Effective regional, rural and remote family and relationships service delivery

Effective regional, rural and remote family and relationships service delivery

L. Roufeil and Kristine Battye

AFRC Briefing No. 10 — April 2008

Contents

Strong and healthy relationships play a vital role in building the ongoing health and wellbeing of individuals, families and the broader community. With increasing pressure on the traditional social support mechanisms of extended family, friends and neighbours, particularly in non-urban regions, there is a growing need for professional family and relationship services. However, there is limited robust evidence about what makes these services effective, especially when delivered in rural, regional or remote settings. This paper briefly reviews recent demographic, social and economic trends in rural, regional and remote Australia in order to provide the contextual background to service delivery in the region. A number of enablers and limiting factors for effective rural service delivery are outlined. These factors are based on a review of the limited evidence base on family and relationships service delivery and the broader literature on service delivery to rural settings. Considerable emphasis is given to workforce issues as a way of addressing service sustainability.

Introduction

Many individuals, families and communities outside the major urban regions of Australia, particularly Indigenous communities, are under pressure. Rising rates of mental health problems and family breakdown are placing an additional load on mental health and family and relationships services that were already struggling to assist families across the vastness of the Australian continent (Alston, 2000). People living in rural1 communities generally score lower on various health indices and display higher disability and mortality rates than their urban counterparts (Australian Institute of Health and Welfare [AIHW], 2006). The social and economic disadvantage is strongest in the more remote communities.

Hall and Scheltens (2005) have argued that, since 2002, a discourse of "rural crisis" has begun to dominate public and media reports and overshadowed traditional belief in the resilience and self-reliance of rural people. The social, emotional and financial problems we are presently seeing in many rural regions are due to a complex and longstanding array of factors, including the changing composition of rural communities, decline in the rural labour market and loss of human services (Alston & Kent, 2004). The interconnectedness so frequently seen in rural communities is often viewed as an important resilience factor but, on the other hand, it can also make it difficult for many country people to acknowledge that they have a problem and to seek help (Judd et al., 2006). This chronic decline has made rural communities even more vulnerable in times of natural disaster, such as the current drought, and has created a situation where personal and family problems thrive (Alston & Kent, 2004).

The notion of "crisis" as outlined above allows us to believe that rural Australia will return to "normal" at some point, despite the evidence that rural disadvantage is chronic and requires long-term commitment to the delivery of a range of services, including family and relationship programs (Hall & Scheltens, 2005). One of the most important avenues for intervention to ameliorate the impact of chronic rural disadvantage is to provide effective support to children, young people and adults so they can develop and sustain safe, supportive and nurturing relationships. Strong families and healthy relationships are widely accepted as fostering individual resilience (Luthar, 2006) and community resilience (Vinson, 2004) that are particularly critical during times of adversity.

The aim of this paper is to identify how family and relationships service providers operating in non-urban regions of Australia can provide effective services to support children, young people and adults. The focus of the paper is thus on the "how", that is, not the therapeutic content of programs or interventions, but rather on how best to deliver services outside the metropolitan regions. We address some of the problems confronting rural service providers but, in doing so, we have been mindful that the problems in the bush are well-documented. As argued in a discussion paper prepared by Catholic Welfare Australia (CWA) and the Department of Families, Community Services and Indigenous Affairs (FaCSIA) (2006), it is time to progress to developing and implementing solutions. Despite this imperative, there is a limited evidence base on effective regional, rural and remote family and relationships service models. While we attempted to focus on family relationships and counselling services, men's and women's counselling services, and parenting programs, we have drawn from a much broader range of research to identify factors that enable and limit sustainable rural service delivery.

For a paper that sets out to address the issue of family and relationships service delivery in non-urban regions, it is critical that we consider cultural issues. In particular, we recognise that the proportion of the population who is of Indigenous descent increases with distance from urban centres - from 2.1% in inner regional centres to 35.2% in very remote areas (Australian Bureau of Statistics [ABS], 2002). It is beyond the scope of this paper to adequately address the unique and serious concerns relevant to the delivery of family and relationships services to Indigenous communities, but we note that the establishment of the Australian Family Relationships Clearinghouse and its resources will help to address this important issue.

