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December 2002

World study of rural health best practices

By Wendy Abbott [B. Occ. Thy.]
Occupational Therapist at Warwick Health Service,
Bluecare Stanthorpe,
and the Department of Veterans Affairs Country Panel.

Last year I was fortunate enough to win a Churchill Fellowship to investigate models of allied health service delivery in rural areas in Canada, USA , England, Scotland, and Ireland.

The aim of project was to explore the best cost effective way of achieving optimal quality, evidence based outcomes, given the limited resources allocated to health care in rural Australia. The focus was particularly on the provision of occupational therapy services to the aged and people with disabilities, in their home environment.

For over 20 years I have been the only regular Occupational Therapist servicing a higher than average aged and disabled population (25%), in the largely rural area of the Southern Queensland Downs and Northern Tablelands of New South Wales, over 30,000 square kilometres. I have long been frustrated by the tyranny of distance, lack of community access to services and resources, inadequate allied health funding (presently at 3% of the total health budget for the region), and the difficulties attracting and retaining allied health professionals, who include physiotherapists, speech pathologists, social workers, podiatrists, dieticians, psychologists, etc. The basis of the present limited Australian research on rural allied health service provision has been largely modelled on the Northern Territory rural and remote healthcare system, highlighting innovative programmes involving indigenous populations. Whilst important research, it appears to be inappropriate to apply to "closer rural" and definitely less remote areas such as mine.

On my Fellowship, I investigated proven models of allied health service delivery in comparable rural communities around the world, and centres of excellence supporting the elderly and disabled in their own environment. Hopefully I am now better able to influence the use of our limited allied health budget, to be more cost effective, linked to evidence based outcomes, and directed more towards primary health care and community education empowerment. My position on the district Allied Health Provider's Network, and my access to community support groups through being part of a well respected ancillary health agency, has enabled me to disseminate positive feedback from my study tour, and hopefully shape future allied health initiatives in our region.

Sascka Poles - some equipment I'd never seen before in an equipment store Alberta Canada.

The program
2 weeks sponsored by Faculty of Rehabilitation Medicine, University of Alberta, Edmonton. Visited centres at Edmonton, Vegreville, Stony Plain, Edson, Rocky Mountain House, Peigan Indian Reserve, Crowsnest Pass, and Blairmore.
1 week sponsored by School of Health Professions, University of Missouri, Columbia. Visited centres at Columbia, Boonville, Bland, Fort Leonardwood, Rolla, Belle, California, and Centertown.
1 week sponsored by Occupational Therapy Program, University of St. Augustine, St. Augustine, and Department of Occupational Therapy, University of Florida, Gainesville. Visited centres at St. Augustine, Gainesville, Brooker, and Dowling Park.
1 week sponsored by Highland Primary Care Health Trust, Wick. Visited centres at Wick, and Canisbay.
1 week sponsored by Community Care Centre, Wicklow. Visited centres at Dublin, Wicklow, Greystones, Loughlinstown, Carnew, and Hacketstown.
1 week sponsored by Ottery St. Mary Hospital, Exeter. Visited centres at Ottery St. Mary, and Exeter.

Firstly I need to acknowledge that I would not have been able to absorb as much information about the various countries' health systems as I did, had it not been for the extreme generosity of all the people I encountered in my travels, whether it was professors, deans of schools, doctors, lecturers, clinical nurses, researchers, directors, co-ordinators, occupational therapists, allied health teams, or patients/clients I was privileged to meet, all over the world. I am also indebted to the many folk who invited me to stay in their homes, thereby being able to experience the culture of each region more fully (as well as ease any feelings of homesickness I may have had)!

I wish to add how disappointed I was at having to cancel my visit to the Clalit Health Maintenance Organization in Jerusalem, Israel, as was proposed in my original submission, to observe an innovative and very successful Home Hospitalization programme. On the federal Department of Foreign Affairs advice, I reluctantly decided not to put myself in any potential personal danger in a politically unstable country, at the point of my departure. Ironically I was actually in the World Trade Center buildings in New York nine weeks to the day before the catastrophic events of September 11th, 2001!

Because of the diverse nature of health systems I visited around the world, it was not possible to compare them with our Australian health philosphy with any sense of a level playing field". I listed significant aspects of each country's healthcare provision under individual country classifications as Western healthcare philosphy differs markedly in each country visited.


