- Email: [email protected]
A long way from home: Access to cancer care for rural Australians
Radiography 18 (2012) 38e42
Contents lists available at SciVerse ScienceDirect
Radiography journal homepage: www.elsevier.com/locate/radi
A long way from home: Access to cancer care for rural Australians Tony Smith* University Department of Rural Health, Northern NSW, University of Newcastle, Locked Bag 9783 NEMSC, Tamworth, NSW 2348, Australia
a r t i c l e i n f o
a b s t r a c t
Article history: Received 3 August 2011 Accepted 21 October 2011 Available online 10 November 2011
In 2002, the Commonwealth Radiation Oncology Inquiry reported that access to cancer care services in Australia was seriously limited. Several recommendations were made, including improving access to cancer care in rural areas by increasing the number of comprehensive oncology facilities outside the cities. Much has changed since 2002, with the establishment of a number of Regional Integrated Cancer Centres. This has been boosted again in 2011 by further Commonwealth Government funding. Cancer is primarily a disease of the elderly and, with the ageing population access to cancer care for rural and remote Australians remains a major challenge. Cancer is the second most common cause of death in Australia, exceeded only by cardiovascular disease. It has been reported that the relative risk of dying of cancer within 5 years of diagnosis is 35% higher for those living in remote locations compared with major cities. Overall cancer mortality is significantly higher in rural and remote locations (206 deaths per 100,000) compared with urbanised areas (172 per 100,000). Cancer mortality is higher again for the Aboriginal population (230 per 100,000). The reasons for the disparity in cancer outcomes for metropolitan versus non-metropolitan Australians are varied. In general, rural and remote residents have to travel long distances and stay away from home, family and work for long periods of time to access the care they need. Hence, distance is the overriding barrier to access, compounded by the financial costs and disruption to family life, not to mention the endemic lack of specialist medical and allied health workforce outside the major cities. Some rural and remote Australians choose to compromise, accessing whatever care they can locally, although this contributes to the need for cancer care services close to where people choose to live and die, to deal with the complex associated morbidities. Recent government investment in new regional cancer care infrastructure is essential; however, it is not the entire solution. Staffing the new facilities calls for innovative solutions, including managed care pathways, outreach programs, models of shared care and the use of telemedicine. There is also a need to better address issues of Indigenous cultural safety and risk reduction in the Aboriginal population. Ó 2011 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.
Keywords: Oncology Cancer treatment Rural and remote health Equity of access
Introduction In June 2002, the Commonwealth Radiation Oncology Inquiry,1 chaired by Professor Peter Baume, reported that only four-fifths of the patients who required radiotherapy actually received it and that waiting times were much too long. The report found critical shortages of radiation oncologists, radiation therapists and medical physicists to staff existing, let alone any new machines. Consequently, patients were falling through loopholes, exacerbated by cost shifting arrangements between the States and the Commonwealth.1 At that time, only a minority of the State and Territory health departments had a strategic plan for radiation oncology and
* Tel.: þ61 2 6767 8464; fax: þ61 2 6761 2355. E-mail address: [email protected].
little thought had been given to access to cancer care for Australians living outside the capital cities. Among the five key recommendations of the Baume report was to improve the availability of radiotherapy services in rural and regional Australia by increasing the number of comprehensive oncology facilities outside the major cities, by the use of outreach services, and by better reimbursement of travel and accommodation expenses. The Baume report precipitated substantial and rapid changes, although they were long overdue.2 Within a decade of the report being handed down, most of the recommendations have now been implemented. The number of radiotherapy facilities in regional and rural areas has increased, University places for radiation therapy students have increased, the three radiotherapy professions (Radiation Oncologists, Radiation Therapists and Medical Physicists) have implemented continuing professional development programmes, and
1078-8174/$ e see front matter Ó 2011 The College of Radiographers. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.radi.2011.10.041
T. Smith / Radiography 18 (2012) 38e42
a Tripartite Committee has been formed, comprising representatives from the three professions. Access to cancer care services for non-metropolitan Australians has improved substantially in the last ten years and will continue to improve under the Commonwealth Government’s current policies. In the May 2011 budget the Government announced further funding for Regional Integrated Cancer Centres, including radiation therapy departments. This follows the establishment of cancer care facilities in many various regional centres, such as Cairns and Toowoomba, Orange, Lismore, Darwin, Launceston and Bunbury. The recent budget allocation will build another ten oncology facilities in regional locations. Nevertheless, access to cancer care for patients from regional, rural and remote parts of Australia is an ongoing challenge. This article examines the barriers to accessing cancer care for nonmetropolitan Australians and discusses some of the many ways that these challenges may be, and are being addressed. Cancer in Australia Because cancer is primarily a disease of the elderly, the ageing of the population will cause the number of new cancers diagnosed in the future to increase. The most recent report from the Australian Institute of Health and Welfare (AIHW) put the 2007 age-standardised incidence of cancer, excluding basal and squamous cell carcinomas of the skin, at 485 cases per 100,000 people, with significantly higher rates for males (595 per 100,000) than for females (394 per 100,000),3 (p.10) (see Table 1). The risk of dying from cancer before the age of 75 years was 1 in 8 for males and 1 in 12 for females, but this trend was reversed after the age of 85 years, with 1 in 4 cancer deaths for males and 1 in 6 for females,3 (p.24). The mean age at diagnosis was 67 years for males and 64 years for females,3 (p.12). As shown in Table 1, in 2007, the six most common cancers accounted for 68% of all cancers diagnosed,3 (p.160). Prostate cancer was by far the most common male cancer, accounting for almost a third of new cancers, followed by bowel cancer, melanoma, lung cancer and lymphoid cancers,3 (pp.1112). In women, breast cancer was twice as common as bowel cancer, followed again by melanoma, lung and lymphoid cancers,3 (pp.1112). Cancer caused about three of every ten deaths (29%) in Australia in 2007, exceeded only by cardiovascular diseases (34%),3 (pp.2223). A greater proportion of males (57%) than females (43%) died of cancer. Table 1 shows that lung cancer contributed most to cancer deaths for both males and females. For males prostate cancer was the next most common fatal cancer, and breast cancer for females, both followed by bowel cancer, lymphoid cancers and melanoma. Combined, the six cancer types listed in Table 1 accounted for 50% of cancer deaths in 2007,3 (pp.2223). Rural and remote versus metropolitan Jong et al.4 analysed data from the NSW Central Cancer Registry and determined the five-year relative excess risk of dying from
39
