The efficiency, timeliness, health outcomes and cost-effectiveness of a new aeromedical retrieval model in Central Australia: A pre- and post-implementation observational study.

OBJECTIVE: To assess timeliness, efficiency, health outcomes and cost-effectiveness of the 2018 redesigned Central Australian aeromedical retrieval model. DESIGN: Pre- and postimplementation observational study of all patients receiving telehealth consultations from remote medical practitioners (RMPs) or Medical Retrieval and Consultation Centre (MRaCC) physicians between 1/1/2015 and 29/2/2020. Descriptive and inferential statistics measuring system efficiency, timeliness, health outcomes and incremental cost-effectiveness. FINDINGS: There were 9%-10% reductions in rates of total aeromedical retrievals, emergency department admissions and hospitalisations postimplementation, all p-values < 0.001. Usage rates for total hospital bed days and ICU hours were 17% lower (both p < 0.001). After adjusting for periodicity (12% fewer retrievals on weekends), each postimplementation year, there were 0.7 fewer retrievals/day (p = 0.002). The mean time from initial consultation to aeromedical departure declined by 18 minutes post-implementation (115 vs. 97 min, p = 0.007). The hazard of death within 365 days was nonsignificant (0.912, 95% CI 0.743-1.120). Postimplementation, it cost $302 more per hospital admission and $3051 more per year of life saved, with a 75% probability of cost-effectiveness. These costs excluded estimated savings of $744,528/year in reduced hospitalisations and the substantial social and out-of-pocket costs to patients and their families associated with temporary relocation to Alice Springs. CONCLUSION: Central Australia's new critical care consultant-led aeromedical retrieval model is more efficient, is dispatched faster and is more cost-effective. These findings are highly relevant to other remote regions in Australia and internationally that have comparable GP-led retrieval services.

Telehealth in remote Australia: a supplementary tool or an alternative model of care replacing face-to-face consultations?

BACKGROUND: The COVID-19 pandemic increased the use of telehealth consultations by telephone and video around the world. While telehealth can improve access to primary health care, there are significant gaps in our understanding about how, when and to what extent telehealth should be used. This paper explores the perspectives of health care staff on the key elements relating to the effective use of telehealth for patients living in remote Australia. METHODS: Between February 2020 and October 2021, interviews and discussion groups were conducted with 248 clinic staff from 20 different remote communities across northern Australia. Interview coding followed an inductive approach. Thematic analysis was used to group codes into common themes. RESULTS: Reduced need to travel for telehealth consultations was perceived to benefit both health providers and patients. Telehealth functioned best when there was a pre-established relationship between the patient and the health care provider and with patients who had good knowledge of their personal health, spoke English and had access to and familiarity with digital technology. On the other hand, telehealth was thought to be resource intensive, increasing remote clinic staff workload as most patients needed clinic staff to facilitate the telehealth session and complete background administrative work to support the consultation and an interpreter for translation services. Clinic staff universally emphasised that telehealth is a useful supplementary tool, and not a stand-alone service model replacing face-to-face interactions. CONCLUSION: Telehealth has the potential to improve access to healthcare in remote areas if complemented with adequate face-to-face services. Careful workforce planning is required while introducing telehealth into clinics that already face high staff shortages. Digital infrastructure with reliable internet connections with sufficient speed and latency need to be available at affordable prices in remote communities to make full use of telehealth consultations. Training and employment of local Aboriginal staff as digital navigators could ensure a culturally safe clinical environment for telehealth consultations and promote the effective use of telehealth services among community members.

Addressing the GP vocational training crisis in remote Australia: Lessons from the Northern Territory.