Defining "regional", "rural" and "remote"

Before proceeding to discuss the evidence for what makes an effective service, we need to examine the meaning of the terms "regional", "rural" and "remote". It is indeed telling that we were asked to explore effective service delivery models in the context of these three locality categories for this paper, implying that they are not interchangeable terms. Unfortunately, there are no agreed-upon definitions or categories of rurality (AIHW, 2004). For the purpose of this paper, the terms "regional", "rural" and "remote" are differentiated by respectively decreasing populations and accessibility to services. Broadly speaking:

  • "regional" refers to non-urban centres with a population over 25,000 and with relatively good access to services;
  • "rural" refers to non-urban localities of under 25,000 with reduced accessibility; and
  • "remote" communities are those of fewer than 5,000 people with very restricted accessibility.2

Where necessary, we make distinctions between the three categories, but will often employ the acronym "RRR" when referring to non-metropolitan regions in general.

Despite providing general definitions for degrees of rurality, it is important to note that, while some patterns can be seen in communities according to population and distance from services, there is considerable variation within each broad geographical area. As Larson (2006) argues, "if you have seen one country town, you have seen only one country town" (p. 2). This theme permeates not only Australian research findings (e.g., Cheers, 1998), but also international rural research (e.g., Pugh, Scharf, Williams, & Roberts, 2007).

Issues in RRR Australia that impact on service delivery

It is generally accepted that providing services to RRR Australia is similar to but also different from service delivery in metropolitan regions, and not just because of the obvious issue of distance that impacts on service costs, productive time on site, and staff exhaustion due to travel commitments. Rural service providers have identified a range of issues that are more likely to impact on service delivery in non-metropolitan regions (CWA/FaCSIA, 2006; Lehmann, 2005). These factors include:

  • community pressure to be "all things to all people" (CWA/FaCSIA, 2006, p. 11) in the absence of an adequate range of health and welfare services;
  • the long time required to foster community acceptance;
  • the challenge of managing confidentiality in small communities;
  • limited access to other support professionals, especially specialists;
  • difficulty recruiting and retaining staff; and
  • the limited ability of communities to pay for services.

RRR service providers may also have to work hard at engaging their target group, due to the strict boundaries on self-disclosure that make many country people reluctant to seek help when it is needed (Judd et al., 2006; Harvey & Hodgson, 1995).

Review of service models

Before trying to identify the factors that contribute to an effective service delivery model, it is important to be clear about the characteristics of an ineffective service model. According to Battye (2007b), a service model is dysfunctional if it does not support or enable the worker to provide effective care to clients and communities on a sustainable basis. Sustainability needs to be addressed on three levels:

  • sustainability of the organisation to enable the program staff to get on with delivering the program;
  • sustainability of the program in terms of having access to quality staff who can effectively meet client needs; and
  • sustainability of the linkages with other services that support the program.

Table 1 outlines some of the common service delivery models operating in RRR Australia and identifies their advantages and disadvantages. There is limited published research evaluating the effectiveness of any of the models presented, and it is evident in Table 1 that few of these existing service models are problem-free. However, in most cases, there is evidence about maximising the efficacy of a service model. Some of the suggested ways to improve the service models are not easily implemented (e.g., revisions to government tender processes), but others need to be strongly considered by provider organisations. For example, hub and spoke models appear to be highly effective when locals are consulted about the service plan, adequate attention is given to appropriately staffing and resourcing outreach services, and adequate time is allowed and prioritised for frontline staff to get to know a local community and vice versa (Battye & McTaggart, 2003).

In addition to considering specific types of service models, it is important to acknowledge that rural communities firstly need strong, broad-based generalist services with strong local links before they can successfully accommodate specialist services (e.g., targeting a specific cohort) (CWA/FaCSIA, 2006). There are clear disadvantages to locating specialist services in RRR regions if these services are not underpinned by a strong generalist workforce (Hodgkin, 2002).

