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Hello, I'm Norman Swan.
Welcome to this program - Fly-In Fly-Out: A Healthcare Option.
It's coming to you on the Rural Health Channel.
I'd first like to acknowledge the program is being broadcast
from the land of the Wangal people of the Darug tribe,
traditional custodians of the land
and part of the wider Aboriginal nation commonly known as Eora,
and we acknowledge their Elders past and present.
Tonight our panel will focus on
the fly-in fly-out healthcare services
which provide medical and allied healthcare
to otherwise isolated communities.
As you'll find out, sometimes these communities aren't so isolated,
but have different needs.
These services are vital to the provision of healthcare
in rural and remote Australia.
It's not just a narrative we're going to be giving you tonight
about these services.
It's also going to be a bit of a how-to.
If you're thinking about getting involved,
what should you watch out for?
What sort of personality should you have if you're going to get involved?
And if you're a member of a community
watching us, say, on NITV, as well as the Rural Health Channel,
what should communities do to engage better
with their fly-in fly-out services
to get the most from them?
Tonight's program is webcast
so you can log in to the Rural Health Education website - rhef.com.au -
and type your questions into the Live Talk tab box and click 'submit'.
You can also email, text, reach us on Twitter -
@rhef... I'll come to that in a minute. I've forgotten what that is.
But the details are on your screen now.
Send your emails to -
Text us on -
But I'd particularly like you to phone us
and share your experiences of fly-in fly-out services,
either as somebody providing it or as a member of the community
who's experienced them.
Tell us about the good, the bad and the ugly, if you like.
And you can tweet us by following us on -
Any of these means will get to us
and we'll take your questions and comments, or, indeed, stories.
Let's meet our panel.
Christine Barlow is a nurse who does contract fly-in fly-out work
for between one and four weeks,
relieving staff primarily in remote Aboriginal communities,
usually in the Northern Territory.
- Welcome, Christine. - Thank you.
Tristram Duncan is a consultant psychiatrist,
and he's also unit director of the Mental Health Rural Outreach Service,
providing services and supervision
to smaller towns across Western New South Wales local health district
using a combination of travel and telehealth.
- Welcome, Tristram. - Good afternoon.
Dr Tonia Marquardt is a general practitioner
and also senior medical officer in primary healthcare
located in Cairns, working with the Royal Flying Doctors Service
fly-in fly-out into Cape York.
- Welcome, Tonia. - Thank you.
And David Poff is a staff specialist and retrieval physician
with the Royal Flying Doctors Service in Western Australia,
but he actually flies between Queensland and WA to do his work.
- Welcome, David. - Thanks.
NORMAN: And welcome to you all.
Christine, how long have you been doing this?
A couple of years, fly-in fly-out.
NORMAN: What were you doing before that?
I worked in Queensland in one of the big hospitals there.
NORMAN: Why did you start doing it?
I was interested in it, 'cause in a few years' time, back then,
my husband and I were going to travel around Australia.
Through word of mouth, nurses where I worked.
NORMAN: So a good lifestyle as well as career option?
Yes.
Was it a shock when you started?
It was probably the unknown, you know?
NORMAN: You didn't know what was going to hit you when you got there.
No, exactly right.
But with support to go out there, with the orientation I was given,
it was very interesting.
And I've built on it since then.
So tell me what would happen.
You're not flying in for the day then out.
- You'd fly in and stay for a while. - Yes.
Myself, I'll stay in for up to four weeks maximum,
just relieving the nurses on the ground there
for education or annual leave.
So in a sense you're being a locum rather than
the only nurse that was going in.
In other words, no nurse, you're a nurse for a while, then coming out.
You were actually relieving an existing position usually?
Yes.
Tell me the most surprising case, if you like, early on,
the one that made you realise this is a different world.
Oh, for example, in the big hospitals,
you know, you get your trauma and all your general problems there.
But when I first went out to remote communities,
one of the things I'd never come across before,
which is prevalent out there, is scabies, for example.
And it was a whole new learning curve for me
on that particular grounds.
That was probably the biggest thing that stood out for me.
Something simple - a skin disease - that I hadn't come across before.
And what about acute care?
OK. I've pulled on my experiences from the big hospitals.
So if anything acute happened in the clinic
it's very similar to what I'd experienced in the big hospitals.
Of course, you don't have the facilities
that you have available to you in the big hospitals.
And what sort of resources could you call upon
if you didn't know something or you wondered what the protocol was?
For example, the CRANA manual for remote nurses is pretty good.
I think a lot of people in cities would quite like to have that.
Did you find that useful?
Very useful. Extremely. It's your bible.
But you always ask. There's generally other nurses with you.
If they're not there at the time, you've got telephone support.
You can call for backup help from your managers.
You can speak with the DMO, the doctor on call and everything.
So there's always somebody there.
Some people would say, look, it's a bit frustrating,
because you don't develop long-term relationships.
True. That can be a problem.
That's a problem with myself going out
and only being there for a short time.
You can't form those relationships.
Sometimes I've been back to a community several times
and people there do remember me.
But, again, they're not really long-form relationships.
Aboriginal communities are based on trust and knowing who you are.
They want to know who you are, what your relationships are,
where you come from and so on.
And in Aboriginal communities, you've got to earn that.
It doesn't come easily,
and it's hard to earn that respect and trust in a week.
True. But I've had feedback from certain people in the communities,
and they just find that my friendly nature...