OBJECTIVE: GP vocational training enrolments are declining Australia-wide and, in the Northern Territory (NT), considered by some as '…the litmus test for the national scene' the decline is precipitous. This research investigates the drivers of declining GP training uptake in the NT and identifies and ranks potential solutions. SETTING: NT, Australia. PARTICIPANTS: Ten senior medical students, 6 junior doctors, 11 GP registrars, 11 GP supervisors and 31 stakeholders. DESIGN: Mixed methods: scoping review of Australian literature mapping key concepts to GP training pathway stages and marketing/communications; secondary data analyses; key informant interviews; and a stakeholder validation/prioritisation workshop. Interview data were thematically analysed. Workshop participants received summarised study findings and participated in structured discussions of potential solutions prior to nominating top five strategies in each of five categories. RESULTS: Highly prioritised strategies included increasing prevocational training opportunities in primary care and selecting junior doctors interested in rural generalism and long-term NT practice. Also ranked highly were: [Medical School] ensuring adequate infrastructure; [Vocational Training] offering high quality, culturally sensitive, flexible professional and personal support; [General Practice] better remunerating GPs; and [Marketing] ensuring positive aspects such as diversity of experiences and expedited GP career opportunities were promoted. CONCLUSION: Multifaceted strategies to increase GP training uptake are needed, which target different stages of GP training. Effective action is likely to require multiple strategies with coordinated action by different jurisdictional and national key stakeholder agencies. Foremost amongst the interventions required is the urgent need to expand primary care training opportunities in NT for prevocational doctors.

Evaluation of a new medical retrieval and primary health care advice model in Central Australia: Results of pre- and post-implementation surveys.

INTRODUCTION: In February 2018 the Remote Medical Practitioner (RMP)-led telehealth model for providing both primary care advice and aeromedical retrievals in Central Australia was replaced by the Medical Retrieval and Consultation Centre (MRaCC) and Remote Outreach Consultation Centre (ROCC). In this new model, specialists with advanced critical care skills provide telehealth consultations for emergencies 24/7 and afterhours primary care advice (MRaCC) while RMPs (general practitioners) provide primary care telehealth advice in business hours via the separate ROCC. OBJECTIVE: To evaluate changes in clinicians' perceptions of efficiency and timeliness of the new (MRaCC) and (ROCC) model in Central Australia. DESIGN: There were 103 and 72 respondents, respectively, to pre- and post-implementation surveys of remote clinicians and specialist staff. FINDINGS: Both emergency and primary care aspects of telehealth support were perceived as being significantly more timely and efficient under the newly introduced MRaCC/ROCC model. Importantly, health professionals in remote community were more likely to feel that their access to clinical support during emergencies was consistent and immediately available. DISCUSSION: Respondents consistently perceived the new MRaCC/ROCC model more favourably than the previous RMP-led model, suggesting that there are benefits to having separate referral streams for telehealth advice for primary health care and emergencies, and staffing the emergency stream with specialists with advanced critical care skills. CONCLUSION: Given the paucity of literature about optimal models for providing pre-hospital medical care to remote residents, the findings have substantial local, national and international relevance and implications, particularly in similar geographically large countries, with low population density.

What progress can the Australian Journal of Rural Health celebrate on its thirtieth anniversary?

Thirty years ago the first edition of the Australian Journal of Rural Health (AJRH) was published. Following reviews published in 2002 and 2012, it is again time to review what progress has been made in bringing about improved health outcomes for residents of rural and remote Australia over the past decade. Compounded by the Covid-19 crisis that has affected the health and health care system throughout Australia, this review notes the significant lack of progress over the past decade in ameliorating ongoing problems of poor access to primary health care and associated avoidable hospitalisations, persistent poor health of Indigenous Australians, and the greater prevalence of a range of health risk factors. Following the findings of the recent New South Wales enquiry into rural health, this review highlights what is needed to implement the many recommendations that have emerged from the wealth of evidence-based research published in journals such as the AJRH to improve health outcomes and increase the parity and equity in health between metropolitan and non-metropolitan Australians.

Optimising medical retrieval processes and outcomes in remote areas in high-income countries: A scoping review.

OBJECTIVE: This scoping review explores the structure and process-level strategies that are associated with medical retrieval outcomes. A secondary aim is to identify the range of medical retrieval outcomes used to assess the performance of remote retrieval services. DESIGN: A scoping review of peer-reviewed literature from PubMed, CINAHL and the Web of Science was undertaken following guidelines set by the Johanna Briggs Institute manual for scoping reviews. All articles were assessed by two reviewers. Themes were derived inductively from the data extracted. SETTING: Medical retrievals in sparsely populated remote locations in high-income countries. PARTICIPANTS: Staff and clients of remote medical retrieval services. INTERVENTIONS: Structures and processes (e.g. resource availability, retrieval staff structures and governance protocols) that aimed to improve medical retrieval outcomes. OUTCOMES: Patient health outcomes and service efficiency. RESULTS: Twenty-four articles were included. Three broad themes, related to the nature of the interventions, were included: optimising prehospital management of retrievals, staffing and resourcing of retrieval services and retrieval model evaluation. Mortality was the most frequently used outcome indicator in these studies, but was not measured consistently across studies. CONCLUSIONS: This review highlights significant gaps in the literature that describes the structure and processes of retrieval models operating in remote areas and a dearth of literature evaluating specific operational strategies implemented within medical retrieval models. The available literature does not meaningfully assist with identifying key outcome indicators for developing a consistent monitoring and evaluation framework for retrieval services in geographically, culturally and demographically diverse remote contexts.