cancer in the more remote regions of NSW compared to the most accessible regions. A significant increased risk was found for remote locations for cervix and prostate cancers and for cancer overall, even when adjusted for the stage of the disease. It was concluded that, compared to those living in major cities, residents of remote regions of NSW were 35% more likely to die of their cancer within 5 years of being diagnosed4 The AIHW’s 2006 overview of cancer in Australia reported that while the incidence of cancer in 2003 was 10% lower outside of the major cities, the mortality rate from cancer was 10% higher.5 The most recent AIHW report found that the highest incidence rate for cancer was in inner regional areas of Australia (496 per 100,000) compared with both metropolitan centres (474 per 100,000) and remote areas (475 per 100,000),3 (pp.3839). The incidence of particular types of cancer also varied with geographical location. For example, incidence rates for breast and lymphoid cancers in remote areas was 0.8 times the rate for major cities, while rates for cervical cancer, lung cancer and secondary cancer with an unknown primary were 1.5, 1.4 and 1.3 times higher in remote areas. For the period between 2003 and 2007, the overall cancer mortality rate was also significantly higher in rural and remote locations compared with urbanised areas, with 206 deaths per 100,000 in remote areas compared to 172 per 100,000 in the major cities,3 (p.40). The AIHW suggested that some of the geographical difference in cancer mortality could be explained by the relatively high proportion of the population in more remote areas being either Aboriginals or Torres Strait Islanders. The incidence of death due to cancer is significantly higher for Indigenous Australians (230 per 100,000) compared to non-Indigenous Australians (178 per 100,000),3 (pp.3435). The most common types are lung, breast and bowel cancer. In 2007, Indigenous Australians were 1.7 times more likely to die of lung cancer and 5 times more likely to die of cervical cancer than non-Indigenous Australians,3 (pp.3435). Risk factors are generally higher, with cigarette smoking twice as common amongst the Indigenous population,6 while cervical cancer screening is much lower than the national average.7 Barriers to cancer care There are various reasons for the disparity in cancer outcomes for metropolitan versus non-metropolitan Australians, including delayed diagnosis due to the lack of availability of health care services generally,8 as well as lack of state-of-the-art diagnostic imaging and radiation therapy technology.4 Therefore, to access the same sort of care available to city dwellers, rural and remote residents have to travel long distances and stay away from their home, family and place of work for long periods of time.9 Hence, the overriding barrier to equitable access to cancer care for all Australians is distance. Australia has a land area equivalent to about 83% of that of the United States of America (USA) [http://wiki. answers.com/] but has a total population of only about 22.6 million people, or only about 7% of that of the USA [http://en.wikipedia.org/
Table 1 The most common cancers diagnosed in Australia, together with incidence and mortality rates, in 2007.3 Cancer Type
Number of Cancers Diagnosed (%)
Incidence Rate (per 100,000)
Mortality Rate (per 100,000)
Male
Female
Persons
Male
Female
Persons
Male
Female
Persons
Prostate Breast Bowel Melanoma Lung Lymphoid All Cancers
19,403 (17.9) 103 (0.1) 7804 (7.2) 5980 (5.5) 5948 (5.5) 4116 (3.4) 62,019 (57.2)
e 12,567 (11.6) 6430 (5.9) 4362 (4.0) 3755 (3.5) 3160 (2.9) 46,349 (42.8)
19,403 (17.9) 12,670 (11.7) 14,234 (13.1) 10,342 (9.5) 9703 (9.0) 7276 (6.7) 108,368 (100)
182.9 1.0 75.2 57.2 57.9 39.6 595.1
e 109.2 53.4 38.2 31.3 26.8 393.9
e 56.9 63.4 46.7 43.3 32.8 484.6
31.0 0.3 21.7 8.5 46.3 14.2 224.6
e 22.1 14.6 3.4 24.0 8.8 139.1
e 11.9 17.8 5.7 34.0 11.2 176.1
40
T. Smith / Radiography 18 (2012) 38e42
]. As shown in Fig. 1, Australia’s population is concentrated around the better-watered coastal regions, leaving vast expanses of the interior unpopulated, most of which is unsuitable for any form of primary production other than mining. Indeed, there are some mining communities of several thousand people located fifteen hundred kilometres and more from definitive cancer care services. Even patients from large regional centres with greater than twentyfive thousand inhabitants have to travel to their nearest capital city to access specialist surgical, medical and radiation oncology treatment. Inevitably, this imposes additional financial burden on the patient and their family. That burden can be enormous, given that socio-economic status is typically lower for rural and remote compared to metropolitan populations.11 Because of all of these contributing factors (and more) cancer patients in rural and remote areas often present with a later stage of their disease and have lower survival rates compared to those from major cities. For Indigenous Australians, for example, the higher cancer mortality rate is explained by their greater likelihood of being diagnosed at a location where the prospect of accessing treatment is poorest,12,13 or being diagnosed at an advanced stage of the disease when the chances of survival are less.14,15 Hospitalisation for cancer treatment away from the usual support networks of family, friends and work, has many costs and unmet needs that are discussed elsewhere in the literature.16e20 The patients’ needs can also limit access to the highest quality of care. Clavarino et al.21 reported that the conflict between treatment location and disruption to family life often influences patient preferences and their treatment decisions. Fundamental cultural issues and beliefs also have a powerful influence. It has long been recognised that rural and remote Australia is ‘sociologically, culturally, economically and spiritually different from metropolitan areas’, which influences the ‘way health and medical care is provided’.22 Some rural and remote Australians choose to compromise, accessing whatever care they can locally rather than having to travel. For them, this is a quality of life decision9; however, it contributes to the need to provide high quality cancer
care services close to where people choose to live and die, to deal with the complex morbidities associated with the various cancers. The financial costs of accessing cancer care can be of critical importance, as well as being disruptive to family life. They include the loss of income as well as out-of-pocket expenses such as travel and accommodation (at city prices) and the cost of care beyond that covered by either government rebate or private health insurance.16 Following the recommendations of the Baume Report,1 patient accommodation and travel schemes (PATS) that partially reimburse patients for out-of-pocket expenses are available in all Australian States and Territories. For example, in NSW under the Isolated Patients Travel and Accommodation Assistance Scheme (IPTAAS)23 eligible patients can receive various types of assistance, as shown in Box 1. However, the conditions of eligibility are flawed and some patients still fall between the gaps. Where a patient chooses not to access the nearest possible specialist treatment, they become ineligible for assistance under the scheme. Distance from cancer care is compounded by the shortage of health professional workforce in rural and remote regions, which is well documented elsewhere.24,25 Generally, there are fewer health professionals per capita in rural and remote areas. For example, the number of allied health professionals (including radiographers) per 10,000 population steadily decreases with increasing remoteness from a major capital city.26 Underhill et al.27 surveyed 161 Regional Hospitals Administering Chemotherapy (RHAC) in Australia and found that only 21% reported having a resident medical oncology service, 7% had a radiation oncology unit and 6% a resident surgical oncologist. Only 24% had a dedicated palliative care specialist and 39% had dedicated oncology counselling. Solutions The Australian Government has committed AUD$1.3 billion over the next 6 years to the development of new infrastructure for cancer care, including AUD$560 million for a network of new and enhanced regional cancer centres.28 Investment in new infrastructure in regional areas is essential to improve access to world-
Figure 1. Australia’s population distribution.10 [Inset: Australia’s land area compared to the contiguous United States.].
