Team Work in Remote Health Services

The following article appeared in 6minutes about nurses, GPs and teamwork in one remote health service.

Many concerns have been expressed over an expanded role for nurses in future General Practice. One area that may be neglected is the effect on team structure.

I have worked in teams with nurses in the past where there was a great cooperation between nurses and doctors and for many years my immediate boss in several jobs was a nurse. I have been an advocate of nurse practitioners. However 18mths ago I moved to a remote area of NT where there has been a shortage of doctors for many years. Because nurses have been given extra powers and have managed without a doctor for many years, they resent our presence and our input. I am now leaving, for the same reason my predecessors did. There is no teamwork with nurses who say “I am an independent practitioner.” Doctors are regularly asked ” Are you looking after this patient or am I?’. If we are, the nurse leaves!

I do not want to be waited on, and have always been happy to value add in those areas where I have more expertise than the nurse, such as in physical examination, complicated diagnosis and pharmacology. I believe antenatal patients do benefit from seeing a doctor twice during the pregnancy and not being managed totally by a midwife. We are regularly not called for such emergencies as the birth of a prem baby, or a patient with an AMI having reteplase and developing VT as a perfusion arrhythmia!

I am not an independent practitioner – I want to work in a team where everyone has their own area of expertise recognised.

Please, Ms Roxon, do not change all general practices to this model which is not working in NT.

I think it is a little unjust to say a system does not work based on one example. Dr Alex Hope, a remote GP for many years placed the following post into the CARPA (Central Australia Rural Practitioners Association) discussion group (as well as commenting at 6minutes).

G’day All,
You may be interested in this link to which is pertinent to remote GPs and remote clinics in the NT.
I’ve never come across this doctor, but her comment encapsulates a problem that collectively we should have fixed by now.

For myself, I have to admit I gave up working on the structural end of the problem 7 years ago. Soon after getting involved with the Division I was involved in discussions about two remote GP positions where the GP suffered especially as a result of impossible working conditions in a government clinic.

After 5 years of involvement in the system through the Division and the then NTRHWA I couldn’t see that there was much happening for the blackfellas in the scrub as a result, nor for the GPs (and other staff) who were prevented from making the best use of their skills because of the structural limitations they worked under. I thought my energies and skills would be better spent on making the model work on the ground, and it’s quite enough to keep me fully occupied.

Reading this post by the Galiwinku GP gave me a strong feeling of deja vue.

    Where is the blockage in the system?
    Are we really on track to fixing things using the opportunities offered by phase III of Mad Mal’s invasion?
    Does this strategic review of Nicola Roxon’s offer another opportunity to move things along?

I really do believe that we should be proud of the functional examples
of primary health care delivery in Aboriginal Australia, and that it
does offer a model to the mainstream.

How can we foster and generalise it?

There are many ways in which health is provided out bush. It may be nurses provided by a government department and fly-in, fly-out doctors. It could even be a large community with a core group of nurses working for a long intervals in-between doctors out visiting for a short term contract. In others, all staff are employed by the health service with roles clearly defined. Some clinics are with sole GPs making their money by bulk-billing Medicare for their consults with patients. Staff turn-over is high amongst doctors and remote area nurses. This also affects patients and other health workers who have just got used to someone and then relationships have to be developed over again. Continuity of care can also be disrupted. Despite all this and the remoteness of some health services the majority of those I have been involved in over 10years or so work well.

There are also the flash in the pan visits. Pharmacists visiting under the S100 support allowance may fly or drive in(if flown in often the nurse has to leave the clinic to pick them up), physicians may visit under MSOAP arrangements, other organisations such as NPY also visit, or depending on your location, ring about a patient and want to become involved.

Funding is often not long term. Over the last twelve months as an example our planes were flying only with 3 month contracts from DOTARS. “Mr Smith, we can fly you in to get to hospital for your operation. We just don’t know when we can get you home”.

Funding needs to be provided over a longer term and adequate funding needs to be provided. Access Economics suggest the funding needs to be increased by $150m, $250m, $350m, $400m, $500m per annum over 5 years and then sustained at this level until the Indigenous Australian health gap closes. Oxfam and other agencies regularly suggest $400 million is required now and then every year to provide equitable access to healthcare.

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NT Intervention a Failure – How Could That Be?

The Intervention has been running in the NT for a year now and is under review. For those of you in Australia that have been under a rock the Northern Territory Emergency Response was ostensibly brought in by the last government to stop all the child abuse they knew was happening in the NT. I don’t know if they actually identified one case.

But the Intervention is under review. The NTER Review Board is on the job to see if it was beneficial for kids health. Most who have worked bush says it mainly duplicated what was there, and from what I understand in some instances were reporting incidences of disease far lower than what was known to be there.

Twenty-eight doctors have made a formal submission to the NTER Review Board. many of these doctors came to the Territory to assist with the Intervention. And their view – “health checks for indigenous children under the federal intervention have largely been useless.”

“health checks have been costly but ineffective.” (quote from ABC)

They also stated the obvious. The health checks do not make a difference to the child, it is the follow up treatment that provides this. “The main thing about child health checks is that in of themselves they will not improve the health of that child,” she said.

And that is where we require the funding. To ensure we can get people in to town and back for their operation. Lets spend the money on these areas rather than it waste it all on duplicating resources.

I have placed a post on the Intervention previously.

The Intervention: Develop Some Real Solutions

Thanks to the cache on the internet here is an earlier post I lost from Monday Aug 11th.

“I have just completed a six-week stint working as a sexual health specialist in remote Central Australian Aboriginal communities, during which time I revisited many places where I had previously worked and lived as a remote area nurse over a 10-year period. During my latest stint, I was not with the NT Intervention but part of the annual Tri-State screening for STIs (sexually transmitted infections) in Central Australia.

While I saw some positive effects of the Intervention, I have also been horrified by the many negatives.

I am particularly concerned by the huge waste of resources with the child health checks program. What was the point of spending so much money effort describing problems that were already well described? Children in remote communities are the most examined there are in Australia. The Intervention has not turned up anything that was not already known, and it is the follow up treatments that need to be concentrated on.”

So started the article penned by remote area nurse, Chris Wilson in an article in today’s Crikey newsletter. Take a look at the full article here also have a page of comments and articles on the Intervention here

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