YArnhem: Co-designing a model of social and emotional wellbeing stepped care for young people of the north east Arnhem region: A development study protocol.

INTRODUCTION: More Aboriginal and Torres Strait Islander young people experience high or very high levels of psychological distress compared to their non-Indigenous counterparts. This may be partly attributed to systemic barriers resulting in lower rates of help-seeking, sub-optimal identification of psychological challenges, and undertreatment. Reducing these barriers within health systems is an important factor in reducing the Social and Emotional Wellbeing (SEWB) health burden on young Aboriginal and Torres Strait Islander people. OBJECTIVES: In partnership with Miwatj Health Aboriginal Corporation (Miwatj), this project will co-design an integrated youth Social and Emotional Wellbeing (SEWB) and mental health stepped care model for remote Aboriginal communities in the north east Arnhem region of the Northern Territory. DESIGN: A collaborative research approach using co-design methods will underpin a community-centric stepped care allocation method, to which culturally appropriate SEWB and mental health interventions and treatments are assigned. These components of the project will inform a digital platform which will facilitate access to SEWB care for young people in north east Arnhem land. This concept was co-developed in a partnership between researchers and Miwatj and builds on Miwatj's previous work to map the stepped needs of young people. The co-design of the content and features of these outputs will be facilitated through community participation and overseen by community, health, and cultural governance structures. This will ensure the solutions developed by the project are culturally responsive, fit for purpose, and will enhance self-determination while reducing systemic barriers to care.

Interventions for health workforce retention in rural and remote areas: a systematic review.

BACKGROUND: Attracting and retaining sufficient health workers to provide adequate services for residents of rural and remote areas has global significance. High income countries (HICs) face challenges in staffing rural areas, which are often perceived by health workers as less attractive workplaces. The objective of this review was to examine the quantifiable associations between interventions to retain health workers in rural and remote areas of HICs, and workforce retention. METHODS: The review considers studies of rural or remote health workers in HICs where participants have experienced interventions, support measures or incentive programs intended to increase retention. Experimental, quasi-experimental and observational study designs including cohort, case-control, cross-sectional and case series studies published since 2010 were eligible for inclusion. The Joanna Briggs Institute methodology for reviews of risk and aetiology was used. Databases searched included MEDLINE (OVID), CINAHL (EBSCO), Embase, Web of Science and Informit. RESULTS: Of 2649 identified articles, 34 were included, with a total of 58,188 participants. All study designs were observational, limiting certainty of findings. Evidence relating to the retention of non-medical health professionals was scant. There is growing evidence that preferential selection of students who grew up in a rural area is associated with increased rural retention. Undertaking substantial lengths of rural training during basic university training or during post-graduate training were each associated with higher rural retention, as was supporting existing rural health professionals to extend their skills or upgrade their qualifications. Regulatory interventions requiring return-of-service (ROS) in a rural area in exchange for visa waivers, access to professional licenses or provider numbers were associated with comparatively low rural retention, especially once the ROS period was complete. Rural retention was higher if ROS was in exchange for loan repayments. CONCLUSION: Educational interventions such as preferential selection of rural students and distributed training in rural areas are associated with increased rural retention of health professionals. Strongly coercive interventions are associated with comparatively lower rural retention than interventions that involve less coercion. Policy makers seeking rural retention in the medium and longer term would be prudent to strengthen rural training pathways and limit the use of strongly coercive interventions.

Developing the geographic classification for health, a rural-urban classification for New Zealand health research and policy: A research protocol.