T. Smith / Radiography 18 (2012) 38e42
class cancer treatment for all Australians in the future. However, it is not the entire solution to the problem of closing the gap in cancer outcomes described above. A fundamental problem exists around staffing the new facilities, which calls for innovative workforce solutions that address recruitment and retention problems that have plagued rural health services for decades. In 2009, NSW Cancer Institute published a literature review on models of rural and remote cancer services.29 They examined existing models in Canada and Scotland, as well as in Australia, and described four models of cancer care as potential foci for future development: integrated and managed care pathways; outreach programs; shared care; and telemedicine. Integrated and managed care pathways are dependent on the development of new forms of professional interaction and collaboration, such as interprofessional team-based models of care with flexibility of roles and responsibilities and delegation of tasks across professional boundaries.30 Such models require cultural adjustments and reeducation of the existing workforce, as well as changes in traditional models of undergraduate health professional education aimed at contextualising health, health care and health professional practice in a broader setting. The foundation of integrated and managed care pathways is a welldeveloped primary health care system. Primary care has a role in reducing the risk of cancer, early detection, access to specialist treatment, support for patients living with cancer and, particularly, reducing inequalities for people living in poorer resourced rural areas.31 Outreach programs have the advantages of improving GPspecialist communication and enhancing patients’ treatment experiences, but they result in increased costs.32 There is no evidence of a difference in health outcomes with outreach programs and the benefits of better patient satisfaction and convenience must be balanced against the costs. Shared care models similarly involve collaboration between the primary care physician and the specialist in the delivery of planned care.33 Shared care arrangements have the potential to improve the coordination of care across the primary-speciality care interface and to improve patient outcomes; however, similar to outreach programs, there is little evidence to date of a demonstrable benefit. The use of telemedicine in the delivery of oncology services has great potential that is yet to be realised. In the past its use has been limited by common problems, such as unreliability of equipment and connections, negative opinions about the need for telemedicine, and instability of management structures in health care, with a high turnover of personnel.34 However, the new generation fast broadband technology and the gradual roll-out of the optic-fibre Australian National Broadband Network, capable of downloading up to 100 megabits per second depending on the available technology, opens new horizons in telemedicine. The increasing complexity of information shared across cyberspace will transform case management of cancer in non-metropolitan areas,35 adding value to existing and future models of care. Finding a solution to close the gap in the cancer statistics between Indigenous and non-Indigenous Australians is far more complex than telemedicine. Much depends on creating a culturally safe environment, which can be defined as ‘an environment which is safe for people . shared respect, shared meaning, shared knowledge and experience, of learning together with dignity and truly listening’.36 To be most effective, models of cancer care for Indigenous people must include a range of measures, including devolving decision-making about health care needs and priorities to a local level; consulting with Indigenous people and including them in governance structures that promote culturally appropriate services; and educating service providers about Indigenous cultural safety and respect.37
41
Conclusions Australia has an excellent health care system, supported by high standards of health professional education and world-class research endeavours. However, like the health care system in other countries, it is in need of modernisation to meet the challenge of the ageing baby-boomer population, as well as to address health care inequities such as those described in this article. The State and Commonwealth governments have now agreed to embark on an agenda of health care reform that promises to address some longstanding, systemic problems. While the inequity in outcomes for rural and remote cancer patients is a substantial challenge for the health care system in Australia, it is not an insurmountable problem. Building on the substantial investment of the Australian government in Regional Integrated Cancer Centres, new models of multidisciplinary cancer care will develop, involving the close links with major metropolitan specialist services. This will create opportunities for greater support and education for rural cancer patients and their families, improve access high level diagnostic and treatment technology, and facilitate the development of new and expanded health care roles.
Box 1. The patients’ accommodation and travel scheme (PATS) in New South Wales. Isolated Patients Travel and Accommodation Assistance Scheme (IPTAAS)23 Eligibility Criteria Permanent resident of New South Wales Live more than 100 km from the nearest treating specialist Referred by a medical practitioner for specialist treatment Have already claimed the maximum available benefits from their private health fund Not eligible for assistance under any other government assistance scheme Types of Assistance Partial reimbursement of costs associated with treatment not locally available Public transport fares at economy rates, less GST Private motor vehicle subsidy at 15 cents/km Subsidised hotel, motel, hostel, apartment or caravan park accommodation: e $33 per night per single e $46 per night per double Subsidised taxi fares, to a maximum amount per specialist visit/consultation: e One visit/consultation ¼ $20 e Short term visit (2e7 days) ¼ $40 e Medium term visit (8e14 days) ¼ $80 e Long term visit (15 or more days) ¼ $160
References 1. Baume P. A vision for radiotherapy: report of the radiation oncology inquiry. Canberra: Commonwealth of Australia Department of Health and Aging; 2002. 2. Barton MB, Peters LJ, Kenny LM. Radiotherapy in Australia one year after the Baume report: vision or mirage? Medical Journal of Australia 2004;180(2):55e6. 3. Australian Institute of Health and Welfare & Australasian Association of Cancer Registries. Cancer in Australia: an overview, 2010. Cancer series no. 60. Cat. no. CAN 56. Canberra: AIHW; 2010. 4. Jong KE, Smith DP, Yu XQ, O’Connell DL, Goldstein D, Armstrong BK. Remoteness of residence and survival from cancer in New South Wales. Medical Journal of Australia 2004;180(12):618e22.