I've been told I have friendly eyes.
- They've been able to come to me. NORMAN: 'Look into my eyes.'
Just that. Just being open, and welcoming these people
and not being stand-offish
and saying, 'You haven't done something right.'
Just treating them with respect.
Had you dealt with many Aboriginal communities before
or people from the Aboriginal community in your clinical practice?
Only a few people coming through.
NORMAN: And did you get any training in cultural safety?
I did, yes.
NORMAN: I would think that was pretty essential.
CHRISTINE: It was, definitely.
Tristram, describe your service in Central...
Is it Central West or Central and Far West New South Wales?
At the moment we're Central West and Northern Central.
So it's Dubbo, Orange, Coonanbarabran...
Yes, Dubbo, Orange, and reaching up Coonanbarabran
all the way up to Lightning Ridge on the Queensland border.
NORMAN: Right.
And then out far west to Cobar, Bourke.
And our southern border, where we're currently reaching...
- Only the size of half of Europe. - Just a...
Describe what sort of service you provide.
This is a newer service that I'm currently developing.
NORMAN: You were a nurse before you became a doctor.
- Yes, I was. NORMAN: And now you're a
psychiatrist.
You were playing with your psychological health a bit
so you thought...
Anyway, carry on. Tell us more about the service.
So this is one of the needs that we identified.
I'd been previously involved
during my training which I did for psychiatry at Orange,
and we were working with acute telepsychiatry services,
so providing just acute assessments.
But it was noticed that there was a lot of sub-acute need.
So patients or clients who were developing mental illness
that required sub-specialty assistance
in regional and remote towns,
but weren't able to get access to those services.
So these include things such as psychiatry and allied health.
So senior social work...
These are people with the full range of mental health problems
from depression and anxiety
through to psychosis and drug and alcohol problems?
- Absolutely. NORMAN: So anything?
Referred by general practitioners?
Referred by general practitioners, but co-case-managed,
so the patients we intend to look after
will be looked after primarily by the community mental health teams
existent within the community,
and we provide augmentative care.
So where there's an identified need
that can't be met within the local community
we would provide that service.
So it's a true consultation or consultation liaison service.
Yeah, running along similar lines.
So how much are you in a plane, a car,
versus on Skype doing a telehealth consultation?
At the moment it's more trending towards telepsychiatry,
so using video links and providing support through those methods.
But there's a component of drive-in drive-out,
and also looking to utilise some of the existing flying services
that we'd be able to piggyback on if possible.
So give me a sense of your week.
My week at the moment is still looking at developing this model.
So a lot of what we're doing at the moment is around needs analysis.
Instead of saying, for example, the requirements for Bourke
are exactly the same as the requirements for Lightning Ridge
so we'll do exactly the same...
So are you asking communities, or are you asking the teams
to identify the needs?
Initially, we've done a broad consultation across the area,
but now we're looking at the specific towns
and looking at going across the town.
For example, in Bourke,
we'd be looking at talking to both the communities,
the teams that are there, the NGOs, the local hospital districts,
and just trying to build a picture of what's available.
How much of your objective is...
..somebody is having an acute psychotic episode
with a history of chronic psychosis
and they don't know what to do and how to manage that
versus sharing the care of somebody
so that you leave greater skills with the community mental health team
or the local GP?
Both parts are a big part of this project.
Part of those acute services
are already provided by some of our existing frameworks,
such as the MHEC-RAP service,
which provides the acute telepsychiatry links.
But part of our model
will be looking at increasing the capacity of the local community
just to be able to deal with issues as they arise.
The idea, I guess, being that we create a stable senior workforce
that can provide these augmentative strategies or services,
as well as educational resources.
To what extent do you have your own patients in this model?
Within this, the primary care of the patient
remains with the community mental health team.
NORMAN: So you're purely consultative, really.
In fact, it's truly fly-in fly-out,
because whether you're on a video link or on the phone
or driving in and out of a community,
you're really doing that on a one-off basis
to help the local team look after somebody better.
TRISTRAM: Absolutely.
So it's only when somebody needs to be brought into the acute ward
that you get involved in the longer term.
We would hopefully be actually involved before then.
So the idea is to detect that need beforehand.
Minimise seclusion rates and restraint rates.
To minimise the impact of mental illness on the patient
so that we can get in there before the acuity rises.
And your relationship with the communities themselves,
that must be difficult to develop.
You rely on the local teams to do that.
Certainly, we rely on the local teams to have that local contact,
and that can't be minimised.
But part of our role is to be more involved and to understand
so that if, for example, something happens to the community teams,
we're able to continue that service and that support.
Don't forget, if you want to make a comment or share an experience,
why not give us a call?
1800 817 268 - we'll put you on air. Don't be frightened.
I'll be very gentle with you.
If you wanted to do it... anon...
..not anonymously, you know what I mean,
you can send us an email or you can actually text us.
Tonia, how long have you been at this?
Currently about 3.5 years with the Flying Doctors.
Before that I was overseas with another organisation
also working in remote communities,
which I guess was kind of fly-in fly-out for six months at a time
and then leaving again.
But 3.5 years going to the one community
with the RFDS up on the Cape.
NORMAN: Just one community? - Predominantly one community.
We cover each other a little bit,
but most of our team of doctors have a community we regularly go back to,
so that we're a regular GP service.
And our work is a mix of providing the general practice service,
as well as the after-hours on call as well as the retrieval service.
