Rationing is a reality in rural physiotherapy: a qualitative exploration of service level decision-making

Abstract

BackgroundDeciding what health services are provided is a key consideration in delivering appropriate and accessible health care for rural and remote populations. Despite residents of rural communities experiencing poorer health outcomes and exhibiting higher health need, workforce shortages and maldistribution mean that rural communities do not have access to the range of services available in metropolitan centres. Where demand exceeds available resources, decisions about resource allocation are required.MethodsA qualitative approach enabled the researchers to explore participant perspectives about decisions informing rural physiotherapy service provision. Stakeholder perspectives were obtained through surveys and in-depth interviews. A system theory-case study heuristic provided a framework for exploration across sites within the investigation area: a large area of one Australian state with a mix of rural, regional and remote communities.ResultsThirty-nine surveys were received from participants in eleven communities. Nineteen in-depth interviews were conducted with physiotherapist and key decision-makers. Increasing demand, organisational priorities, fiscal austerity measures and workforce challenges were identified as factors influencing both decision-making and service provision. Rationing of physiotherapy services was common to all sites of this study. Rationing of services, more commonly expressed as service prioritisation, was more evident in responses of public sector physiotherapy participants compared to private physiotherapists. However, private physiotherapists in rural areas reported capacity limits, including expertise, space and affordability that constrained service provision.ConclusionsThe imbalance between increasing service demands and limited physiotherapy capacity meant making choices was inevitable. Decreased community access to local physiotherapy services and increased workforce stress, a key determinant of retention, are two results of such choices or decisions. Decreased access was particularly evident for adults and children requiring neurological rehabilitation and for people requiring post-acute physiotherapy. It should not be presumed that rural private physiotherapy providers will cover service gaps that may emerge from changes to public sector service provision. Clinician preference combines with capacity limits and the imperative of financial viability to negate such assumptions. This study provides insight into rural physiotherapy service provision not usually evident and can be used to inform health service planning and decision-making and education of current and future rural physiotherapists.

Human resources for health (and rehabilitation): Six Rehab-Workforce Challenges for the century

“…This includes high-income countries, such as the USA [26, 27, 60], Canada [72–75] and Australia [69, 70, 76–78]. Care rationing may come as a result [79]. Particularly in Canada [72–74] and Australia [68, 70, 76, 77, 80, 81], a set of educational, recruitment and retention measures have been implemented to help supply rural or remote areas with the rehabilitation workers they need.…”

Cardiorespiratory physiotherapy as a career choice—perspective of students and physiotherapists in Portugal

“…An independent researcher with experience in 22 leading focus groups facilitated both sessions. The questions required participants to 23 provide feedback on presentation, design, structure and organisation of the survey; 1 clarity, adequacy and comprehensiveness of the questions; and suggestions for 2 improvement. Focus groups lasted between 60 to 90 minutes and were audio-recorded 3 and transcribed verbatim.…”

“…19 Among the remaining students, most clinical placements requested were in 20 musculoskeletal (n=58, 51%) and neurology (n=36; 32%). 21 Physiotherapy career intentions 1 Prior to commencing their physiotherapy undergraduate programme, only 62 (34%) 2 students knew that physiotherapists treated patients with cardiorespiratory conditions 3 and only 41 (22%) knew what they wanted to work in [34 specified their preference: 16 4 (39%) musculoskeletal, 11 (27%) sports, 3 (7%) paediatrics, 2 (5%) neurology, 1 (2%) 5 oncology and 1 (2%) CRP]. 6 One hundred and ten (60%) students reported to be definitely interested in specialising 7 in any area of physiotherapy, while 68 (37%) were still undecided and 4 (2%) showed no 8 interest in specialising.…”

“…22 The students' lack of interest by the CRP area has been raising concern within 23 international physiotherapy societies (Dean et al, 2014;Limb, 2009 ), as it may lead to 24 few specialised cardiorespiratory physiotherapists. CRP is one of the main non-invasive 1 and cost-effective practices with a labor pattern consistent with the needs of effective 2 health education delivery and implementation (Dean et al, 2011;Dean et al, 2014). 3 Thus, having few professionals in this area may affect the prevention and treatment 4 options offered to patients and families with NCD.…”

“…(please insert figure 4 about here) 16 17 Opinions of cardiorespiratory physiotherapy 18 Opinions regarding the main factors for not pursuing a career in CRP were "having 19 greater interest in another area of physiotherapy" (n=61; 46%), "few job opportunities 20 in the region" (n=47; 35%) and "never having had a placement in CRP during the 21 physiotherapy programme" (n=11; 8%). When asked if anything could influence them to 1 choose specialising in CRP, most students answered negatively (n= 154; 85%). 2 3 General questions and suggestions on CRP 4 All students (n=189) were asked to rate how certain factors had influenced their opinion 5 of CRP.…”