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5. AIHW (Australian Institute of Health and Welfare) & AACR (Australasian Association of Cancer Registries). Cancer in Australia: an overview, 2006. Cancer series no. 37. Cat. no. CAN 32. Canberra: AIHW; 2007. 6. Johnston V, Thomas DP. Smoking behaviours in a remote Australian Indigenous community: the influence of family and other factors. Social Science & Medicine 2008;67:1708e16. 7. Binns PL, Condon JR. Participation in cervical screening by Indigenous women in the northern territory: a longitudinal study. Medical Journal of Australia 2006;185(9):490e4. 8. Humphreys J, Hegney D, Lipscombe J, Gregory G, Chater B. Whither rural health? Reviewing a decade of progress in rural health. Australian Journal of Rural Health 2002;10(1):2e14. 9. Payne S, Jarrett N. The impact of travel on cancer patients’ experiences of treatment: a literature review. European Journal of Cancer Care 2000;9: 197e203. 10. Australian Bureau of Statistics 2003, Census of Population and Housing 2001: Population Growth and Distribution, Australian Bureau of Statistics, Canberra, viewed 13 May 2011.http://abs.gov.au/ausstats/[email protected]/b06660592430724 fca2568b5007b8619/4274f3e53c143e57ca256d46008193a0! OpenDocument [accessed 02.08.11]. 11. Dixon J, Welch N. Researching the ruralemetropolitan health differential using the ‘social determinants of health’. Australian Journal of Rural Health 2000;8(5):254e60. 12. Condon J, Armstrong B, Barnes A, Cunningham J. Cancer in Indigenous Australians: a review. Cancer Causes & Control 2003;14:109e21. 13. Threlfall TJ, Thompson JR. Cancer incidence and mortality in Western Australia, 2007. Perth: Department of Health, Western Australia; 2009. 14. Australian Institute of Health and Welfare (AIHW). Australia’s health 2010. Cat. no. AUS 122. Canberra: AIHW; 2010. 15. Cunningham J, Rumbold AR, Zhang X, Condon JR. Incidence, aetiology, and outcomes of cancer in Indigenous peoples in Australia. Lancet Oncology 2008;9:585e95. 16. Gordon LG, Ferguson M, Chambers SK, Dunn J. Fuel, beds, meals and meds: outof-pocket expenses for patients with cancer in rural Queensland. Cancer Forum 2009;33(3):204e10. 17. Hegney D, Pearce S, Rogers-Clark C, Martin-McDonald K, Buikstra E. Close, but still too far: the experience of Australian people with cancer commuting from a regional to a capital city for radiotherapy. European Journal of Cancer Care 2005;14:75e82. 18. Martin-McDonald K, Rogers-Clark C, Hegney D, McCarthy A, Pearce S. Experiences of regional and rural people with cancer being treated with radiotherapy in a metropolitan centre. International Journal of Nursing Practice 2003;9:176e82. 19. Fitch MI, Gray RE, McGowan T, Brunskill I, Steggles S, Sellick S, et al. Travelling for radiation cancer treatment: patient perspectives. Psycho-Oncology 2003;12:664e74. 20. Girgis A, Boyes A, Sanson-Fisher RW, Burrows S. Perceived needs of women diagnosed with breast cancer: rural versus urban location. Australian and New Zealand Journal of Public Health 2000;24(2):166e73.
21. Clavarino AM, Lowe JB, Carmont S-A, Balanda K. The needs of cancer patients and their families from rural and remote areas of Queensland. Australian Journal of Rural Health 2002;10(4):188e95. 22. Wakerman J, Humphreys J. Rural health: why it matters. Medical Journal of Australia 2002;176:457e8. 23. NSW Health. Transport for Health. http://www.health.nsw.gov.au/initiatives/ iptaas/. 24. National Rural Health Alliance (NRHA). Position paper e current issues for Australia’s rural and remote health workforce. Available at, http://nrha. ruralhealth.org.au/cms/uploads/publications/pp0304-1.pdf; May 2004 [accessed 02.08.11]. 25. National Rural Health Alliance (NRHA). Models of specialist outreach services for rural, regional and remote Australia. Paper by the National Rural Health Alliance for the Rural Sub-Committee of AHMAC, http://nrha.ruralhealth.org.au/cms/ uploads/publications/04_specialistoutreach.pdf; February 2004 [accessed 12.07.11]. 26. Lowe S, O’Kane A. National Allied Health Workforce Report. [article on the Internet]. Canberra, 2004. [cited 1 Mar 2010 ]. Available from: http://www. sarrah.org.au/site/index.cfm?display¼65820. 27. Underhill C, Bartel R, Goldstein D, Snodgrass H, Begbie S, Yates P, et al. Mapping oncology services in regional and rural Australia. Australian Journal of Rural Health 2009;17:321e9. 28. Australian Government Department of Health and Ageing. http://www.health. gov.au/internet/yourhealth/publishing.nsf/Content/cancer-policy-bookletw WhatþtheþGovernmentþisþdoingþtoþtackleþcancer. 29. Adams P, Hardwick J, Embree V, Sinclair S, Conn B, Bishop J. Literature review: models of cancer services for rural and remote communities. Sydney: Cancer Institute NSW; March 2009. 30. Rygh EM, Hjortdahl P. Continuous and integrated health care services in rural areas. A literature study. Rural and Remote Health 7 (online). Available from, http://www.rrh.org.au, 2007;766. 31. Campbell NC, MacLeod U, Weller D. Primary care oncology: essential if high quality cancer care is to be achieved for all. Family Practice 2002;19:577e8. 32. Powel J. Systematic review of outreach clinics in primary care in the UK. Journal of Health Services Research & Policy 2002;7(3):177e83. 33. Smith SM, Allwright S, O’Dowd T. Effectiveness of shared care across the interface between primary and specialty care in chronic disease management. Cochrane Database of Systematic Reviews 2007. Issue 3. Art. No.: CD004910. DOI: 10.1002/14651858.CD004910.pub2. 34. Hailey D, Crowe B. A profile of success and failure in telehealthdevidence and opinion from the successes and failures in telehealth conferences. Journal of Telemedicine and Telecare 2003;9(Suppl. 2):22e4. 35. Selva-Nayagam S, Olver I, Shepherd L. Beyond the bush telegraph: telehealth for remote cancer control and support. Cancer Forum 2007;31(2):77e80 [online]. 36. Eckermann A, Dowd T, Chong E, Nixon L, Gray R, Johnson S. Binang Goonj: bridging cultures in aboriginal health. 3rd ed. Sydney: .Elsevier; 2010. 37. Roder D. Epidemiology of cancer in Indigenous Australians: implications for service delivery. Cancer Forum 2007;31(2):85e90 [online].