So you're not working for a community-controlled organisation,
you're working for RFDS.
TONIA: Correct.
NORMAN: But into an area where Apunipima doesn't serve.
Yes. So they're Queensland Health clinics
which don't have a medical officer for whatever reason,
and we're filling that gap, in terms of having a GP service.
Some of them... Apunipima is also providing a chronic disease service,
which has started to come in now
with a regular GP targeting chronic diseases.
So you're effectively the regular GP for a community.
Correct.
NORMAN: It's just that you don't live there 7 days a week, 365 days a year?
Yeah, exactly.
In essence, while Christine was talking about
the fly-in fly-out in terms of replacing staff who were there,
and the difficulty of making relationships
'cause you're there for a short term,
if you have a fly-in fly-out service
with the same doctor going back for 10 or 15 years,
it protects you from having someone going
for six months or one year then leaving again.
In actual fact you can build better relationships with the community,
by having a single GP service consistently, continuously,
and actually form relationships with the community
and have an impact on chronic diseases, one of the biggest issues.
NORMAN: So what does the community think when you fly home
at the end of the week?
Yeah, I guess...
So you're there Monday to Friday or what?
It varies from community to community.
It depends on the number of people.
Some of them are quite small, only a few hundred people.
So they don't need a doctor five days a week.
It's targeted according to the size of the population and other services
depending where there's...
So you're going to several places in one area?
For RFDS on the Cape or in Cairns we cover about 14 communities.
Some of them will be two different communities half a day each
and some of them will be the same community for three days.
So you fly in, stay a couple of nights in the same community,
so it varies a bit.
When you started, what did it feel like leaving them for a few days?
It's odd.
I guess a GP doesn't go into the practice on a weekend either,
so in some respects it's normal to have a normal working week as a GP.
The handover and transition of care to a different doctor
when you switch over halfway through a week,
that needs to be very complete and very well done
to avoid that... you weren't able to stay
and follow through what was happening
to a patient you were worried about.
- Where are the medical records? - They're kept in the community.
They're the property of the Cape clinic.
So there's no electronic storage here? You're not going to PCHR?
Not yet. We are in the process of transitioning,
but I think we're one of the last places in Australia
not to have general practice with an electronic medical record.
So tell me how you do handover.
You record in lots of places. You record in the patient's notes.
We have a doctor's diary where we transition messages to each other.
We will send messages to each other or call each other up
and say, 'Can you catch up with this person?'
We pass on to the nursing staff, and have a nurses' diary
with messages to follow through.
So a multitude of places.
There's databases where you record patients you're keeping an eye on.
So you try and record in as many places as possible
to make sure it doesn't fall through the gaps, but it is hard.
Is it any different from being a GP in an isolated community,
or can it be scarier clinically?
Are you having to confront situations which get your adrenaline going?
I think any isolated community is scary but interesting.
I've had days where I've had a mental health issue
followed by an obstetric issue
followed by a very sick child followed by someone with chest pain.
Just the broad range of skills you have to bring as a rural generalist.
I don't think it matters which community you're in.
If you're isolated and you're the sole practitioner
you have to have that really wide range of skills.
That's part of the interest for me of working in these settings.
NORMAN: How long will you do it for?
This could be a career-ending question, of course,
if the RFDS is watching.
I've done it for a long time,
so I suspect I probably won't stop soon.
I think part of the issue is maintaining your skills,
so I think you have to dip in and out a little bit
and go back into more specific services and keep your skills up,
be it in obstetrics, be it in intensive care, things like that.
So part of the advantage of a pool approach
like the Flying Doctors has,
is that you can take a period away
and maintain your skills and up-skill all the time.
NORMAN: Have to consciously do that. - Yep.
It must play hell with your social life. Do you have one?
Yeah, I think the fly-in fly-out does support a social life.
I think that's part of the benefit
and why I stepped away from going in six months continuously,
because then you're in the community.
I think with the fly-in fly-out you do get that possibility
to go in, do your work, and fly out and have a life-work balance.
- David, you're doing retrieval now. - Yes.
Give us a sense of your history in this area.
I've been working with Western Operations RFDS for seven years.
NORMAN: And before that?
I went through my advanced training in emergency medicine,
so I'm a fellow of the College of Emergency Medicine.
Prior to that I was a gardener before I did medicine
so I have a background in multiple industries
before I started medicine,
went through advanced training, I'm an emergency physician...
- You got the tetanus spores off... - I know how to wash my hands.
My last job as a training registrar was with the RFDS
as a retrieval registrar.
And that was in Jandakot, Western Australia.
And that gave me an insight into something I've come to love.
I continued on with my advanced training at the hospital base
then took the opportunity to go back to RFDS
on a fly-in, fly-out,
although I never recognised it as that term at that time in 2006,
and I've been doing it ever since,
principally providing relief to the five bases of Western Australia.
So slotting in to whichever roster needed staff relief.
Doing acute work or doing general practice work?
Initially doing both, so I was doing clinic work...
Whatever that gap on the roster implied,
I would do the clinics that doctor who was away at the time
was scheduled to do, as well as the retrieval work.
With time, I've evolved that
into a position where I just do the retrieval work now
'cause I find that for continuity of care,
the base doctors which are all residential
throughout Western Australia,
are, by and large, they go to the clinics week in, week out
so I take over their retrievals.
NORMAN: So that's more like Tonia's role.