INTRODUCTION: Rural-urban health inequities, exacerbated by deprivation and ethnicity, have been clearly described in the international literature. To date, the same inequities have not been as clearly demonstrated in Aotearoa New Zealand despite the lower socioeconomic status and higher proportion of Maori living in rural towns. This is ascribed by many health practitioners, academics and other informed stakeholders to be the result of the definitions of 'rural' used to produce statistics. AIMS: To outline a protocol to produce a 'fit-for-health purpose' rural-urban classification for analysing national health data. The classification will be designed to determine the magnitude of health inequities that have been obscured by use of inappropriate rural-urban taxonomies. METHODS: This protocol paper outlines our proposed mixed-methods approach to developing a novel Geographic Classification for Health. In phase 1, an agreed set of community attributes will be used to modify the new Statistics New Zealand Urban Accessibility Classification into a more appropriate classification of rurality for health contexts. The Geographic Classification for Health will then be further developed in an iterative process with stakeholders including rural health researchers and members of the National Rural Health Advisory Group, who have a comprehensive 'on the ground' understanding of Aotearoa New Zealand's rural communities and their attendant health services. This protocol also proposes validating the Geographic Classification for Health using general practice enrolment data. In phase 2, the resulting Geographic Classification for Health will be applied to routinely collected data from the Ministry of Health. This will enable current levels of rural-urban inequity in health service access and outcomes to be accurately assessed and give an indication of the extent to which older classifications were masking inequities.

Remote health service vulnerabilities and responses to the COVID-19 pandemic.

The rapid response to the COVID-19 pandemic in Australia has highlighted the vulnerabilities of remote Aboriginal and Torres Strait Islander communities in terms of the high prevalence of complex chronic disease and socio-economic factors such as limited housing availability and overcrowding. The response has also illustrated the capability of Aboriginal and Torres Strait Islander leaders and the Aboriginal Community Controlled Health Services Sector, working with the government, to rapidly and effectively mitigate the threat of transmission into these vulnerable remote communities. The pandemic has exposed persistent workforce challenges faced by primary health care services in remote Australia. Specifically, remote health services have a heavy reliance on short-term or fly-in, fly-out/drive-in, drive-out staff, particularly remote area nurses. The easing of travel restrictions across the country brings the increased risk of transmission into remote areas and underscores the need to adequately plan and fund remote primary health care services and ensure the availability of an adequate, appropriately trained local workforce in all remote communities.

Remote health workforce turnover and retention: what are the policy and practice priorities?

BACKGROUND: Residents of remote communities in Australia and other geographically large countries have comparatively poorer access to high-quality primary health care. To inform ongoing policy development and practice in relation to remote area health service delivery, particularly in remote Indigenous communities, this review synthesizes the key findings of (1) a comprehensive study of workforce turnover and retention in remote Northern Territory (NT) of Australia and (2) a narrative review of relevant international literature on remote and rural health workforce retention strategies. This synthesis provides a valuable summary of the current state of international knowledge about improving remote health workforce retention. MAIN TEXT: Annual turnover rates of NT remote area nurses (148%) and Aboriginal health practitioners (80%) are very high and 12-month stability rates low (48% and 76%, respectively). In remote NT, use of agency nurses has increased substantially. Primary care costs are high and proportional to staff turnover and remoteness. Effectiveness of care decreases with higher turnover and use of short-term staff, such that higher staff turnover is always less cost-effective. If staff turnover in remote clinics were halved, the potential savings would be approximately A$32 million per annum. Staff turnover and retention were affected by management style and effectiveness, and employment of Indigenous staff. Review of the international literature reveals three broad themes: Targeted enrolment into training and appropriate education designed to produce a competent, accessible, acceptable and 'fit-for-purpose' workforce; addressing broader health system issues that ensure a safe and supportive work environment; and providing ongoing individual and family support. Key educational initiatives include prioritising remote origin and Indigenous students for university entry; maximising training in remote areas; contextualising curricula; providing financial, pedagogical and pastoral support; and ensuring clear, supported career pathways and continuing professional development. Health system initiatives include ensuring adequate funding; providing adequate infrastructure including fit-for-purpose clinics, housing, transport and information technology; offering flexible employment arrangements whilst ensuring a good 'fit' between individual staff and the community (especially with regard to cultural skills); optimising co-ordination and management of services that empower staff and create positive practice environments; and prioritising community participation and employment of locals. Individual and family supports include offering tailored financial incentives, psychological support and 'time out'. CONCLUSION: Optimal remote health workforce stability and preventing excessive 'avoidable' turnover mandates alignment of government and health authority policies with both health service requirements and individual health professional and community needs. Supportive underpinning policies include: Strong intersectoral collaboration between the health and education sectors to ensure a fit-for-purpose workforce;A funding policy which mandates the development and implementation of an equitable, needs-based formula for funding remote health services;Policies that facilitate transition to community control, prioritise Indigenous training and employment, and mandate a culturally safe work context; andAn employment policy which provides flexibility of employment conditions in order to be able to offer individually customised retention packages There is considerable extant evidence from around the world about effective retention strategies that contribute to slowing excessive remote health workforce turnover, resulting in significant cost savings and improved continuity of care. The immediate problem comprises an 'implementation gap' in translating empirical research evidence into actions designed to resolve existing problems. If we wish to ameliorate the very high turnover of staff in remote areas, in order to provide an equitable service to populations with arguably the highest health needs, we need political and executive commitment to get the policy settings right and ensure the coordinated implementation of multiple strategies, including better linking existing strategies and 'filling the gaps' where necessary.