Contents lists available at SciVerse ScienceDirect
Radiography journal homepage: www.elsevier.com/locate/radi
A long way from home: Access to cancer care for rural Australians Tony Smith* University Department of Rural Health, Northern NSW, University of Newcastle, Locked Bag 9783 NEMSC, Tamworth, NSW 2348, Australia
a r t i c l e i n f o
a b s t r a c t
Article history: Received 3 August 2011 Accepted 21 October 2011 Available online 10 November 2011
In 2002, the Commonwealth Radiation Oncology Inquiry reported that access to cancer care services in Australia was seriously limited. Several recommendations were made, including improving access to cancer care in rural areas by increasing the number of comprehensive oncology facilities outside the cities. Much has changed since 2002, with the establishment of a number of Regional Integrated Cancer Centres. This has been boosted again in 2011 by further Commonwealth Government funding. Cancer is primarily a disease of the elderly and, with the ageing population access to cancer care for rural and remote Australians remains a major challenge. Cancer is the second most common cause of death in Australia, exceeded only by cardiovascular disease. It has been reported that the relative risk of dying of cancer within 5 years of diagnosis is 35% higher for those living in remote locations compared with major cities. Overall cancer mortality is significantly higher in rural and remote locations (206 deaths per 100,000) compared with urbanised areas (172 per 100,000). Cancer mortality is higher again for the Aboriginal population (230 per 100,000). The reasons for the disparity in cancer outcomes for metropolitan versus non-metropolitan Australians are varied. In general, rural and remote residents have to travel long distances and stay away from home, family and work for long periods of time to access the care they need. Hence, distance is the overriding barrier to access, compounded by the financial costs and disruption to family life, not to mention the endemic lack of specialist medical and allied health workforce outside the major cities. Some rural and remote Australians choose to compromise, accessing whatever care they can locally, although this contributes to the need for cancer care services close to where people choose to live and die, to deal with the complex associated morbidities. Recent government investment in new regional cancer care infrastructure is essential; however, it is not the entire solution. Staffing the new facilities calls for innovative solutions, including managed care pathways, outreach programs, models of shared care and the use of telemedicine. There is also a need to better address issues of Indigenous cultural safety and risk reduction in the Aboriginal population. Ó 2011 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.
Keywords: Oncology Cancer treatment Rural and remote health Equity of access
Introduction In June 2002, the Commonwealth Radiation Oncology Inquiry,1 chaired by Professor Peter Baume, reported that only four-fifths of the patients who required radiotherapy actually received it and that waiting times were much too long. The report found critical shortages of radiation oncologists, radiation therapists and medical physicists to staff existing, let alone any new machines. Consequently, patients were falling through loopholes, exacerbated by cost shifting arrangements between the States and the Commonwealth.1 At that time, only a minority of the State and Territory health departments had a strategic plan for radiation oncology and
* Tel.: þ61 2 6767 8464; fax: þ61 2 6761 2355. E-mail address: [email protected].
little thought had been given to access to cancer care for Australians living outside the capital cities. Among the five key recommendations of the Baume report was to improve the availability of radiotherapy services in rural and regional Australia by increasing the number of comprehensive oncology facilities outside the major cities, by the use of outreach services, and by better reimbursement of travel and accommodation expenses. The Baume report precipitated substantial and rapid changes, although they were long overdue.2 Within a decade of the report being handed down, most of the recommendations have now been implemented. The number of radiotherapy facilities in regional and rural areas has increased, University places for radiation therapy students have increased, the three radiotherapy professions (Radiation Oncologists, Radiation Therapists and Medical Physicists) have implemented continuing professional development programmes, and
1078-8174/$ e see front matter Ó 2011 The College of Radiographers. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.radi.2011.10.041
T. Smith / Radiography 18 (2012) 38e42
a Tripartite Committee has been formed, comprising representatives from the three professions. Access to cancer care services for non-metropolitan Australians has improved substantially in the last ten years and will continue to improve under the Commonwealth Government’s current policies. In the May 2011 budget the Government announced further funding for Regional Integrated Cancer Centres, including radiation therapy departments. This follows the establishment of cancer care facilities in many various regional centres, such as Cairns and Toowoomba, Orange, Lismore, Darwin, Launceston and Bunbury. The recent budget allocation will build another ten oncology facilities in regional locations. Nevertheless, access to cancer care for patients from regional, rural and remote parts of Australia is an ongoing challenge. This article examines the barriers to accessing cancer care for nonmetropolitan Australians and discusses some of the many ways that these challenges may be, and are being addressed. Cancer in Australia Because cancer is primarily a disease of the elderly, the ageing of the population will cause the number of new cancers diagnosed in the future to increase. The most recent report from the Australian Institute of Health and Welfare (AIHW) put the 2007 age-standardised incidence of cancer, excluding basal and squamous cell carcinomas of the skin, at 485 cases per 100,000 people, with significantly higher rates for males (595 per 100,000) than for females (394 per 100,000),3 (p.10) (see Table 1). The risk of dying from cancer before the age of 75 years was 1 in 8 for males and 1 in 12 for females, but this trend was reversed after the age of 85 years, with 1 in 4 cancer deaths for males and 1 in 6 for females,3 (p.24). The mean age at diagnosis was 67 years for males and 64 years for females,3 (p.12). As shown in Table 1, in 2007, the six most common cancers accounted for 68% of all cancers diagnosed,3 (p.160). Prostate cancer was by far the most common male cancer, accounting for almost a third of new cancers, followed by bowel cancer, melanoma, lung cancer and lymphoid cancers,3 (pp.1112). In women, breast cancer was twice as common as bowel cancer, followed again by melanoma, lung and lymphoid cancers,3 (pp.1112). Cancer caused about three of every ten deaths (29%) in Australia in 2007, exceeded only by cardiovascular diseases (34%),3 (pp.2223). A greater proportion of males (57%) than females (43%) died of cancer. Table 1 shows that lung cancer contributed most to cancer deaths for both males and females. For males prostate cancer was the next most common fatal cancer, and breast cancer for females, both followed by bowel cancer, lymphoid cancers and melanoma. Combined, the six cancer types listed in Table 1 accounted for 50% of cancer deaths in 2007,3 (pp.2223). Rural and remote versus metropolitan Jong et al.4 analysed data from the NSW Central Cancer Registry and determined the five-year relative excess risk of dying from
39
