OPINION: Telehealth will kill rural and remote communities if we don't get it right

In a recent speech to the Regional Australia Institute the Deputy Prime Minister, The Hon Michael McCormack, said that: “[Telehealth] doesn’t replace a doctor but it ensures reliable medical services in some cases where there were very little”.

Yet in the same week, the ABC reported that a rural GP in Gulgong had his pay to be on-call as a Visiting Medical Officer (VMO) at the local rural hospital cut by 40 percent because on-site services would be replaced by Telehealth. There is evidence that Telehealth is now being used to replace rural GPs.

It is well known that most rural and remote GPs cannot make a living without being paid to be on-call as a VMO to attend emergencies at the local hospital. A mix of Medicare and VMO funding has always been essential to ensure the sustainability of general practice in small rural and remote towns.

If VMO funding for rural GPs is reduced the government knows it will have only one outcome – the gradual loss of on-site rural GPs and primary health services and an inevitable shift to Telehealth only hospital and primary care.

There will no doubt be some who believe that rural and remote people have no right to complain if they choose to live at a distance from where health services are delivered. There is a sentiment in some parts of government and our health bureaucracies that rural and remote people bring it on themselves.

What this sentiment ignores however is that rural and regional communities are responsible for generating 65 percent of Australia's export wealth, delivering fresh and high quality food to our tables and ensuring Australia comes out of this Global Recession in better shape. These communities are also home to many First Australians who hold the stories and history of the world's oldest continuous culture.

The sentiment also ignores the fact that the Council of Australian Governments has committed to "provide all Australians with timely access to quality health services based on their needs, not ability to pay, regardless of where they live in the country". Access to health care is not a privilege, it is a right.

Would anyone living in a major city think it was appropriate if Royal Prince Alfred Hospital in Sydney had no doctors on duty or on call to deal with emergencies? If not, then why should it be acceptable for rural and remote Australians?

If healthcare is a right as we are told it is, then it is a right that must be shared equitably among all Australians. But rural and remote people know from decades of hard experience that healthcare is a privilege, and Medicare is universal only to the extent that you can access a doctor.

Due to the failure to address rural doctor shortages for two decades, our governments are fast making Telehealth the default option for rural and remote residents - a model that would never be imposed on a major city.

The reality is that Telehealth is a wonderful tool, but its not a solution for everything. Having local doctors on-call in rural and remote towns to deal with emergencies like heart attacks, motor vehicle accidents and premature labour is costly but essential if we are to ensure access to healthcare remains a human right.

While there is substantial research on the use of Telehealth in managing specific diseases in a hospital setting, Telehealth has never been used as a complete model of care for a whole community and there is a dearth of research on the safety or quality of this approach.

By replacing rural GPs with Telehealth, we are effectively creating a different model of health care for rural and remote communities without fully understanding the implications for the health and sustainability of rural and remote communities.

The replacement of rural GPs using Telehealth also raises concerns about the long-term commitment of governments to addressing rural doctor shortages. If rural and remote communities lose local GPs who will be left to provide the training and clinical placements that health and medical students need to prepare for rural careers? This will effectively waste the billions of dollars spent on rural medical and health training to grow the next generation of rural GPs and nurses.

Further, rural and remote towns rely on the funding and jobs generated by local hospitals to support small business and create local employment (just like cities do). Health is typically the 2nd or 3rd largest employer of people in rural and remote towns. Indeed, a recent report by the World Health Organization found that for every $100,000 spent on health systems it generates 5 jobs in the local economy. Without health funding coming into these towns, as it does in our cities, then they will lose hundreds of jobs and small businesses.

In his speech to the Regional Australia Institute the Deputy Prime Minister said: “Family and small businesses are the backbone of regional economies. We know once a small business shuts, often it doesn’t sadly come back. So it’s vital we have as many small businesses as possible stay open – not just to keep existing jobs but create new ones”. This is true, particularly of local health services.

Many rural and remote communities rely on having a strong and accessible health and hospital system not only to support better health for the resident population, but to attract tourists and sustain and grow small business. This will be jeopardised if people do not believe they will have access to the right care if they need it in these communities.