Exactly. So I provide a retrieval role on top of that.
I suppose as an ED physician
you're used to the transient relationship with patients
rather than where GPs get their jollies from,
which is the continuity with a family.
I think different people are drawn to different aspects of medicine,
and certainly that's my ED training.
And my retrieval practice is certainly that.
- Having said that.. NORMAN: Are you a bit of a loner?
- Do you like the loner life? - I think my wife would say I'm not.
I've got four children, teenagers included.
NORMAN: That's why you spend all your time in the air.
I spend probably half my year at home, or just over half.
And that's full-time dad.
NORMAN: You're home more than most. - I am, indeed.
I've done the numbers, and I am home a lot.
But when I'm away I work intensely away,
and I work six or seven days a week.
And in doing so I feel like I provide support to my colleagues,
and the advantage to the community is my colleagues then get breaks
and get time away for the education that's been talked about.
They also get time just to chill a bit,
but also stay with their clinics
rather than having to abandon their clinics
for the time that they're away and having no-one relieve them.
How do you organise your CPD?
It's complex.
The fact is that I have substantial requirements to keep up my CPD.
I endeavour to go to conferences, workshops and so on
while I'm away from home and integrate that into my travel,
'cause as you can imagine I travel an awful lot.
So this three weeks away is a classic example.
I'm on a full-time roster in Jandakot in Perth at the moment.
I sneaked away two days to come here.
I've got three days at a conference in Melbourne on the way home
and I'll get a two-day workshop on the Gold Coast
before I even touch home.
That's at the same time as committing myself
to the roster that I do
and achieving that.
- So it's very busy. - Will you do this indefinitely?
I've been doing it for seven years now
and I can see myself doing it for another seven, easily.
Can you tell me some memorable things from your early times,
that you thought, 'I never thought I'd see this'?
Absolutely. There's many cases.
Float plane retrievals to the remote Kimberley...
..running resuscitations down telephone lines,
organising extractions of people from remote stations in the Pilbara.
The logistics of my work is what fascinates me
as much as the actual flying.
NORMAN: Are they flying jets these days?
The majority of the fleet across Australia is turboprop.
We have one jet in Western Australia
and it's pretty much a 'watch this space' in the coming years.
So it's no longer the little single-engined Piper
landing bumpily...
No, the bug-smashers are pretty much a thing of the past,
which changes our input into remote communities
in a substantial way.
NORMAN: Has that limited your access, then?
It limits it to the point where the upkeep of airstrips
is very important in terms of being able to get our bigger aircraft
into those places.
For clinics, that's a different story.
Obviously they are using smaller piston-driven aircraft.
Bu for remote retrievals, the classic station retrieval,
requires the station owners to keep their station strips up to scratch.
And sometimes when that's not done
there's a necessity to move patients on the ground
to a point where we can retrieve them from.
So it adds to the complexity and the interest of the work.
When I was a paediatric registrar
you had to go on the roster for paediatric retrievals.
This was in New South Wales.
I can still remember the cases.
You'd fly into somewhere like Grafton in the middle of a storm
and there'd be a baby with pulmonary hypertension
and the ambulance driver would say, 'Have you ever been to Grafton?'
and insist on taking you on a tour of Grafton before you go there,
then you've got to ventilate this baby on the way back.
I suspect it's more sophisticated these days than in those days.
The back of the aircraft is a mobile ICU unit
and it's becoming more sophisticated with time,
and that's changing around Australia and indeed around the world.
Which is why the aircraft are bigger and presumably safer.
Correct.
TONIA: But why you need ongoing up-skilling, as well.
NORMAN: Because there's more and more kit on board.
Why I find myself heading more towards retrieval
as opposed to try and manage
all the skills of general practice and so on.
We've got a few questions coming in on the webcast.
Remember, you can go to the webcast if you like.
If you're already on it just click the Live Talk tab
and then 'submit'.
Of if you want to go to the webcast go to rhef.com.au and then log on.
Melanie Walker from South Australia asks,
'How can professionals be attracted and retained
to do fly-in fly-out work and DIDO...'
What's DIDO again?
TONIA: Drive-in, drive-out. - Right, OK.
Depending how fast you drive it could be FIFO as well.
'What successful models are the panel aware of?'
What have you seen around the place?
I might ask Tonia and David this question.
The most successful model in terms of fly-in fly-out is to have...
I don't think it matters whether it's fly-in fly-out or resident,
is to have a really comprehensive primary healthcare service
and then to have the specialties coming in and supporting that.
But if you have a good comprehensive primary healthcare team,
they can manage a lot
of what you'd need a fly-in fly-out specialist to try and manage.
So I guess what works for us is having a pool of doctors,
who all know the Cape, who can all cover each other
so that people can maintain their skills...
NORMAN: But Queensland has some interesting models.
There's a group of GPs, I think out of the Sunshine Coast,
who go into remote communities,
provide a standard general practice service
and go home to Noosa at the weekend.
There are places where GPs have their regular practice,
for example a lot of the women's health service,
they go out and provide the GP service intermittently
in other locations, but still have their base practice
somewhere more central, as well.
I think a lot of the allied health services of fly-in fly-out
are in support of the team on the ground.
So I think you need a well supported team on the ground
and then whatever additional needs there are
to be supported with a fly-in fly-out.
But the team on the ground
doesn't have to be resident necessarily.
