Cairns Consensus Statement on Rural Generalist Medicine


Improved health for rural communities through accessible, high quality healthcare.
BACKGROUND
Cairns Consensus Statement on Rural Generalist Medicine
The Health of Rural Communities and Rural Generalist Medicine
1
We resolve to strengthen health care systems in rural communities by promoting the practice of Rural Generalist Medicine. Our goal is to improve the health of people living in rural areas through access to effective, safe and affordable healthcare.
2
People living in rural communities typically suffer poorer health status than their urban counterparts. In spite of this , rural communities have less access to health care
. Individuals and families living in rural areas are often obliged to travel unreasonable distances to access essential health care, including lifesaving emergency care, maternity care and child health services. They may receive only fragmented care or periodic visiting clinics with a narrow focus . These inequities are compounded for Indigenous rural communities.
3
Rural communities comprise almost half the world’s population and a greater proportion again in low-income countries. Rural communities produce most of the world’s food and natural resources and are entitled to equitable access to safe, effective and affordable health care as close to home as possible.
4
The broader social and economic development of rural communities is promoted through the availability of quality local health care , of which Rural Generalist Medicine is an essential component.
5
We assert that rural communities requir a strong generalist approach to all health professional services and in particular, skilled doctors who can provide a broad scope of clinical care, working in concert with other members of the health care team. That tradition, the tradition of Rural Generalist Medicine, is under threat as a result of trends to medical sub-specialization in cities and a diminished role for generalist
doctors as a consequence. What do we mean by the term ‘Rural Generalist Medicine’
6
We define ‘Rural Generalist Medicine’ as the provision of a broad scope of medical care by a doctor in the rural context that encompasses the following :
• Comprehensive primary care for individuals, families and communities ;
• Hospital in -patient and /or related secondary medical care in the institutional, home or ambulatory setting ;
• Emergency care ;
•Extended and evolving service in one or more areas of focused cognitive and/or procedural practice as required to sustain needed health services locally among a network of colleagues;
• A population health approach that is relevant to the community;
• Working as part of a multi-professional and multi- disciplinary team of colleagues, both local and distant, to provide services within a ‘system of care’ that is
aligned and responsive to community needs.
7
The practice of Rural Generalist Medicine is unique in the combination of abilities and aptitude that is required of a doctor for a distinctly broad scope of practice in a rural context. Rural Generalist Medicine is a concept that is grounded in the needs of rural communities, not on professional ‘turf ’ nor professional craft-group identity or ambition .
8
We acknowledge and respect the fact that elements of the scope of Rural Generalist Medicine are shared across a number of professions and medical professional craft groups, including the care that is provided by those General Practitioners or Family Physicians (GPs/FPs) who are trained primarily in community-based primary care roles, Cairns Consensus: Nov, 2013.Hospitalists, emergency physicians, GPs/FPs with special interests as well as a range of consultant medical specialists. All these groups have their contribution to make Similarly, we recognise that there are still doctors around the world who work to a comparably broad scope of practice in the urban context and this is to be supported.
9
We assert that those doctors who are trained and credentialed to practise Rural Generalist Medicine have been, are and always will be an essential requirement for health service delivery in rural communities. Their services are also likely to be increasingly required in larger population centres. Why is Rural Generalist Medicine important?
10
We believe that Rural Generalist Medicine is an essential component of healthcare if
rural communities are to be assured of access to comprehensive primary care that is integrated with secondary and tertiary healthcare services. The strength of Rural Generalist Medicine is the ability to deliver quality, personalised and contextual care across the continuum of health services and from cradle to grave.
11
From a rural patient and community perspective, Rural Generalist Medicine has many specific advantages. These include: ready access to skilled, culturally competent and locally-informed practitioners; improved continuity-of-care and follow-up; a better patient experience through familiarity, trust, personal relationships and patient- centred care; stronger integration of visiting consultant specialist services and tele health;reduced healthcare costs; and less personal and economic disruption associated with transport to distant services.
12
Rural Generalist Medicine can be tailored to available resources and local healthcare
priorities of communities. For Indigenous communities and marginalised groups, skilled local doctors practising Rural Generalist Medicine as part of a team offers the best prospect of assuring effective medical care that is culturally competent and responsive to priority community needs.
13
From a health systems perspective, Rural Generalist Medicine has doctors applying
a full and evolving skill-set, thereby increasing professional satisfaction, productivity and rural retention. Stable models of team-based care are promoted and there is a reduced reliance on locums. This in turn supports establishment of a quality rural learning environment for students, doctors-in-training and others. Medico-legal risk and associated costs are reduced.
14
While there may be a sufficient overall supply of doctors in some countries, the
medical workforce is maldistributed, being concentrated in urban areas and overly subspecialised. In other areas and particularly low-income countries, these same
factors exacerbate overall medical workforce shortages and are compounded by medical migration.
15
We assert that simply training more doctors using conventional models in the hope that they might ‘trickle-out’ to rural communities is a failed strategy. Paradoxically, this approach may lead to further fragmentation and specialization of care, waste scarce healthcare resources, undermine the practice of Rural Generalist Medicine
and team-based models of care and thereby worsen inequities in healthcare for rural communities.
16
Around the world, health systems are
under pressure due to unsustainable growth in expenditures, ageing populations, an increasing burden of chronic non-communicable disease, unwarranted fragmentation and specialization of care, persistent health inequities and, in many countries, large gaps in medical, nursing and midwifery workforce. Rural Generalist Medicine– and clinical generalism more broadly -offers an important positive contribution to meeting these challenges. What action is required to advance Rural Generalist Medicine?