As an overview, after my visits to all highly developed "Western" countries, I would have to say Australia is faring reasonably well, in most aspects of healthcare provision, given our large, mostly arid country, hugely scattered population, multi-cultural diversity, constrained budget, and being relatively young in the settlement of the world.

We can be justifiably proud of our relatively recent advancements in raising public awareness of disabled people's rights to equal access, equal opportunity, and policies of non-discrimination. Access to public spaces is gradually becoming more disabled-friendly, transport and communication issues are being addressed, albeit slowly due to budgetary constraints, and housing options are becoming more wheelchair friendly. Compared to the bulk of public housing I visited overseas, Australia is making a significant effort to purpose build all new public housing with the disabled in mind, and funding modifications to existing public dwellings on the advice of health professionals.

We are sadly lacking in appropriate funding grants to allow people to modify private dwellings to increase their independence, as observed in Canada, UK, and Ireland, with the only section of the community with access to such services, the War Veteran population. On the subject of services accessed by these veterans, Australia definitely has the most comprehensive and diverse programmes to assist this section of the community to "age in place".

Another area of expertise that became evident to me after my travels, is the high regard for our tertiary training of allied health professionals, in international circles. Australian trained therapists are warmly welcomed and sought after in most overseas employment situations, and overseas trained therapists/educators/ students would like to partake of the Australian work experience, seeing us as offering a much more diverse view of their professions, especially occupational therapists. I intend to follow up on the possibility of offering overseas students practical placements, especially therapy students wishing to get a broad overview of rural community OT service provision. Occupational Therapists in this country have really seized on the opportunity to secure their position as the best health professionals to assess functional need and then design for independence, being intimately involved in assessing for, recommending, and designing specific modifications/ alterations to suit the client. This skill appeared neglected in some countries, resulting in inappropriate use of often very generous funding resources, an observation that frequently frustrated me.

Home on Indian Reserve Alberta Canada.
No Occupational Therapy involvement in any home modifications.

Home with two elaborate ramps, however the resident is still stuck inside the house because both ramps are the wrong gradient for her wheelchair.

Upon reflection of the various countries' use of nurses in community settings, I am pleased to report that Queensland's non-government home nursing agencies [and I am best qualified to use Bluecare as the comparison, it being the biggest agency in Qld, and one of my employers], are unique in providing holistic care to the aged and disabled, in their own homes. Health professionals in countries I visited were envious of the range and frequency of services offered, and were astounded at the distances we sometimes cover, with the luxury of an employer provided vehicle. The District Nurses in remote Scotland felt they had had a particularly tiring day after travelling 150 kilometres all up; I didn't like to tell them I travel that to and from work each day!

Since my return I have given many guest lectures to professionals, community groups, and the general public, supported by a slide series of entertaining aspects of my Fellowship, with particular emphasis on what constitutes a universally recognised disabled toilet or bathroom!! I hadn't realised the extent of my fascination for the endless variations of a "disabled toilet" until one member of the public, after the slide show, suggested it should have been titled "Toilet Tour of the World". I also have a pictorial resume of my wonderfully diverse trip (32 rolls of film altogether!), and much to the increasing distress of the baggage check-in clerks at each airport, I managed to collect armloads of potentially useful assessment documentation, innovative product catalogues, information booklets, service provision rationale, specific agency data, research articles, etc.

I have collated all this with a view to pursuing specific avenues of follow-up and contacts, as time permits, as well as pass the collected information on to relevant agencies to use in funding submissions, research, etc. I have started to track down rehabilitative equipment not seen before in Australia, but commonplace and very effectively used in rural settings in other countries. I also collected specific data relevant to the various community groups I am involved in, eg Parkinsonism literature, brochures relevant to the local Visually Disabled Self-Help group, innovative community transport schemes, disability guidelines, home modification schedules, etc.

As a rural representative for allied health, I have been invited to sit on a Queensland Health state-wide working party looking into Admission of the Aged to Hospital. I have written several articles for local, regional, and state publications. I have been pursuing any opportunity to represent my profession and/or rural community, in order to disseminate the wealth of information gained on the Fellowship, and promote the unique concept of Churchill Fellowships. Please feel free to contact me if you would like more information or access to the resources I collected.

Postal Address:

P. O. Box 68,
Glen Aplin, Queensland, 4381.

Phone: 07.46616853 [W]
Fax: 07.46616825 [W]

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