Table 1: Review of service provider models in RRR Australia
Model Characteristics Advantages Disadvantages

Purchaser-provider

The purchaser is generally the government, which specifies the type, level, target groups and location of a service that is subsequently delivered by an auspicing body (the provider); usually involves a fixed-term contract.

Provides an effective way to distribute finite funds.
Potentially facilitates delivery of services by local people, as opposed to "new" services coming into town.
It is preferable if purchaser and provider are able to be flexible with the specified service guidelines so local needs can be accommodated (McDonald & Zetlin, 2004).

Tender process fosters competition, not cooperation, between agencies (McDonald & Zetlin, 2004; Munn, 2003).

Tenders tend to be granted on grounds of pricing, not on basis of local knowledge (Alston & Kent, 2004).

Contract usually developed off-site and rarely reflects local needs (can be overcome by requiring tenderers to tailor service to meet local needs) (Lovatt & Dow, 2004).

Many providers are urban-based, with service delivery by "outsiders" leading to loss of local trust, reduced local knowledge, diminished local capacity-building and reduced options for local community development (Paton & Cuckson, 2004).

Rigid adherence by purchaser to specified services and target groups limits ability of provider to implement flexible and holistic services to families (Lovatt & Dow, 2004).

Hub and spoke

A way of facilitating regionalisation and centralisation of services, such that services tend to be based in areas of greatest population density (hub) and provide services out to smaller centres (spokes). Can operate under a variety of funding models, including purchaser-provider.

Makes economic sense.
Works well when outreach services are regular, reliable, and adequately resourced, and have sufficient time to engage with local community (see Battye & McTaggart, 2003).

Many outreach services are unreliable and susceptible to the vagaries of the weather, transport and availablity of staff (Battye, 2007a).

"Outsiders" often have little local knowledge and lack community trust.

Managers generally isolated from spokes, with little local knowledge (Alston & Kent, 2004).

Collaborative models: interagency collaboration/networking

Interagency collaboration spans informal networks (e.g., knowing who to talk to in order to reduce red tape) and formal networks (e.g., partnerships in service delivery using existing networks, referral protocols, case conferences, memoranda of understanding, co-location, and joint training)

Scarce resources can be maximised to produce the critical mass needed to sustain effective service delivery (e.g., Bila Muuji Social and Emotional Wellbeing Initiative (Perino, 2007)).
Fosters holistic approach to assisting families.
Collaboration builds trust and a culture of reciprocity between providers and communities.
Collaboration becomes increasingly important as remoteness increases.
Although partnerships involve non-local educators, local agencies doing the promotion/practical setup can help ameliorate concerns about confidentiality (e.g., Lutheran Community Care's Through Thick and Thin program).
Works best with active managerial support, time allocation and strong leadership/role modelling (Munn, 2003).

Collaboration and effective networking challenges frontline staff, management and organisations - work overload often distracts from collaborative approach (Munn, 2003).

Attitudes toward interagency collaboration at local level can be negatively influenced by competitive tendering processes (Munn, 2003).

Collaborative models: co-location

 

Sharing expensive infrastructure between agencies.

 

Useful for small agencies that would otherwise spend a high proportion of budget on infrastructure.

Can be a valuable one-stop-shop for clients (e.g., Early Years Centre in Nerang, Queensland).

Research evidence of efficacy of co-location is equivocal and co-location alone is probably insufficient to improve service delivery (Brown, Tucker, & Domokos, 2003).

Co-located agencies in small communities are vulnerable if one of the participating agencies closes (CWA/FaCSIA, 2006).

One-stop-shops rarely overcome tyranny of distance for rural or remote communities.

Collaborative models: fund blending

A type of collaborative model that involves one agency receiving funds from multiple sources to create a resource pool, with staff straddling various programs.