I think any model that provides a continuity of care,
even if it's with somewhat changing faces,
is very much accepted by people,
'cause that's what they want - they want ongoing care.
NORMAN: But in Western Australia,
it's not necessarily always to remote communities.
No, it's not. I certainly know a group of emergency physicians
which provide seven-day-a-week cover,
for instance, in a regional hospital like Kalgoorlie,
which is an evolved practice.
It's obviously outside the RFDS's work,
but knowing those guys personally,
they provide a very important specialist level of care
to a community that not that many years ago never had that.
And none of them, as far as I'm aware,
are resident in Kalgoorlie.
They're Perth specialists, they work in the Perth tertiary hospitals,
and yet they spend time on their own roster going to Kalgoorlie
and providing that level of service.
That's one of those under-the-radar type fly-in fly-out things
that people aren't aware of
that's contributing greatly to regional health services.
Another example, as Tonia alluded to,
it was the Royal Women's Health Service
that is run by the RFDS
into the wheat belt towns of Western Australia.
And that is not to take over from the local GP practice,
but to supplement them,
and they work within the practices that are already established.
By doing so, they give those GPs support
or a chance for a break and so on and they're the...
And give local women a chance to see a woman.
And gender choice of visiting doctor.
And they've been doing that for years.
Again, possibly much of the community
aren't aware that actually happens.
Have you seen many alternate models
that you're learning from in terms of psychiatry?
Certainly.
One of the first models we looked at
when we were looking around Australia
was looking at the South Australian model.
They've been running for a long time under Ken Fielke.
I think Peter Yellowlees started...
the very first telehealth service for psychiatry in South Australia.
That's right. They've been running that service very successfully.
As they often quote all their psychiatrists,
I apologise if I'm misquoting now, but...
All their psychiatrists are located within the Adelaide region,
but still provide
a complete outreach service from that one site.
So certainly looking at their models and what they've been doing
we've been able to learn from their fly-in fly-out services
and sub-acute work they've been doing.
But even within our district
we have a number of services that are running
that have been running for quite a while,
and a number of psychologists that have been flying or driving out
to various places, such as Bourke and Cobar,
from our major regional towns,
to provide these outreach support and services.
To what extent are you, in mental health, using online?
The people who develop the online therapies?
MoodGYM, the people at St Vincent's CRUfAD and others,
say that in many ways they've designed it for people in rural areas
who can't get access to healthcare practitioners,
and arguably provide better care, because it's high-fidelity care,
to chronic cognitive behavioural therapy
than experienced therapists do,
because the computer doesn't deviate.
Are you encouraging people to do online therapy
for the high-prevalence disorders?
Absolutely.
I think they're just one part of the whole armament that we've got.
You're recruiting people to do that?
Yes. I'm registered to prescribe on CRUfAD and utilise their services,
and have used them on occasions where it's been useful,
where psychological intervention on a regular basis wasn't available
and I was only able to visit and telelink on limited occasions.
So having that available is a good option,
but I think it's just one part of all the tools
that are being looked at
and certainly used in my clinics in the past.
NORMAN: And are you finding more rational prescribing?
Because there has been criticism that the less experienced you are
the more likely you are to throw around
things like haloperidol and olanzapine unnecessarily.
Are you getting better-quality use of medicines?
- Short answer is yes, but... - It would have to be, wouldn't it?
(Laughs) But I think it's multi-factorial,
and part of that is around making sure
you've got your own level of peer supervision
and ability to be able to reflect your practice to others
and ensure that you're remaining in line.
The other thing, the danger in specialist practice,
is people with schizophrenia
have a reduction in life expectancy of about 25 years
and it's not suicide, it's cancer, heart disease,
it's basically that they're not getting good physical care.
And the risk is with fly-in fly-out psychiatry services
you become even more fragmented from physical care
and you're actually not getting them healthy.
It's a big problem.
A project running within the area health service at the moment,
and I believe it's Statewide in New South Wales Health,
is, for example, with schizophrenia, looking at metabolic syndrome,
and there's a whole...
NORMAN: Olanzapine again.
TONIA: I think you do need good GP services as well.
I think that still comes back to having good GP services.
The arterial model for psychiatry outreach
is the psychiatrist sits in the general practice surgery
and sees cases that the GP has referred,
but the GP sits in and actually gets up-skilled,
so that as time goes on,
the psychiatrist is seeing more and more complex cases
more appropriate to the psychiatrist,
and the GP is doing far more.
You get more integration with physical health, as Tonia was saying.
Is that a conscious strategy on your part,
or are you so swamped by the regular mental health stuff you're sinking?
There's a lot of need out there,
but there are certainly models operating within general practices,
a lot of which is being supported
by some of the newer Medicare initiatives using telepsychiatry,
where there's a number of...
You are sitting with a GP, then, often.
TRISTRAM: Exactly.
And presumably going into remote Aboriginal communities, Christine,
you're not really seeing many different models.
It's usually either a community-controlled organisation
or a local primary health service with Aboriginal health workers.
Yeah. So if we have needs that come through like that,
we do a lot of referrals.
So when clients come in, if they have mental health issues,
if there is a doctor in the clinic, we can refer to the doctor there
and ask them to review the patient.
Or we can do a referral
for when a GP or psychologist comes into the clinic.
So we've got some more questions here.
Another one from Holly Parker at Edith Cowan, Western Australia.
'Hi, I'm a student nurse.
What services in Western Australia
provide fly-in fly-out services to which communities?'