cancer in the more remote regions of NSW compared to the most accessible regions. A significant increased risk was found for remote locations for cervix and prostate cancers and for cancer overall, even when adjusted for the stage of the disease. It was concluded that, compared to those living in major cities, residents of remote regions of NSW were 35% more likely to die of their cancer within 5 years of being diagnosed4 The AIHW’s 2006 overview of cancer in Australia reported that while the incidence of cancer in 2003 was 10% lower outside of the major cities, the mortality rate from cancer was 10% higher.5 The most recent AIHW report found that the highest incidence rate for cancer was in inner regional areas of Australia (496 per 100,000) compared with both metropolitan centres (474 per 100,000) and remote areas (475 per 100,000),3 (pp.3839). The incidence of particular types of cancer also varied with geographical location. For example, incidence rates for breast and lymphoid cancers in remote areas was 0.8 times the rate for major cities, while rates for cervical cancer, lung cancer and secondary cancer with an unknown primary were 1.5, 1.4 and 1.3 times higher in remote areas. For the period between 2003 and 2007, the overall cancer mortality rate was also significantly higher in rural and remote locations compared with urbanised areas, with 206 deaths per 100,000 in remote areas compared to 172 per 100,000 in the major cities,3 (p.40). The AIHW suggested that some of the geographical difference in cancer mortality could be explained by the relatively high proportion of the population in more remote areas being either Aboriginals or Torres Strait Islanders. The incidence of death due to cancer is significantly higher for Indigenous Australians (230 per 100,000) compared to non-Indigenous Australians (178 per 100,000),3 (pp.3435). The most common types are lung, breast and bowel cancer. In 2007, Indigenous Australians were 1.7 times more likely to die of lung cancer and 5 times more likely to die of cervical cancer than non-Indigenous Australians,3 (pp.3435). Risk factors are generally higher, with cigarette smoking twice as common amongst the Indigenous population,6 while cervical cancer screening is much lower than the national average.7 Barriers to cancer care There are various reasons for the disparity in cancer outcomes for metropolitan versus non-metropolitan Australians, including delayed diagnosis due to the lack of availability of health care services generally,8 as well as lack of state-of-the-art diagnostic imaging and radiation therapy technology.4 Therefore, to access the same sort of care available to city dwellers, rural and remote residents have to travel long distances and stay away from their home, family and place of work for long periods of time.9 Hence, the overriding barrier to equitable access to cancer care for all Australians is distance. Australia has a land area equivalent to about 83% of that of the United States of America (USA) [http://wiki. answers.com/] but has a total population of only about 22.6 million people, or only about 7% of that of the USA [http://en.wikipedia.org/
Table 1 The most common cancers diagnosed in Australia, together with incidence and mortality rates, in 2007.3 Cancer Type
Number of Cancers Diagnosed (%)
Incidence Rate (per 100,000)
Mortality Rate (per 100,000)
Male
Female
Persons
Male
Female
Persons
Male
Female
Persons
Prostate Breast Bowel Melanoma Lung Lymphoid All Cancers
19,403 (17.9) 103 (0.1) 7804 (7.2) 5980 (5.5) 5948 (5.5) 4116 (3.4) 62,019 (57.2)
e 12,567 (11.6) 6430 (5.9) 4362 (4.0) 3755 (3.5) 3160 (2.9) 46,349 (42.8)
19,403 (17.9) 12,670 (11.7) 14,234 (13.1) 10,342 (9.5) 9703 (9.0) 7276 (6.7) 108,368 (100)
182.9 1.0 75.2 57.2 57.9 39.6 595.1
e 109.2 53.4 38.2 31.3 26.8 393.9
e 56.9 63.4 46.7 43.3 32.8 484.6
31.0 0.3 21.7 8.5 46.3 14.2 224.6
e 22.1 14.6 3.4 24.0 8.8 139.1
e 11.9 17.8 5.7 34.0 11.2 176.1
40
T. Smith / Radiography 18 (2012) 38e42
]. As shown in Fig. 1, Australia’s population is concentrated around the better-watered coastal regions, leaving vast expanses of the interior unpopulated, most of which is unsuitable for any form of primary production other than mining. Indeed, there are some mining communities of several thousand people located fifteen hundred kilometres and more from definitive cancer care services. Even patients from large regional centres with greater than twentyfive thousand inhabitants have to travel to their nearest capital city to access specialist surgical, medical and radiation oncology treatment. Inevitably, this imposes additional financial burden on the patient and their family. That burden can be enormous, given that socio-economic status is typically lower for rural and remote compared to metropolitan populations.11 Because of all of these contributing factors (and more) cancer patients in rural and remote areas often present with a later stage of their disease and have lower survival rates compared to those from major cities. For Indigenous Australians, for example, the higher cancer mortality rate is explained by their greater likelihood of being diagnosed at a location where the prospect of accessing treatment is poorest,12,13 or being diagnosed at an advanced stage of the disease when the chances of survival are less.14,15 Hospitalisation for cancer treatment away from the usual support networks of family, friends and work, has many costs and unmet needs that are discussed elsewhere in the literature.16e20 The patients’ needs can also limit access to the highest quality of care. Clavarino et al.21 reported that the conflict between treatment location and disruption to family life often influences patient preferences and their treatment decisions. Fundamental cultural issues and beliefs also have a powerful influence. It has long been recognised that rural and remote Australia is ‘sociologically, culturally, economically and spiritually different from metropolitan areas’, which influences the ‘way health and medical care is provided’.22 Some rural and remote Australians choose to compromise, accessing whatever care they can locally rather than having to travel. For them, this is a quality of life decision9; however, it contributes to the need to provide high quality cancer
care services close to where people choose to live and die, to deal with the complex morbidities associated with the various cancers. The financial costs of accessing cancer care can be of critical importance, as well as being disruptive to family life. They include the loss of income as well as out-of-pocket expenses such as travel and accommodation (at city prices) and the cost of care beyond that covered by either government rebate or private health insurance.16 Following the recommendations of the Baume Report,1 patient accommodation and travel schemes (PATS) that partially reimburse patients for out-of-pocket expenses are available in all Australian States and Territories. For example, in NSW under the Isolated Patients Travel and Accommodation Assistance Scheme (IPTAAS)23 eligible patients can receive various types of assistance, as shown in Box 1. However, the conditions of eligibility are flawed and some patients still fall between the gaps. Where a patient chooses not to access the nearest possible specialist treatment, they become ineligible for assistance under the scheme. Distance from cancer care is compounded by the shortage of health professional workforce in rural and remote regions, which is well documented elsewhere.24,25 Generally, there are fewer health professionals per capita in rural and remote areas. For example, the number of allied health professionals (including radiographers) per 10,000 population steadily decreases with increasing remoteness from a major capital city.26 Underhill et al.27 surveyed 161 Regional Hospitals Administering Chemotherapy (RHAC) in Australia and found that only 21% reported having a resident medical oncology service, 7% had a radiation oncology unit and 6% a resident surgical oncologist. Only 24% had a dedicated palliative care specialist and 39% had dedicated oncology counselling. Solutions The Australian Government has committed AUD$1.3 billion over the next 6 years to the development of new infrastructure for cancer care, including AUD$560 million for a network of new and enhanced regional cancer centres.28 Investment in new infrastructure in regional areas is essential to improve access to world-
Figure 1. Australia’s population distribution.10 [Inset: Australia’s land area compared to the contiguous United States.].