There is no doubt that the rapid expansion of Telehealth in rural and remote Australia during COVID has transformed how patients are able to access health and medical care for the better, and has the potential to improve the health of many vulnerable rural and remote Australians.

In a recent survey, around 54% of rural and remote respondents were positive about using Telehealth when consulting with their own GP in town and preliminary results from the Rural and Remote Community Healthcare Survey show that rural and remote people are prepared to accept the use of Telehealth for routine matters like medical certificates and prescription renewals.

However, rural and remote Australians have also made it clear that they will not accept Telehealth as a replacement for their local GP VMO services for acute, chronic, sensitive and emergency care.

If Telehealth is going to be used, we need to understand the full impact of what we are doing and all the flow-on implications for patient outcomes and the sustainability of rural and remote towns.

We also need to engage communities about what is happening, why it happened and what we are doing.

Communities like Gulgong should not be forced to wake up one morning to find their local GP has gone and been replaced with Telehealth without any consultation or discussion.

Hundreds of millions of dollars have been spent to roll-out an entire system of hospital-based Telehealth in rural and remote communities without anyone ever asking rural and remote people if this is what they want.

No political party has ever gone to an election openly telling rural and remote people that their policy is to replace local rural doctors with Telehealth. Telehealth has always been presented as a way to better manage low acuity care and as a temporary measure to maintain health services access while workforce issues are resolved.

The organisation that I work for, RARMS, is the largest provider of on-site primary care delivered by doctors and nurses who live and work in rural and remote communities to more than 22,000 patients for the last 20 years - 365 days a year.

We are also the largest and most experienced provider of GP-led rural Telehealth services in NSW designed specifically to support rural and remote communities and doctors. We are the last to argue that Telehealth does not have a place in the provision of care in cities or the bush.

RARMS believes that Telehealth offers clear benefits for patients who live a long distance from their local rural GP or hospital. It can help some patients to get medical advice more easily and enable doctors to monitor patients remotely in their home helping to overcome the tyranny of distance.

But we do not see it as a replacement for local GPs and hospitals.

That is because local GPs are still needed in communities that have some of the highest rates of chronic disease, increasing rates of emergency department usage and earlier age of death compared to major cities.

It is also because there are highly successful models, our own included, that have been proven to increase recruitment of doctors and nurses in rural and remote areas and sustain medical and health services in rural and remote communities.

We don't need Telehealth to replace local rural GPs, we need governments to accept that our current policy approach to rural health is not working and that we should not compound the problem by again imposing on rural and remote people another "solution" designed in our cities that will not benefit the bush.

As our governments try to find better ways manage health budgets, we are seeing an emerging trend of Telehealth being used to replace rural doctors because it is seen as a cheaper way of delivering care to vulnerable patients in rural and remote areas who lack the voice and representation to advocate for their needs.

Put simply, replacing on-call hospital medical officers in rural and remote hospitals with Telehealth will result in more avoidable death of rural and remote people, and will contribute to the death of many of communities.

It will jeopardise the sustainability of on-site primary care services which research shows will lead to an increase in chronic illness, avoidable hospitalisations and a further increase in preventable deaths.

In the long run, government will end up spending more on costly hospitalisations, economic support for rural and remote economies and increased incentives to get teachers, police and others to work in towns without a local rural GP and emergency department.

Our rural health and workforce policies have failed, despite our best intentions.

Telehealth is a critical part of the future of healthcare in our cities and the bush. But we are not going to improve health outcomes in rural and remote communities by simply replacing rural GPs with Telehealth. Telehealth is a means, not an end.

We need to go back to the drawing board and establish a new model of care for rural and remote communities to ensure that it achieves the access and outcomes rural and remote communities have a right to expect.

Mark Burdack is the CEO of Rural and Remote Medical Services (RARMS) and a Hon Adjunct Senior Lecturer in the La Trobe University School of Rural Health. RARMS is the largest charitable provider of on-site and Telehealth care to rural and remote communities in NSW.