The Northern Territory Medical Program - growing our own in the NT.

CONTEXT: The Northern Territory (NT) is characterised by major health inequalities. A high proportion of the population is Indigenous, with poor socioeconomic conditions and a high burden of disease. The small NT population - 1% of the total Australian population - is dispersed over one-sixth of Australia's land mass. Given this very low population density and the geographical isolation of many small communities, access to services is often difficult. Medical workforce recruitment and retention have been persistent problems. Prior to 2011, NT residents who aspired to study medicine had to leave the NT. This was the only Australian state or territory that did not have the capacity for students to complete an entire medical degree within the jurisdiction. This article describes the development, implementation and outcomes of the Northern Territory Medical Program (NTMP), which commenced in Darwin in 2011. This was a major development of the Flinders University distributed program, which aimed to develop the medical workforce for the challenging NT environment. ISSUES: Based on evidence regarding the importance of selection in achieving rural workforce outcomes, and a national priority to graduate more Indigenous Australian doctors, NT residents and Indigenous applicants to the NTMP were prioritised in the selection process. Aspiring doctors would not now have to move interstate to study. The curriculum of Flinders University, based in Adelaide, South Australia, would be contextualised to the NT. The NTMP was developed and implemented in collaboration with Charles Darwin University, the major university in the NT. LESSONS LEARNED: Some of the lessons learned may be useful to others contemplating the delivery of a distributed program that includes a full medical program in a remote area. These include: Leadership at the highest levels of the university is crucial. Expect faculty turnover and avoid single person vulnerabilities. Actively engage local clinicians. Ensure a strong focus on new or alternative selection processes that are able to predict progression. Provide preparatory skills and support for students, especially Indigenous students, with non-science backgrounds. Appreciate and accommodate the community and family pressures experienced by some Indigenous students. Anticipate that the first pioneering cohort of students will not be typical of future cohorts, and work with them to adapt the curriculum, teaching and selection methods. Whilst exemplary telecommunications are needed, some elements of the curriculum will be able to be delivered far better locally than at the larger campus. Do not underestimate the level of student and staff support required both locally and centrally. Develop a 'network' rather than a 'hub and spoke' model. The network may include multiple dispersed placement sites, requiring infrastructure, staffing and ongoing support. The 'new kid' will mean the 'older sibling' will change for the better and use the small size and agility to explore innovations. Focus on the goals. We wanted to contribute to improved economic, social and health outcomes for NT residents by developing an appropriately prepared medical workforce, thereby eliminating the need to recruit doctors from interstate and overseas, and by graduating more Indigenous doctors - potential medical leaders for Australia. Build your expectation for success based on past successes in innovation. Flinders University was able to build on its experience in developing the first 4-year medical program in Australia.

What is the overall impact or effectiveness of visiting primary health care services in rural and remote communities in high-income countries? A systematic review.

