The Robert Wood Johnson Foundation estimates that only 20 percent of health outcomes can be attributed to access to health and medical care.
Social determinants of health account for the other 80 percent including socioeconomic factors such as poverty (40 percent), environmental factors such as air pollutants (10 percent), and individual factors such as smoking (30 percent).
Social determinants are also implicated in a range of other human outcomes such as rates of incarceration, levels of alcohol and drug addiction and the likelihood of being homeless.
Research has shown that addressing the causes of poor health (the social determinants) is essential to reducing preventable illness, long term chronic disease and uncontrolled growth in hospital admissions and costs.
In this regard, integrated care has been recognised as an important goal in preventing illness and improving health system effectiveness and efficiency.
‘Integrated’ care is defined as “the provision of seamless, effective and efficient care that reflects the whole of a person’s health needs: from prevention through to end of life, across both physical and mental health, and in partnership with the individual, their carers and family". [1]
However current strategies largely focussed on integration of hospital care and primary health care (GPs), and improving management of care across teams within hospital settings. NSW Health for example notes that it "is responding to these challenges by investing in ... transforming the health system ... particularly for people with complex, long-term conditions". [1]
In many ways, this is not the main game in rural and remote health. Rural and remote primary health and hospital care is already largely integrated because local GPs also perform the role of hospital emergency physician (VMO) in their communities. Local paramedics work effectively alongside local GPs, in both community and hospital settings, both as first responders and in managing patient care.
In rural and remote communities, where the burden of chronic diseases is highest, the greatest potential gains therefore come from better integration of care at the interface between human services and primary health care.
For example, 83.2% of Australians saw a local GP in 2019-20 making independent general practice one of the most common and regular touch points for Australians seeking care and assistance with physical, mental and social challenges. [2]. On average Australian's see their local GP around 6-7 times a year, and for more complex care such as for people over 70 years this can increase up to 16 times a year.
This also appears to be where rural and remote people prefer to go when they need help. In a 2020 Survey, 87.8% of rural and remote respondents stated that they preferred to receive health care at a local GP clinic (compared to 8.9% in the local hospital). [3]
By comparison, a PwC report found that 28% of Australians sought or used support from a social service organisations compared to 41% in other countries. [4]. As PwC notes, there is a widespread view in Australia that individuals are responsible for addressing their own social determinants. [5]
Rural and remote GPs already play a key role in helping patients and the community to find and access social services to address the causes of poor health. According to research in Scotland between 25% and 50% of GP appointments focus on non-medical issues, such as social isolation, financial struggles, and bereavement. [6]. This would not be uncommon for most rural and remote general practices where the primary health centre is sometimes the only major support service based in the town.
The role of independent general practice in supporting improved integration has been recognised in the UK and other countries with the establishment of care coordinators, link coordinators and social prescribing to improve integration between primary health care and social services and enhance the capacity for early intervention before problems become chronic or acute.
There is an obvious opportunity to better capture rural and remote people earlier through greater collaboration and structural integration between human services and general practice in rural and remote communities.
Rural and remote towns are in many ways a perfect testing ground for integration. Thin populations and the higher cost of service delivery make it economically difficult for both government and NGOs to sustainably delivery services in rural and remote towns.
Increased collaboration and shared service delivery creates opportunities to leverage existing assets and resources on-the-ground.
There are existing examples of integration that could be used as models. The HealthOne model, for example, involves both Federal and State governments pooling funds to integrate community health and primary health care. This enables improved coordination and reduced overhead costs and resources across State and Federal governments to make services more sustainable and accessible in some rural towns. The ACCHO model is also a successful approach to service integration under community leadership.
In rural and remote communities integration of health and hospital care is already achieved through the dual GP/VMO role occupied by local clinicians. But this model is expensive and it is unclear how long it will be supported.
The most significant contributor to improved health is by linking members of rural and remote communities to programs that address social determinants, and improving prevention strategies through independent primary health care.
Such an integrated approach has the potential to:
increase access and utilisation of social services to address social determinants in general practice which reflects how rural and remote people access, and prefer to access, services.
broaden access to a wider range of health and social services locally.
improve early intervention and prevention.
reduce unnecessary duplication of services and effort.
enhance monitoring of performance and outcomes.
reduce both short term and long term financial pressures on the NSW Hospital system.
increase the number of jobs located in rural and remote towns.
make services more relevant by engaging local communities in prioritising needs based on their local context.
Mark Burdack is CEO of The Healthy Communities Foundation Australia and an Adjunct academic in the School of Rural Health at La Trobe University.
NOTES
[1] NSW Agency for Clinical Innovation. https://www.aci.health.nsw.gov.au/nhn/health-professionals/tools-and-resources/nsw-health-integrated-care.
[2] ABS (2021). Patient Experiences in Australia: Summary of Findings
Contains data on access and barriers to, and experiences of, healthcare services including GPs, specialists, dental professionals, hospitals and EDs. https://www.abs.gov.au/statistics/health/health-services/patient-experiences-australia-summary-findings/latest-release
[3] Rural and Remote Communities' Health Care Snapshot 2020. https://65dacf67-a0f3-4821-b697-8e262e976ec1.filesusr.com/ugd/7407db_f8d60e3568b1442393bd7bde715a8868.pdf
[4] PwC Global 2019, Action required: the urgency of addressing social determinants of health. https://www.pwc.com/gx/en/industries/healthcare/publications/social-determinants-of-health.html
[5] PwC Australia. Social Determinants of Health - Bold action needed on social determinants to improve health outcomes. https://www.pwc.com.au/health/health-matters/social-determinants-in-health-australia.html
[6] RSE. A desk review of social prescribing: from origins to opportunities. https://www.rsecovidcommission.org.uk/a-desk-review-of-social-prescribing-from-origins-to-opportunities/?gclid=CjwKCAjw3_KIBhA2EiwAaAAlii0DeIRpWs_ySG1OdIgMPDchC3HpnthKHjO9rw2IcPAW8OOU0UcVAxoCDb4QAvD_BwE