Twenty one interviews were conducted. Three people were interviewed twice so that further contacts could be obtained for the study, and because there were large amounts of relevant information to discuss.
|Canada (2)||20/8||Health Service Manager|
|Canada (2)||22/8||Rural Health Academic|
|New Zealand||21/8||Rural Primary Care Network|
|Australia (2)||2/9||Chief Health Officer|
|South Africa||11/9||Rural Health Academic|
|New Zealand||11/9||Rural Nurse practitioner|
|Iceland||11/9||Rural medical director/ nursing director|
|New Zealand||15/9||Rural GP|
|Australia||16/9||Rural Health Academic|
|New Zealand||16/9||Health Service Manager|
|Norway||20/9||Rural Health Academic|
|Canada||11/11||Rural Health Academic|
Characteristics of participating countries
See Appendix 4 for population, income and health characteristics of participating countries. This is useful for setting the scene, but is of limited value as the statistics take no account of any differences between urban and rural areas.
Below is a brief summary of findings per country. The intention is to publish these finding in detail elsewhere.
Respondents included a rural general practitioner, a health service manager, someone from a primary care network, and a nurse practitioner
New Zealand [NZ] is possibly the best international comparator to Scotland in terms of geography and size. One fundamental difference is care for Maori people, who have reduced life expectancy of about 10 years.
In NZ, general practices are private businesses and set their own fees for consultations and other health services. The NZ Government subsidises fees for enrolled patients.
Some general practices join a Very Low Cost Access (VLCA) programme run by their primary health organisation (PHO). This means they get extra Government funding to keep their fees at low levels for all enrolled patients.
There is a complex payment system, practice income is derived from a number of sources. There are shortfalls in funding to rural practices. Different models of ownership exist within the NZ system, from community owned to corporate, although GP owned premises remain the most common.
Nurses are a key resource in rural health delivery in rural NZ, there are several different levels. Nurse practitioners who hold a masters qualification and are authorised to diagnose conditions and prescribe medications in the same range of conditions of a general practitioner. Nurses are often already embedded in their communities and, with the addition of support and training, have been a consistent provider of primary health care. There are 350 NPs in primary care in New Zealand.
Respondents included three rural health academics, a health service manager, and a remote nurse.
Through the Canada Health Act 1968 (adapted 1984) healthcare is public funded and free at point of use. There is no private sector. There are a range of different provincial models tied into a federal ethos of a public funded service. Contracts are varied, and not province -wide. Devolution between provinces is important. Rural health services and service to Indigenous populations are expensive. In the remote areas, nurses are the front line of care, and there has been a "grow your own" strategy.
There are separate negotiations for rural physician contracts in each province.
Respondent was a rural health academic
Norway has a traditional GP "fastiege" model, where every citizen has the right to be on a GP list. The GP is the key person, or gatekeeper, in rural health delivery. If there is no GP in a practice, then a locum will look after the enrolled patients.
The municipality pays the GPs a capitation fee. This is augmented by a patient fee and by state funded activities. GPs tend to work in groups of three to seven with medical assistants, although their income is independent. Generally, only GPs can prescribe medication, with the exception of contraception. There is a GP recruitment crisis, getting worse with more locums, even in cities. Everything in Norway varies by municipality. Contracts are variable and are mostly individually negotiated between the individual doctor and the municipality.
Respondent was a medical academic.
Thailand, as a middle-income country, has a universal public funded free at point of access service, but there is a lack of health workers, and particularly doctors in the system. Care has been free since 2002, which has made a big impact. 95% of the population are covered. Thailand has progressive inter-professional education programmes where the health professions work together to transform service delivery. There are three main priorities:
1. How to produce physicians in under-served areas
2. The relationship between profession with a horizontal network for collaboration
3. Social accountability through community engagement
There are one million village volunteers in Thailand. Traditional medicine is an important element of service delivery, which works alongside mainstream medicine.
Respondent was a rural physiotherapist.
Finland is interesting because it is similar to Scotland in terms of population and size, and in attitude to public health provision. Payments for access to service have been brought in over the last twenty years up to a ceiling up to 693€ per year, including some medicines. All staff are salaried, funded by taxation. Some areas (3.5- 4 million patients) of Finland have a self-referral system. There is a move away from a GP being the gatekeeper for services. The new system is self-referral for physiotherapy, and other services, and they are finding it more effective.
For twenty years, there have been attempts to reform healthcare. There was a move to introduce more private health care several years ago, to a mixed healthcare model. It didn't get through Parliament and directly led to a change of government.
Respondents were a clinician and a nurse in charge of rural hospital
In Iceland, adults pay at point of access to primary care services, children don't pay, and retired people pay a reduced amount, the range is £10-20. Rural primary care is in crisis due to a shortage of doctors. It is severely undermanned, only the older doctors are left. There are too few GPs per 1000 population. There are very few NPs in Iceland. Nurses can't prescribe. Therapists are all in rural teams – they visit rural health care stations.
On the whole, Icelandic people understand that rural primary care is struggling, but often they prefer to go straight to specialists.
South Africa has a dual health system, private (20%) and public (80%). Nonetheless, as the total spend is 80% private sector, 20% public, there are massive inequities. A national health insurance bill is being reviewed by Parliament. First contact care is at primary care clinics, staffed by NPs, with visiting doctors, the aim is that everyone is within 5km of a clinic, this is not achievable. Health centres are supposed to have more facilities and a doctor present every day.
Respondents included a rural health academic, an academic general practitioner, and a health service manager
There are massive differences in rural and urban delivery in Australia. Urban delivery remains dominated by the traditional general Practice fee for service model and market forces make it difficult to introduce coherent reform. Provision varies considerably by state.
In the remote areas of Northern Territory, Western Australia, South Australia and Queensland the fee-for-service model is not workable, and need has driven change. The Aboriginal health service is seen as an example of multi-disciplinary team working which has not been able to be replicated in urban Australia. One doctor towns have become a thing of the past. Community involvement is key, and respondents stressed the importance of rural generalist practice.
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