BACKGROUND: Visiting services address the problem of workforce deficit and access to effective primary health care services in isolated remote and rural locations. Little is known about their impact or effectiveness and thereby the extent to which they are helping to reduce the disparity in access and health outcomes between people living in remote areas compared with people living in urban regions of Australia. The objective of this study was to answer the question "What is the impact or effectiveness when different types of primary health care services visit, rather than reside in, rural and remote communities?" METHOD: We conducted a systematic review of peer-reviewed literature from established databases. We also searched relevant websites for 'grey' literature and contacted several key informants to identify other relevant reference material. All papers were reviewed by at least two assessors according to agreed inclusion and exclusion criteria. RESULTS: Initially, 345 papers were identified and, from this selection, 17 papers were considered relevant for inclusion. Following full paper review, another ten papers were excluded leaving seven papers that provided some information about the impact or effectiveness of visiting services. The papers varied with regard to study design (ranging from cluster randomised controlled trials to a case study), research quality, and the strength of their conclusions. In relation to effectiveness or impact, results were mixed. There was a lack of consistent data regarding the features or characteristics of visiting services that enhance their effectiveness or impact. Almost invariably the evaluations assessed the service provided but only two papers mentioned any aspect of the visiting features within which service provision occurred such as who did the visiting and how often they visited. CONCLUSIONS: There is currently an inadequate evidence base from which to make decisions about the effectiveness of visiting services or how visiting services should be structured in order to achieve better health outcomes for people living in remote and rural areas. Given this knowledge gap, we suggest that more rigorous evaluation of visiting services in meeting community health needs is required, and that evaluation should be guided by a number of salient principles.

Learning from history: How research evidence can inform policies to improve rural and remote medical workforce distribution.

OBJECTIVE: This article describes the rationale for, and development of, an evidence-based rural typology as the basis for an incentive scheme to improve medical workforce retention. This case study describes the key factors associated with ensuring that research evidence is translated into rural health policy and program implementation. DESIGN: Case study. SETTING: Rural and remote Australia. RESULTS: The development and implementation of the Modified Monash Model in Australia demonstrates some of the key facilitators of knowledge exchange. These include: sound evidence based on good empirical data and rigorous methodology; transparency to peers and stakeholders; the importance of long-term commitment to rural health research; the credibility of the researcher; multiple modes of communication of results; real world validation and amplification of results; patience and persistence underscored by the commitment of researchers to achieving more equitable outcomes for rural and remote doctors; serendipity in terms of timing; and a governmental culture that values evidence-based outcomes. CONCLUSION: The knowledge exchange process is neither easy nor simple and rarely rapid. It often requires the engagement of communities, professional associations, health care providers, researchers, policy-makers and funders. Implementation of evidence into rural health policies and programs benefits all parties through significant improvements in efficiency, effectiveness and equity.

What principles should guide visiting primary health care services in rural and remote communities? Lessons from a systematic review.

Visiting health services are a feature of health care delivery in rural and remote contexts. These services are often described as 'fly-in fly-out' or 'drive-in drive-out'. Posing the question 'What are the different types of visiting models of primary health care being used in rural and remote communities?', the objective of this article was to describe a typology of models of health services that visit remote communities. A systematic review of peer-reviewed literature from established databases was undertaken. Data were extracted from 20 papers (16 peer-reviewed papers and four from other sources), which met the inclusion criteria. From the available evidence, it was difficult to develop a typology of services. The central feature of service providers visiting rural and remote districts on a regular basis was consistent, although the service provider's geographical base varied and the extent to which the same service provider should be providing the service was not consistently endorsed. While a clear typology did not emerge from the systematic review, it became apparent that a set of guiding principles might be more helpful to service providers and planners. Focusing policy and decision-making on important principles of visiting services, rather than their typological features, is likely to be of ultimately more benefit to the health outcomes of people who live in rural and remote communities.

Interplay wellbeing framework: a collaborative methodology 'bringing together stories and numbers' to quantify Aboriginal cultural values in remote Australia.