17
We identify the following as key actions in global efforts to meet the healthcare needs of rural communities by strengthen ing Rural Generalist Medicine: Cairns Consensus: Nov, 2013 Page 3 A. Recognition of Rural Generalist Medicine as distinct scope of medical practice
18
Within health care systems, Rural Generalist Medicine must be recognised and valued
as a distinct scope of medical practice that is essential for
effective rural healthcare. Doctors who are trained and supported to practise Rural Generalist Medicine represent a key component of workforce in a contemporary, technology-enabled and team-based approach to meeting
rural healthcare needs.
19
Along with recognition, Rural Generalist Medicine must be enabled
through the
following actions
: appropriate
systems of clinical
governance (including
clinical
privileging and credentialing);
appropriate
remuneration
(models and levels)
; career
structures;
training
models;
relevant and accessible continuing professional
development
; investment in local health facilities and infrastructure
; provision of
family supports
and living conditions
; investment
in health services and health
systems leadership and in health workforce planning
and investment
.
B. Training pathways
for
Rural Generalist Medicine
20
An active pathway of recruitment to
and training for a distinct
career in
Rural
Generalist
Medicine
is required.
The
training
pathway must produce generalist doctors
who
are certified to deliver th
e full scope of service for Rural Generalist Medicine
. The
pathway to Rural Generalist Medicine is a ‘pip
eline’ that begins prior to medical school
and extends through postgraduate trai
ning to lifelong learning
.
21
The
training
model
must serve to
attract and enthuse people to a Rural Generalist
Medicine career
, particularly
young people f
rom rural areas as well as the cities
,
medica
l students and junior doctors
. Training
model
s should incorporate best
-evidence
in strategies
that have been shown to
produce and retain
a generalist
rural
medical
workforce
. This includes basing training for Rural Generalist Medicine in rural areas
with rotations to larger centres only as training req
uirements dictate.
22
Curricula in undergraduate medical education must include strong
generalist content
and
include
greater
participation
of doctors practising Rural Generalist Medicine
as
teachers and preceptors
.
23
Post
graduate
training
curricula
that
reflect
the
full
scope of Rural Generalist Medicine
have been developed by some agencies and
can
be considered as a reference point
for
the
develo
pment and strengthening
of post
graduate training elsewhere.
24
Specific
pathways to training in Rural Gene
rali
st Medicine should
be
clear and available
at an early stage of medical training, whilst allowing for other
s to take up training at a
later stage
. Training structures should
allow for
flexible entry points and
flexible
training pathways whilst assuring
comparable
outcomes at completion
. Trainees
need
support
on their journey and allow
ance must be made for the possibility
of a graceful
exit.
C. Research agenda
to advance Rural Generalist Medicine
Efficient
use of healthcare
resources
and Rural Generalist Medicine
25
There is good
evidence that where populations have access to primary care and
generalist doctors, healthcare
systems produce better health outcomes at a lesser
cost
than
when
specialised
medical care predominates. There is also
emerging eviden
ce for
the cost
-effectiveness
of generalist models incorporated
into hospital-
based care
including in the
tertiary setting
and
particularly for patients
living
with chronic and
complex conditions
.
26
In order to build the evidence
base
to support rational
healthcare
investment
decisions, further study is required in areas such as: cost analysis and cost
-benefit
analysis of alternative rural medical care models across a range of geographic
contexts
, community and institutional healthcare
settings;
interventions to retain
doctors in rural practice.
Cairns Consensus: Nov, 2013
Page
4
Quality and safety
and Rural Generalist Medicine
27
There is good evidence of equivalent or better outcomes of medical
care
that is
provided by generalist doctors working in rural teams for a
number of areas, including
in provision of maternity services
and some surgical procedures
.
28
Although often assumed, there is actually little evidence of superior
outcomes
for most
common
healthcare
interventions when provided by
doctors
with
focussed
exp
ertise
versus
generalist
practitioners
. There are also
methodological flaws in many
published
studies.
In spite of this, a
concern for quality and safety
of care is often invoked when
decisions are made to restrict
the
scope of practice
or limit
the
location of
service
by
generalist doctors
. Similarly, perceptions of risk tend to
increase medico
-legal hazard.
29
All too often, the consequence of arbitrary
decision
-making
in cities to restrict the
scope of generalist practice is
reduced access by rural communities to
healthcare
,
worse health outcomes and increased costs
to individuals and healthcare
providers
.
30
In order to build the evidence base to strengthen healthcare in rural communities,
further study is required in areas such as: comparative studies on outcomes of care for different rural healthcare models that take the wider view of community access and context of care into account; comparative studies on effective models of care in discrete areas of service (e.g. : cancer care in rural areas); methodologies that move beyond simplistic audit of outcomes for particular interventions by individuals to outcomes of ‘systems of care ’ by teams; development of methodologies appropriate for evaluating complex systems; evaluation of different approaches to clinical
privileging and credentialing; and more critical study of volume of procedures and
outcomes in complex systems. Effective models of training and Rural Generalist Medicine
31
Features of medical education and training models that produce and retain a generalist rural medical workforce are increasingly well characterised . These include: targeting medical school admission to enrol rural- origin students; locating medical schools, campuses and post -graduate residency/training programs in regional locations; scholarships and bursaries with return of service obligations; and supporting an enhanced scope of practice in rural areas.
32
In order to build the evidence base to improve training for Rural Generalist Medicine, further study is required in areas such as: effectiveness of reform of undergraduate medical education (including socially accountable medical education); effective models of distance teaching and supervision; approaches to trainee selection that take into account the qualities and attributes that make for good rural practitioners ; training factors that enable, sustain, support and renew the practice of Rural Generalist Medicine.
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