It's perhaps a more generic question than just RFDS.
Indeed. And I'll be honest to say the breadth of those services
nurses may be able to take advantage of is beyond my knowledge base.
NORMAN: Is there a place that Holly can go to find out?
DAVID: Almost certainly, but I can't put my finger on that. I apologise.
But the truth is there are enormous...
Perhaps Christine can help me out there.
I liaise with an enormous number of remote nurses
and nurses within regional facilities.
And they provide a huge service,
often without the immediate backup of a doctor in the community.
So there are enormous opportunities outside of the RFDS.
Holly, probably you want to talk to the Remote Nurses Association.
- That is CRANA, isn't it? CHRISTINE: That's one of them, yeah.
They probably will be able to put you in touch with the right people.
But it's a good question.
If I can be more anecdotal,
someone like Holly could simply speak to her colleagues,
'cause they'll know people who work in those fields,
and she'll probably be able to make personal contact
and get some insight into those different places.
CHRISTINE: Also through her university.
So for clinical placement
she can ask to be placed in a remote community or a rural community.
Within RFDS we do have fly-in fly-out nursing staff, as well.
But they're certainly not new grads.
They're flight nurses with a broad range of skills,
which take some years...
Which is really the next question from Belinda O'Sullivan
at the School of Rural Health in Bendigo, Victoria.
'What sort of professional...' That's a different question.
'What sort of professional development
do the local workforce need to cope with the fly-in fly-out?'
Let's answer that question,
and we'll come to what professional development do you yourself need
before you take on one of these jobs.
What do you believe...
As a nurse looking at the people on the ground you go to work with,
what do they need, specifically, to be able to handle
that intermittent person who comes in and out?
Probably just to be able to accept the person...
NORMAN: It's about relationships. - Yeah.
To let them know we're coming in to give them a helping hand
and trying to relieve the pressure from them
so they're able to get out and about.
I know that can be very stressful at times for the staff on the ground
and things are just like, 'Argh,' you know?
Tristram, you've said you're trying to build up community-based teams
so they're as strong as possible.
Presumably recruitment is a huge issue.
Absolutely. And around it all is identifying need
and making sure that what the outreach teams are doing
is actually helpful and needed by the community.
I think that helps in the collegiality
between the teams that are already in place
and those flying in, flying out to ensure it's meeting need.
NORMAN: Tonia? - You need really good understanding.
It's a very two-way street.
It's hard for the residential team
to have a fly-in fly-out team suddenly arrive
and start to say, 'I need this, I need this,'
and increase the workload of the team on the ground
when they should be supporting them and assisting them with their work.
So I think that's one for the fly-in fly-out team.
And also for the team on the ground
to understand when you're flying out and you've got 100 things
and you're trying to make sure things don't
fall through the cracks,
and you're feeling under pressure because you've got a plane to catch,
and you're holding other people up that are also catching the plane,
and you feel as though you're dumping and running,
which is a terrible way to leave things.
I think you need everyone to appreciate
what each other's roles is,
how they're supporting each other and how they work together
to make a good team, and to feel you're all part of the same team,
and you need each other to be able to function.
So just that appreciation and understanding
of what everyone's roles are.
NORMAN: David?
I can only agree with what's been said.
It integrates with what was said before about clinical handover
that's equally important,
so there's a relationship between people staying and people going.
So up to what level of training do you need
before you take on one of these jobs?
TRISTRAM: I think it's got to be throughout your training career.
And that's perhaps from my own personal experience,
but to have it not only for myself in my nursing training,
but it was also present in my medical training,
during my registrar years,
and that equipped me quite well to understand...
NORMAN: So it's like anything else.
It's the degree of responsibility you're going to take
as a fly-in fly-out doctor or nurse.
TONIA: Some things you can't train for.
In my experience, especially flexibility.
It doesn't matter how much you try and train -
if someone is very rigid,
they struggle very hard in remote settings wherever you're working.
People who are really flexible and a bit pragmatic
often tend to gel better in these settings where things will go wrong.
And you've got to be able to deal with that
than expect you can control the environment
and fix everything to the way you'd like it.
And that's where I think they struggle a bit.
We could all think of examples of colleagues who are good clinicians
but don't fit the mould for the remote environment.
One, they may not feel comfortable with being somewhat stranded,
whereas other people are infinitely comfortable
with dealing with what they can see in front of them
to the best of their ability.
And then thereafter making the communication that's necessary.
In the same way, understanding what is available within the community,
and ensuring that what they're suggesting is actually valid
and can be put in place.
TONIA: We have teams that don't do fly-in, fly-out
and when you call them for advice,
if they've never been up to the community,
some of the advice you get is really irrelevant to your setting.
So I think fly-in fly-out...
NORMAN: 'Get theatre ready. Call the anaesthetist.'
TONIA: 'Where's your CAT scan?'
A good remote clinician, be they a nurse, a doctor or allied health,
knows how to communicate with other people.
Because they'll, at some stage, be out of their depth,
whether it's relatively simple, but they just don't know it -
never seen the condition before -
or it's something complex and they just need help.
One of the things I love about my job, one of the many things,
is that I can pick up the phone and anybody will talk to me.
Because they'll be interested.
And that's a big bonus.
Another question from Bendigo is - 'What about accommodation?'
Is that a challenge?
Well, everywhere I've been to so far had clean, secure accommodation,
self-contained, you take your own food in and it's been good.