BACKGROUND: Wellbeing has been difficult to understand, measure and strengthen for Aboriginal people in remote Australia. Part of the challenge has been genuinely involving community members and incorporating their values and priorities into assessment and policy. Taking a 'shared space' collaborative approach between remote Aboriginal communities, governments and scientists, we merged Aboriginal knowledge with western science - by bringing together stories and numbers. This research aims to statistically validate the holistic Interplay Wellbeing Framework and Survey that bring together Aboriginal-identified priorities of culture, empowerment and community with government priorities including education, employment and health. METHOD: Quantitative survey data were collected from a cohort of 842 Aboriginal people aged 15-34 years, recruited from four different Aboriginal communities in remote Australia. Aboriginal community researchers designed and administered the survey. RESULTS: Structural equation modeling showed good fit statistics (χ/df = 2.69, CFI = 0.95 and RMSEA = 0.045) confirming the holistic nature of the Interplay Wellbeing Framework. The strongest direct impacts on wellbeing were 'social and emotional wellbeing' (r = 0.23; p < 0.001), 'English literacy and numeracy' (r = 0.15; p < 0.001), 'Aboriginal literacy' (r = 0.14; p < 0.001), 'substances' (lack thereof; r = 0.13; p = 0.003), 'work' (r = 0.12; p = 0.02) and 'community' (r = 0.08; p = 0.05). Correlation analyses suggested cultural factors have indirect impacts on wellbeing, such as through Aboriginal literacy. All cultural variables correlated highly with each other, and with empowerment and community. Empowerment also correlated highly with all education and work variables. 'Substances' (lack thereof) was linked with positive outcomes across culture, education and work. Specific interrelationships will be explored in detail separately. CONCLUSION: The Interplay Wellbeing Framework and Survey were statistically validated as a collaborative approach to assessing wellbeing that is inclusive of other cultural worldviews, values and practices. New community-derived social and cultural indicators were established, contributing valuable insight to psychometric assessment across cultures. These analyses confirm that culture, empowerment and community play key roles in the interplay with education, employment and health, as part of a holistic and quantifiable system of wellbeing. This research supports the holistic concept of wellbeing confirming that everything is interrelated and needs to be considered at the 'whole of system' level in policy approaches.

Patterns of resident health workforce turnover and retention in remote communities of the Northern Territory of Australia, 2013-2015.

BACKGROUND: The geographical maldistribution of the health workforce is a persisting global issue linked to inequitable access to health services and poorer health outcomes for rural and remote populations. In the Northern Territory (NT), anecdotal reports suggest that the primary care workforce in remote Aboriginal communities is characterised by high turnover, low stability and high use of temporary staffing; however, there is a lack of reliable information to guide workforce policy improvements. This study quantifies current turnover and retention in remote NT communities and investigates correlations between turnover and retention metrics and health service/community characteristics. METHODS: This study used the NT Department of Health 2013-2015 payroll and financial datasets for resident health workforce in 53 remote primary care clinics. Main outcome measures include annual turnover rates, annual stability rates, 12-month survival probabilities and median survival. RESULTS: At any time point, the clinics had a median of 2.0 nurses, 0.6 Aboriginal health practitioners (AHPs), 2.2 other employees and 0.4 additional agency-employed nurses. Mean annual turnover rates for nurses and AHPs combined were extremely high, irrespective of whether turnover was defined as no longer working in any remote clinic (66%) or no longer working at a specific remote clinic (128%). Stability rates were low, and only 20% of nurses and AHPs remain working at a specific remote clinic 12 months after commencing. Half left within 4 months. Nurse and AHP turnover correlated with other workforce measures. However, there was little correlation between most workforce metrics and health service characteristics. CONCLUSIONS: NT Government-funded remote clinics are small, experience very high staff turnover and make considerable use of agency nurses. These staffing patterns, also found in remote settings elsewhere in Australia and globally, not only incur higher direct costs for service provision-and therefore may compromise long-term sustainability-but also are almost certainly contributing to sub-optimal continuity of care, compromised health outcomes and poorer levels of staff safety. To address these deficiencies, it is imperative that investments in implementing, adequately resourcing and evaluating staffing models which stabilise the remote primary care workforce occur as a matter of priority.

Long-term trends in supply and sustainability of the health workforce in remote Aboriginal communities in the Northern Territory of Australia.

BACKGROUND: International evidence suggests that a key to improving health and attaining more equitable health outcomes for disadvantaged populations is a health system with a strong primary care sector. Longstanding problems with health workforce supply and turnover in remote Aboriginal communities in the Northern Territory (NT), Australia, jeopardise primary care delivery and the effort to overcome the substantial gaps in health outcomes for this population. This research describes temporal changes in workforce supply in government-operated clinics in remote NT communities through a period in which there has been a substantial increase in health funding. METHODS: Descriptive and Markov-switching dynamic regression analysis of NT Government Department of Health payroll and financial data for the resident health workforce in 54 remote clinics, 2004-2015. The workforce included registered Remote Area Nurses and Midwives (nurses), Aboriginal Health Practitioners (AHPs) and staff in administrative and logistic roles. MAIN OUTCOME MEASURES: total number of unique employees per year; average annual headcounts; average full-time equivalent (FTE) positions; agency employed nurse FTE estimates; high and low supply state estimates. RESULTS: Overall increases in workforce supply occurred between 2004 and 2015, especially for administrative and logistic positions. Supply of nurses and AHPs increased from an average 2.6 to 3.2 FTE per clinic, although supply of AHPs has declined since 2010. Each year almost twice as many individual NT government-employed nurses or AHPs are required for each FTE position. Following funding increases, some clinics doubled their nursing and AHP workforce and achieved relative stability in supply. However, most clinics increased staffing to a much smaller extent or not at all, typically experiencing a "fading" of supply following an initial increase associated with greater funding, and frequently cycling periods of higher and lower staffing levels. CONCLUSIONS: Overall increases in workforce supply in remote NT communities between 2004 and 2015 have been affected by continuing very high turnover of nurses and AHPs, and compounded by recent declines in AHP supply. Despite substantial increases in resourcing, an imperative remains to implement more robust health service models which better support the supply and retention of resident health staff.