Potential to create a critical mass of resources that might otherwise be impossible to develop.
Fosters mutual support between staff and decreases professional isolation.
Most successful if multi-party agreements, including mechanisms for reporting, are established prior to model implementation (Wakerman et al., 2006).

Demanding and time consuming on management and staff to report to several funding bodies (CWA/FaCSIA, 2006).

Being answerable to multiple funding bodies with inflexible program requirements can impact on agency sustainability in the long term (Wakerman et al., 2006).

Technology-based models

Spans a range of programs delivered by various technologies, including telephone, email counselling, chat rooms and videoconferencing. Often a mix of self-help and e-technology support.

Ease of access for clients in some RRR communities.
May facilitate service use in rural regions, due to increased anonymity of client.
Appears to be useful for facilitating staff professional development, but evidence base still developing for delivery of many therapeutic programs.
Some evidence supporting telephone delivery of non-structured services, (e.g., Lifeline, Watson & McDonald, 2004), and more structured services (e.g., Positive Parenting Telephone Service, Cann, Rogers, & Worley, 2003; Couple CARE, Halford, Moore, Wilson, Dyer, & Farrugia, 2004).

Access to cheap, reliable and efficient Internet service is highly variable across Australia (Chenoweth, 2004).

Need to develop evidence of efficacy of programs developed for face-to-face delivery when implemented via various technologies.

Delivery of services using various technologies often requires staff to acquire new skills. It can take considerable time to train and support workers and develop appropriate usage policies that address the issue of confidentiality (Martin, 2003).

Pilot and seed funding

One-off funding for a specified service. This is not really a service model, but a funding stream. It is included here due to the high prevalence of services in RRR operating in this capacity (CWA/FaCSIA, 2006).

Gets a much-needed service "off the ground".
Works best when there is a mechanism for ongoing funding to be readily available if the program is successful and the pilot funding reflects the actual cost of running the service (CWA/FaCSIA, 2006).

Communities highly suspicious of these funding arrangements, given the preponderance of RRR services that are set up then dismantled due to lack of funds; a situation that has eroded community trust in local agencies (Battye, 2007a; CWA/FaCSIA, 2006).

 

What can be done to improve access to family and relationships services for people in RRR Australia?

According to Battye (2007b), the areas in which we are most likely to have the greatest impact on building sustainable services are the training environment, maximising workforce participation and service re-engineering. The importance of these three areas echo a recent Australian study of the rural social work workforce that found that employer initiatives have been notoriously overlooked as a means of addressing rural service issues, and far too much emphasis has been placed on the problems associated with rural locations and practitioner characteristics (Lonne & Cheers, 2004). In other words, what are needed are people with leadership and vision to build sustainable service models that in turn will foster increased workforce and service capacity (see Figure 1). It is worth noting that, particularly in rural and remote communities, the burden of leadership can all too often fall on one person, and succession plans need to be developed in readiness for change (Wakerman et al., 2006).

Figure 1: Features of a sustainable service model

Figure 1: Features of a sustainable service model

Source: Adapted from Battye (2007b)

Training environment

While it is difficult to directly influence the number or type of training places available, Lonne and Cheers (2004) argued that it is realistic for organisations to create a work environment that maximises the likelihood of trainees completing their course and facilitates retention of new graduates by supporting their transition to work and building local recruitment pipelines.

Maximising workforce participation

Organisations can also create a workplace that facilitates the participation of the entire workforce pool. Research conducted in the central west of NSW, for example, indicated the existence of a sleeper workforce of allied health professionals that chose not to work for a number of reasons, including the inflexibility of local service provider organisations (Battye, Hines, Ingham, & Roufeil, 2006). Agencies that actively support maximal participation in the workforce by providing flexible work conditions for staff and support for re-entry to work are more likely to build sustainable and thus effective service models.