I've heard horror stories,
where people have rocked up and it's been a condemned little building.
They have chosen to stay on, others have totally refused
and said, 'No, I'm not staying here until I get better accommodation.'
Queensland Health got into tiger country
over accommodation at Palm Island.
I worked in Africa for a long time so I feel a bit Pythonesque
in saying, 'It was luxury.'
It's pretty good, most of the places.
There's always problems with maintenance of accommodation.
I think there's huge problems with amount of accommodation.
A fly-in fly-out workforce,
a lot of people need accommodation when you get more services,
and that often limits services - just the lack of accommodation.
But the quality and standard have been pretty good.
- You just sleep on the plane. - I try to at every opportunity.
But I've also experienced excellent accommodation
across most of the places I've been.
But I also know about the horror stories as well,
which are relatively few and far between.
It's incumbent on the organisations who set up the programs
to provide the clinicians with accommodation
that doesn't have to be substantial, it doesn't have to be luxurious,
it just has to be clean and secure.
And another question, 'Do you think the local workforce is more likely
to be retained and stay on by having fly-in fly-out into the community,
or does it not make any difference to their intention to stay?'
I think one has to, once again, complement the other...
I suppose if you feel supported,
in the sense that you're supporting the local teams, you feel better.
That's precisely what we're finding the teams that are isolated and
not receiving that external support
are more likely to find themselves feeling stressed or burnt out.
And so having that extra support,
whether it be personal mentorship,
education or assistance with difficult cases
that they're finding a struggle,
is really important.
NORMAN: I suppose, Christine, where you're relieving people,
that gives them a break and refreshes them for when they come back.
It does, yes. And I can relieve them for their annual leave
or go in for relieving them for their education.
So although it's short timeframes that I do it, it's still...
DAVID: It's just not about service provision.
It actually has all these other side effects or benefits.
NORMAN: Respite, professional development, support.
DAVID: Absolutely.
And a question from New South Wales, from a physiotherapist,
'Is there fly-in fly-out allied health?'
We'd love a physiotherapist on the Cape. We don't have any.
We have one OT and we have huge gaps in some of the allied health.
We have good support for dietician, diabetes, educated podiatry.
Optometry is OK.
But the OT and physio is really one of the biggest gaps we have.
NORMAN: How would they be paid if you got one available?
Would RFDS put them on a salary? Would they charge private fees?
Essentially, mostly, allied health...
NORMAN: OK, we're committing RFDS here now.
TONIA: Most of the allied health are through Queensland Health.
Queensland Health would fund the position if they found one?
As far as I understand, there is an open position.
- I keep being told. - OK. Good.
So you've got allied health people supporting community teams?
Yep. We're very proud.
We've managed to secure an occupational therapist
and we're gradually opening up more and more positions
to be able to get psychology, social work and specific D&A CAMHS
to provide that extra support and service to the local communities
and the community mental health teams.
So there are certainly roles in development.
So a nurse, Matthew Justin, writes,
'Retrieval specialists, locum relief or visiting consultants,
have always been a part of rural and remote healthcare,
however, the changes towards fly-in fly-out,
month-on month-off employment
even in so-called resident healthcare teams,
this has an impact on continuity of care.'
'Discuss' is his demand.
DAVID: I think Tonia alluded to that before,
how that continuity of care can continue
despite the fact that there's changing faces on the team.
On average, our team,
some doctors have been there 20 years, 15 years.
Our average is 8 years.
So I think in actual fact your continuity is better served
through a fly-in fly-out model
or a month-on month-off model, things like that,
purely from experience now.
NORMAN: Rather than a locum coming in
for a couple of weeks then go off again.
And even the residential nursing teams.
You often see 6 months, 12 months maximum,
and then the majority are leaving.
There are a few who stay and love the community and are fantastic
and provide brilliant, long-term continuity of care,
but it's becoming fewer and further between.
And we recognise that for all of remote Australia,
where we have struggled for
medical and healthcare services in all settings,
purely based on the difficulties of family support,
lifestyle and ability to stay permanently in small communities.
And some of the communities are too small to have permanent living,
continuous presence,
be it BreastScreen that does a drive-around service,
because you're going in once a year
to do an entire community, things like that.
Some of the services do not need a permanent living presence,
so they're best dealt with through...
So your argument is that it improves continuity of care?
TONIA: In my experience, it certainly improves continuity of care.
We have really fantastic continuity for our medical teams.
On reflection, even looking at my own experience,
with specialists flying in and out
both from Sydney and from Orange and Dubbo,
the consultants doing it have been doing it for 20 or more years,
and I guess what's apparent is that once...
It's almost like they fall in love
with the regions they're working with.
They become very enmeshed and know the communities,
are able to respond to the communities quite well
and advocate very vocally, as well, during meetings and otherwise,
for retention of those services and for the services for the region.
So I think it provides a level of...
I do think that it provides continuity,
but it's a different picture.
I guess, particularly, as we mentioned before,
being able to base consultants, specialists,
in smaller regional towns
that don't have the capacity to provide all the work
that would be able to retain a specialist in that area...
NORMAN: It just doesn't give a volume.
So FIFO and DIDO, and all the other acronyms
for moving in and out of places,
provides that service on a regular and consistent basis.
NORMAN: What do you think, Christine?
I find that there are issues for myself as a nurse.