Equitable resourcing of primary health care in remote communities in Australia's Northern Territory: a pilot study.

BACKGROUND: Improved Primary Health Care (PHC) utilisation is central to reducing the unacceptable morbidity and mortality rates characterising populations living in remote communities. Despite poorer health, significant inequity characterises the funding of PHC services in Australia's most remote areas. This pilot study sought to ascertain what funding is required to ensure equitable access to sustainable, high quality primary health care irrespective of geographical remoteness of communities. METHODS: High performing remote Primary Health Care (PHC) services were selected using improvement measures from the Australian Primary Care Collaboratives Program and validated by health experts. Eleven PHC services provided data relating to the types of services provided, level of service utilisation, human resources, operating and capital expenses. A further four services that provide visiting PHC to remote communities provided information on the level and cost of these services. Demographic data for service catchment areas (including estimated resident population, age, Indigenous status, English spoken at home and workforce participation) were obtained from the Australian Bureau of Statistics 2011 census. Formal statistical inference (p-values) were derived in the linear regression via the nonparametric bootstrap. RESULTS: A direct linear relationship was observed between the total cost of resident PHC services and population, while cost per capita decreased with increasing population. Services in smaller communities had a higher number of nursing staff per 1000 residents and provided more consultations per capita than those in larger communities. The number of days of visiting services received by a community each year also increased with population. A linear regression with bootstrapped statistical inference predicted a significant regression equation where the cost of resident services per annum is equal to $1,251,893.92 + ($1698.83 x population) and the cost of resident and visiting services is equal to $1,378,870.85 + ($2600.00 x population). CONCLUSIONS: The research findings provide empirical evidence based on real costs to guide funding for remote PHC services that takes into account the safety and equity requirements for a minimum viable service. This method can be used as a transparent, coordinated approach to ensure the equitable delivery of sustainable, high quality PHC in remote communities. This will in turn contribute to improved health outcomes.

Reducing hospital admissions in remote Australia through the establishment of a palliative and chronic disease respite facility.

BACKGROUND: There are limited respite services for palliative care patients and their families in the Northern Territory (NT). The high prevalence of complex chronic diseases, limited access to primary care services, and the poor living situations of many Aboriginal and Torres Strait Islander Australians result in high hospitalisation rates and pressure on tertiary health services. Palliative Care NT identified a need for a flexible, community based, culturally appropriate respite service in Alice Springs. It was of particular interest to assess the impact of the respite service on the extent to which hospital resources were accessed by this population of patients. METHODS: Respite service use and hospital use data were collected over two time periods: the 12 months prior to the establishment of the service; and the first 10 months of the operation of the service. The financial implications of the facility were assessed in terms of the National Weighted Activity Unit (NWAU). Of primary interest in this study was the impact of the respite service on admissions to the Emergency Department (ED), to the Wards, and to the Intensive Care Unit (ICU). The amount of ventilator hours consumed was also of interest. RESULTS: Overall, there was a mean cost saving of $1882.50 per episode for hospital admissions with a reduction in: hospital admissions; mean length of stay; Intensive Care Unit (ICU) hours; and ventilator hours. CONCLUSIONS: The establishment of the respite service has met an important and unmet need in Alice Springs: provision of respite where none has existed before. The service did assist with savings to the health department which could contribute to the cost of the facility over time. Two features of the respite facility that may have contributed to the savings generated were the enhanced coordination of care for patients with complex chronic diseases, as well as improved medication compliance and symptom management.