Service re-engineering

Service re-engineering to foster recruitment and retention offers potentially the most significant gains for building effective and sustainable service models. There is a plethora of literature identifying the factors that contribute to rural workforce shortage (e.g., Battye et al., 2006; CWA/FaCSIA, 2006; Queensland Rural Medical Support Agency, 2004; Services for Australian Rural and Remote Allied Health, 2000), and these can be summarised into three domains:

  • professional issues (e.g., job dissatisfaction, overload/burnout, professional isolation, lack of support and training, burden of rural travel, inadequate orientation to rural/Indigenous practice, lack of adequate remuneration, inflexible award conditions);
  • personal factors (e.g., housing, partner employment issues, access to quality childcare/education); and
  • community factors (e.g., establishment of social networks, local facilities).

In a landmark study of Australian rural social workers, Lonne and Cheers (2004) found that financial and material incentives (e.g., preparatory training, professional development, support systems, relocations assistance, temporary tenure, administrative supervision) significantly contributed to staff turnover. They argued that upfront investment in retention packages and improved work practices would have fiscal benefits and improve service sustainability as a result of decreased staff turnover and enhanced recruitment. Service provider organisations and funding bodies need to consider the apparent advantages of developing realistic retention strategies and operational budgets that address these concerns.

RRR service models that are not funded realistically, that is, in accord with the geographical demands of the area they are servicing, are at significant risk of not becoming sustainable. For example, many funding bodies operate on a flat rate for operating costs (e.g., travel, accommodation, office running costs) of around 15-20% of personnel costs, regardless of geographical location. While there is limited research on actual operating costs in rural and remote regions, one Australian study reported the real operating costs of service delivery to remote areas of Queensland as being around 60% of personnel costs (Battye, 2007b). There may be clear policy implications for state, territory and federal funding bodies: RRR family and relationship services require different funding formulas to urban settings.

Environmental enablers

Wakerman and colleagues' (2006) systematic review of primary health care delivery models in rural and remote Australia has implications for how family and relationships services are delivered in these regions. The review identifies environmental enablers that are crucial in preparing the environment for change. These include supportive policies that recognise the uniqueness of RRR Australia, improved Commonwealth-state relations, and community readiness. Many of these reflect the issues already raised in this paper; however, there are some critical lessons to be learned. For example, for community engagement to be effective, Wakerman and his colleagues emphasised the need for enablers, such as community champions (locals who will drive community engagement); adequate capacity of community members to be involved in governance; and adequate investment in training and capacity building for local boards and committees. The need for community involvement has to be balanced against the burdens placed on small, remote communities to run their own services. Equally, small communities have a relatively limited pool from which to draw managers and leaders and thus need to be supported by staff training, and clear lines of responsibility and practice. To ensure the service is sustainable, a risk management plan needs to be developed that takes into consideration workforce supply, key staff, infrastructure (buildings, vehicles and information technology and information management systems), budgets and possible threats to service viability.

Concluding remarks

The nature of RRR communities is such that the delivery of family and relationships services in these regions must be qualitatively different from those in urban locations. Currently, the services that exist in RRR regions are under enormous pressure and are unable to meet the demands of the communities they serve (Alston & Kent, 2004; Council of Social Service of New South Wales, 2004). It is unlikely that organisations can keep operating in the same manner and achieve different outcomes. Service models need to be re-engineered to ensure sustainability and effectiveness.

The development of effective family and relationships service delivery models for use in RRR regions is currently hindered by a lack of solid evidence about what works, and failure to act on existing research-based information. This failure is most evident in the literature on the actions that can maximise the efficacy of existing service delivery models and factors affecting workforce recruitment and retention. While we have almost no data evaluating or comparing the efficacy of various service delivery models in RRR Australia, we do know what the problems are in the bush and need to develop and test new service delivery models that directly target the identified issues. To enable this evidence base to develop, we need to ensure that consideration is given to the evaluation process during the service planning phase and that appropriate funding is built into service and program budgets to enable quality evaluation to be undertaken. Additionally, service provider organisations often have variable levels of internal capacity to undertake evaluative research and need to be supported to develop skills in this area. Such research needs to be cognisant of the uniqueness of country towns and also explore the factors that underpin a "good match" between a country town and a particular service model. The objective of this line of research must not be to find the model that best suits "rural" Australia, but to determine under what conditions a particular model is most effective.

