements, but these are also being pursued more widely within the health system.
- To assist patient to travel to regional and urban locations. Patients may be assisted to travel, or provided with transport, to travel to a location at which they can receive a service.
Table 24 – Initial analysis of the focus of programs targeted at rural and remote populations
|Service delivery improvement mechanism||Primary care||Secondary/specialist|
|Strengthen local health service infrastructure and viability||
|Support for more appropriate models of service delivery||
|Incentives for practitioners to relocate/remain in practice in rural/remote regions||
|Outreach services into rural and remote areas||
|Assisting patients to access services||
It is important to emphasise that these ‘mechanisms’ are not mutually exclusive. In many instances, several mechanisms need to be in place. For example, an outreach service needs an appropriate location in which the service can be delivered. Also, a patient may need assistance to travel from a more isolated location to attend an outreach services being provided in a small township.Top of page