But where I'll try and carry it through
is I'll go in, I'll use the systems that they have in place,
pick up the area and carry it across.
In doing that, when the permanent nurse does come back through,
she'll be able to see that the care has just carried on through.
NORMAN: And, of course, handover is really important.
CHRISTINE: It is, yes.
So you should really be encouraging a bit of overlap
so you can talk to the person coming back so they know.
Sometimes if you can't talk to the person because you've overlapped,
you've flown back in the morning, she's come back in the afternoon,
there's the diaries and there's the other communications.
We've got electronic communications, on the files, etc,
so we can write notes and what we've done.
NORMAN: You're better off than RFDS, then.
Carly Sutherland, a South Australian psychologist asks,
'What personal qualities/characteristics
are important in health professionals who provide services?'
I think you've said it.
If I've understood you correctly,
flexibility, good communication skills, patience
and expect the unexpected.
And good to have some clinical knowledge. I think it's important.
NORMAN: That's a bit old-fashioned! - Yeah, I know.
Another question from Matthew Justin.
'Staffing the organisation with FIFO employees
means recruiting more individuals than if they were all full-time.'
- Is that true? - To some extent.
We have more part-time staff,
so we have 26 staff covering 18 full-time equivalents, but...
Matthew goes on to make the point with the increased number of staff
you've increased the number of handovers
and the opportunity for diminished quality.
The possibility for drops in care for patients,
and that's where you have to be more exact and more thorough
and really pay attention to it.
But I think that can happen no matter what.
Either way you have to be extremely diligent about following through.
I think that's true of general practice.
Hospital training versus general practice training
are quite different
'cause hospitals, we do a lot of handover in emergency departments.
Every eight hours you have a handover or every ten hours.
So you have a different team come on, a different team come on.
Within the single episode of patient care
you have multiple different teams looking after a patient.
So hospitals are really set up for that rapid transition,
handing over all the time of patient care.
So you just have to pay attention to it and be aware
that's the model you're working in
and make sure that it continues to happen.
The evolution of information systems is helping that process out.
There's no doubt about that.
I had a question for you here. It's disappeared, David,
but it was from Liam O'Doherty, a Victorian general practitioner,
asking about whether or not the Faculty of Emergency Medicine
is coping with these sorts of skills in its training process.
- Specifically... NORMAN: For retrieval.
Absolutely, with respect to retrieval.
Within the training program,
retrieval is a sub-specialty opportunity
which obviously not everyone does.
You can do it for six months or for longer if you want.
You can get six months recognised. That's exactly what I did.
And then you can take it from there.
It's a burgeoning field, retrieval,
not only within Australasia, but worldwide.
So there are lots of opportunities to continue that education,
but specifically in the college, you can have that accredited for sure.
TONIA: I'll come back to my continual point -
a good GP can also manage a lot of the retrieval services
in our setting.
Absolutely. I'll add that I'm the only specialist emergency physician
doing retrieval work for the RFDS outside of Jandakot.
So they're all generalists and they all do a very good job.
A lot of the remote work, you need a rural generalist.
If you tried to put an emergency physician, as Tristram was saying,
you can't have a psychiatrist in every small community,
you can't have an ED physician for every small community,
and a lot of the retrieval emergency work happens with our clinic staff
who are sitting in a clinic
and suddenly the patient arrives from the rollover or whatever
and you have to manage the patient immediately
and be able to manage that without necessarily waiting
for the emergency retrieval physician to come out and help you.
That comes back to your question about what skills people need.
People need to be comfortable
with dealing with those sorts of emergences
and not be too naive as to what might come through the door.
And that may mean you need to have a few years under your belt,
unless you're particularly cocky.
NORMAN: It's been fascinating. I've learned a lot.
What are your take-home messages for those watching
who could be aspiring fly-in fly-out physiotherapists,
occupational therapists, pharmacists even,
and general practitioners and nurses?
What's your take-home message?
Well, mine is certainly two-pronged.
One is there are a lot more
fly-in fly-out, drive-in drive-out type services out there
that significantly contribute to regional and remote health
than one might suspect.
So if you are thinking about doing it
then certainly speak to colleagues
because you may find out there's niches out there
that have already been taken advantage of.
NORMAN: Tonia?
I would say, essentially, you need continuity of services
and good generalist services,
and I think fly-in fly-out, in my experience,
addresses a lot of that need.
NORMAN: Tristram?
I'd suggest if you're doing it,
take your time to know your community
and to know the people that are working in the community,
'cause they can be your greatest ally.
NORMAN: Christine?
If you're keen to get out there and try some remote nursing
I would say have a go,
'cause you'll never, never know if you never, never go.
It gives you a bit of independence and a lot of confidence.
Thank you all very much indeed.
I hope you've also found this program
on Fly-In Fly-Out: A Healthcare Option
informative and useful.
There are plenty more resources and websites
available on this topic.
We've put some on your screen,
including the CRANA website,
if you're interested
in obtaining more information.
And you can always go to
the Rural Health Education Foundation
website where you can watch
this program again
or get those resources.
And if you want to watch the program again
click on the program page Fly-In Fly-Out: A Healthcare Option.
If you're a health professional
don't forget to complete your CPD evaluation form,
which can be completed online.
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Our thanks to the Department of Health and Ageing
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but a special thanks to you for watching and contributing,
including you, Matthew.
We'd appreciate your feedback. Your comments are important to us.
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I'm Norman Swan. See you next time.
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