By placing so much emphasis on the need for further research to determine what an effective RRR family and relationships service model might look like, we are not suggesting that there is no point in taking action now. Box 1 sets out the lessons learned from this literature review and identifies factors that enable (or limit) sustainable service delivery. While "fixing" the problem may ultimately require re-engineering service models, much can be done at the local level now to improve access to family and relationships services for people living in regional, rural and remote regions of Australia.

Box 1: Barriers and factors that enable or limit effective and sustainable RRR service delivery3

Barriers and limiting factors

  • Policies that fail to recognise the unique nature of RRR Australia, including policies of regionalisation, centralisation, marketisation.
  • Failure to put research findings into action.
  • Long history of managerial overload.
  • Incomplete and ad hoc implementation of plans/models.
  • Rigid implementation of highly standardised urban service delivery models.
  • Competitive tendering and environment of "turf protection".
  • Use of "outsiders" to deliver services.
  • Resource allocator/management absent from frontline.
  • Dependence on sole workers.
  • Variability of reliable Internet access across RRR Australia.
  • Pilot funding without adequate establishment time and mechanism for ongoing funding.

Enabling factors4

  • Strong leadership with a clear vision.
  • Local knowledge.
  • Community readiness.
  • Investment in community development.
  • Strong, supported local governance and management arrangements.
  • Links with other service providers and key stakeholders, such as schools and health agencies.
  • Culture of reciprocity between providers within a community.
  • Trust between service providers and communities.
  • Regular, reliable, adequately resourced outreach services to smaller communities.
  • A critical mass of appropriately qualified staff and resources.
  • Ability to deliver holistic care that is flexible and able to meet local needs.
  • Shared infrastructure.
  • Realistic operational budgets.
  • Investment in retention packages.
  • Provision of supervision and professional development for staff.
  • Supporting trainees, providing transition to work programs.
  • Recruitment pipelines.
  • Flexible work conditions.

Useful resources

The AFRC website has sections hosting resources for rural and remote practitioners and information for practitioners working with Indigenous families.

AFRC Briefing No. 7, titled Strengthening Aboriginal Family Functioning: What Works and Why?

References

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Endnotes

1    The term “rural” is used here to refer to communities outside the major urban regions of Australia. More complete definitions of the terms “regional”, “rural” and “remote” are provided later in this paper.

2    These definitions are loosely based on the Rural, Remote and Metropolitan Areas (RRMA) classification system (AIHW, 2004).

3    See Alston & Kent, 2004; Battye, 2007b; Chenoweth, 2004; Lovatt & Dow, 2004; McDonald & Zetlin, 2004; Mlcek, 2005; Munn, 2003; Wakerman et al., 2006.

4    The research supporting some of these factors is inconclusive, but results are promising. Furthermore, a complex array of these factors may need to be in place in order to foster change. For example, shared infrastructure is likely to also require strong local governance, good relationships with local communities and clear internal policies in order to be effective.

Authors and Acknowledgements

Dr Louise Roufeil is an Adjunct Lecturer in Psychology at Charles Sturt University and has extensive experience managing an innovative rural and remote psychology service. She is currently a consultant psychologist providing community based planning, workforce planning and evaluation services, and service modeling and re-engineering to rural and remote Australia.

Dr Kristine Battye is the Director of Kristine Battye Consulting Pty Ltd, a consultancy company specialising in community based health service planning, workforce planning and development, program evaluation and review, and health service modelling. Kristine’s particular areas of interest include Indigenous health, and interagency and intersectoral service development to promote sustainable service provision. Kristine is an Adjunct Associate Professor with the Mt Isa Centre for Rural and Remote Health, James Cook University.

The authors would like to thank Professor Margaret Alston for her suggestions and feedback on this paper.

Publication details

AFRC Briefing
No. 10
Published by the Australian Institute of Family Studies, April 2008.
12 pp.
ISSN: 
1834-2434

Publication meta

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