T. Smith / Radiography 18 (2012) 38e42
class cancer treatment for all Australians in the future. However, it is not the entire solution to the problem of closing the gap in cancer outcomes described above. A fundamental problem exists around staffing the new facilities, which calls for innovative workforce solutions that address recruitment and retention problems that have plagued rural health services for decades. In 2009, NSW Cancer Institute published a literature review on models of rural and remote cancer services.29 They examined existing models in Canada and Scotland, as well as in Australia, and described four models of cancer care as potential foci for future development: integrated and managed care pathways; outreach programs; shared care; and telemedicine. Integrated and managed care pathways are dependent on the development of new forms of professional interaction and collaboration, such as interprofessional team-based models of care with flexibility of roles and responsibilities and delegation of tasks across professional boundaries.30 Such models require cultural adjustments and reeducation of the existing workforce, as well as changes in traditional models of undergraduate health professional education aimed at contextualising health, health care and health professional practice in a broader setting. The foundation of integrated and managed care pathways is a welldeveloped primary health care system. Primary care has a role in reducing the risk of cancer, early detection, access to specialist treatment, support for patients living with cancer and, particularly, reducing inequalities for people living in poorer resourced rural areas.31 Outreach programs have the advantages of improving GPspecialist communication and enhancing patients’ treatment experiences, but they result in increased costs.32 There is no evidence of a difference in health outcomes with outreach programs and the benefits of better patient satisfaction and convenience must be balanced against the costs. Shared care models similarly involve collaboration between the primary care physician and the specialist in the delivery of planned care.33 Shared care arrangements have the potential to improve the coordination of care across the primary-speciality care interface and to improve patient outcomes; however, similar to outreach programs, there is little evidence to date of a demonstrable benefit. The use of telemedicine in the delivery of oncology services has great potential that is yet to be realised. In the past its use has been limited by common problems, such as unreliability of equipment and connections, negative opinions about the need for telemedicine, and instability of management structures in health care, with a high turnover of personnel.34 However, the new generation fast broadband technology and the gradual roll-out of the optic-fibre Australian National Broadband Network, capable of downloading up to 100 megabits per second depending on the available technology, opens new horizons in telemedicine. The increasing complexity of information shared across cyberspace will transform case management of cancer in non-metropolitan areas,35 adding value to existing and future models of care. Finding a solution to close the gap in the cancer statistics between Indigenous and non-Indigenous Australians is far more complex than telemedicine. Much depends on creating a culturally safe environment, which can be defined as ‘an environment which is safe for people . shared respect, shared meaning, shared knowledge and experience, of learning together with dignity and truly listening’.36 To be most effective, models of cancer care for Indigenous people must include a range of measures, including devolving decision-making about health care needs and priorities to a local level; consulting with Indigenous people and including them in governance structures that promote culturally appropriate services; and educating service providers about Indigenous cultural safety and respect.37
41
Conclusions Australia has an excellent health care system, supported by high standards of health professional education and world-class research endeavours. However, like the health care system in other countries, it is in need of modernisation to meet the challenge of the ageing baby-boomer population, as well as to address health care inequities such as those described in this article. The State and Commonwealth governments have now agreed to embark on an agenda of health care reform that promises to address some longstanding, systemic problems. While the inequity in outcomes for rural and remote cancer patients is a substantial challenge for the health care system in Australia, it is not an insurmountable problem. Building on the substantial investment of the Australian government in Regional Integrated Cancer Centres, new models of multidisciplinary cancer care will develop, involving the close links with major metropolitan specialist services. This will create opportunities for greater support and education for rural cancer patients and their families, improve access high level diagnostic and treatment technology, and facilitate the development of new and expanded health care roles.
Box 1. The patients’ accommodation and travel scheme (PATS) in New South Wales. Isolated Patients Travel and Accommodation Assistance Scheme (IPTAAS)23 Eligibility Criteria Permanent resident of New South Wales Live more than 100 km from the nearest treating specialist Referred by a medical practitioner for specialist treatment Have already claimed the maximum available benefits from their private health fund Not eligible for assistance under any other government assistance scheme Types of Assistance Partial reimbursement of costs associated with treatment not locally available Public transport fares at economy rates, less GST Private motor vehicle subsidy at 15 cents/km Subsidised hotel, motel, hostel, apartment or caravan park accommodation: e $33 per night per single e $46 per night per double Subsidised taxi fares, to a maximum amount per specialist visit/consultation: e One visit/consultation ¼ $20 e Short term visit (2e7 days) ¼ $40 e Medium term visit (8e14 days) ¼ $80 e Long term visit (15 or more days) ¼ $160
References 1. Baume P. A vision for radiotherapy: report of the radiation oncology inquiry. Canberra: Commonwealth of Australia Department of Health and Aging; 2002. 2. Barton MB, Peters LJ, Kenny LM. Radiotherapy in Australia one year after the Baume report: vision or mirage? Medical Journal of Australia 2004;180(2):55e6. 3. Australian Institute of Health and Welfare & Australasian Association of Cancer Registries. Cancer in Australia: an overview, 2010. Cancer series no. 60. Cat. no. CAN 56. Canberra: AIHW; 2010. 4. Jong KE, Smith DP, Yu XQ, O’Connell DL, Goldstein D, Armstrong BK. Remoteness of residence and survival from cancer in New South Wales. Medical Journal of Australia 2004;180(12):618e22.
42
T. Smith / Radiography 18 (2012) 38e42
5. AIHW (Australian Institute of Health and Welfare) & AACR (Australasian Association of Cancer Registries). Cancer in Australia: an overview, 2006. Cancer series no. 37. Cat. no. CAN 32. Canberra: AIHW; 2007. 6. Johnston V, Thomas DP. Smoking behaviours in a remote Australian Indigenous community: the influence of family and other factors. Social Science & Medicine 2008;67:1708e16. 7. Binns PL, Condon JR. Participation in cervical screening by Indigenous women in the northern territory: a longitudinal study. Medical Journal of Australia 2006;185(9):490e4. 8. Humphreys J, Hegney D, Lipscombe J, Gregory G, Chater B. Whither rural health? Reviewing a decade of progress in rural health. Australian Journal of Rural Health 2002;10(1):2e14. 9. Payne S, Jarrett N. The impact of travel on cancer patients’ experiences of treatment: a literature review. European Journal of Cancer Care 2000;9: 197e203. 10. Australian Bureau of Statistics 2003, Census of Population and Housing 2001: Population Growth and Distribution, Australian Bureau of Statistics, Canberra, viewed 13 May 2011.http://abs.gov.au/ausstats/[email protected]/b06660592430724 fca2568b5007b8619/4274f3e53c143e57ca256d46008193a0! OpenDocument [accessed 02.08.11]. 11. Dixon J, Welch N. Researching the ruralemetropolitan health differential using the ‘social determinants of health’. Australian Journal of Rural Health 2000;8(5):254e60. 12. Condon J, Armstrong B, Barnes A, Cunningham J. Cancer in Indigenous Australians: a review. Cancer Causes & Control 2003;14:109e21. 13. Threlfall TJ, Thompson JR. Cancer incidence and mortality in Western Australia, 2007. Perth: Department of Health, Western Australia; 2009. 14. Australian Institute of Health and Welfare (AIHW). Australia’s health 2010. Cat. no. AUS 122. Canberra: AIHW; 2010. 15. Cunningham J, Rumbold AR, Zhang X, Condon JR. Incidence, aetiology, and outcomes of cancer in Indigenous peoples in Australia. Lancet Oncology 2008;9:585e95. 16. Gordon LG, Ferguson M, Chambers SK, Dunn J. Fuel, beds, meals and meds: outof-pocket expenses for patients with cancer in rural Queensland. Cancer Forum 2009;33(3):204e10. 17. Hegney D, Pearce S, Rogers-Clark C, Martin-McDonald K, Buikstra E. Close, but still too far: the experience of Australian people with cancer commuting from a regional to a capital city for radiotherapy. European Journal of Cancer Care 2005;14:75e82. 18. Martin-McDonald K, Rogers-Clark C, Hegney D, McCarthy A, Pearce S. Experiences of regional and rural people with cancer being treated with radiotherapy in a metropolitan centre. International Journal of Nursing Practice 2003;9:176e82. 19. Fitch MI, Gray RE, McGowan T, Brunskill I, Steggles S, Sellick S, et al. Travelling for radiation cancer treatment: patient perspectives. Psycho-Oncology 2003;12:664e74. 20. Girgis A, Boyes A, Sanson-Fisher RW, Burrows S. Perceived needs of women diagnosed with breast cancer: rural versus urban location. Australian and New Zealand Journal of Public Health 2000;24(2):166e73.
21. Clavarino AM, Lowe JB, Carmont S-A, Balanda K. The needs of cancer patients and their families from rural and remote areas of Queensland. Australian Journal of Rural Health 2002;10(4):188e95. 22. Wakerman J, Humphreys J. Rural health: why it matters. Medical Journal of Australia 2002;176:457e8. 23. NSW Health. Transport for Health. http://www.health.nsw.gov.au/initiatives/ iptaas/. 24. National Rural Health Alliance (NRHA). Position paper e current issues for Australia’s rural and remote health workforce. Available at, http://nrha. ruralhealth.org.au/cms/uploads/publications/pp0304-1.pdf; May 2004 [accessed 02.08.11]. 25. National Rural Health Alliance (NRHA). Models of specialist outreach services for rural, regional and remote Australia. Paper by the National Rural Health Alliance for the Rural Sub-Committee of AHMAC, http://nrha.ruralhealth.org.au/cms/ uploads/publications/04_specialistoutreach.pdf; February 2004 [accessed 12.07.11]. 26. Lowe S, O’Kane A. National Allied Health Workforce Report. [article on the Internet]. Canberra, 2004. [cited 1 Mar 2010 ]. Available from: http://www. sarrah.org.au/site/index.cfm?display¼65820. 27. Underhill C, Bartel R, Goldstein D, Snodgrass H, Begbie S, Yates P, et al. Mapping oncology services in regional and rural Australia. Australian Journal of Rural Health 2009;17:321e9. 28. Australian Government Department of Health and Ageing. http://www.health. gov.au/internet/yourhealth/publishing.nsf/Content/cancer-policy-bookletw WhatþtheþGovernmentþisþdoingþtoþtackleþcancer. 29. Adams P, Hardwick J, Embree V, Sinclair S, Conn B, Bishop J. Literature review: models of cancer services for rural and remote communities. Sydney: Cancer Institute NSW; March 2009. 30. Rygh EM, Hjortdahl P. Continuous and integrated health care services in rural areas. A literature study. Rural and Remote Health 7 (online). Available from, http://www.rrh.org.au, 2007;766. 31. Campbell NC, MacLeod U, Weller D. Primary care oncology: essential if high quality cancer care is to be achieved for all. Family Practice 2002;19:577e8. 32. Powel J. Systematic review of outreach clinics in primary care in the UK. Journal of Health Services Research & Policy 2002;7(3):177e83. 33. Smith SM, Allwright S, O’Dowd T. Effectiveness of shared care across the interface between primary and specialty care in chronic disease management. Cochrane Database of Systematic Reviews 2007. Issue 3. Art. No.: CD004910. DOI: 10.1002/14651858.CD004910.pub2. 34. Hailey D, Crowe B. A profile of success and failure in telehealthdevidence and opinion from the successes and failures in telehealth conferences. Journal of Telemedicine and Telecare 2003;9(Suppl. 2):22e4. 35. Selva-Nayagam S, Olver I, Shepherd L. Beyond the bush telegraph: telehealth for remote cancer control and support. Cancer Forum 2007;31(2):77e80 [online]. 36. Eckermann A, Dowd T, Chong E, Nixon L, Gray R, Johnson S. Binang Goonj: bridging cultures in aboriginal health. 3rd ed. Sydney: .Elsevier; 2010. 37. Roder D. Epidemiology of cancer in Indigenous Australians: implications for service delivery. Cancer Forum 2007;31(2):85e90 [online].