Rural speech pathologist and PhD candidate, Ed Johnson, reflects on the difficulty people with disabilities in rural and remote areas face in accessing services.

The National Disability Insurance Scheme 

The National Disability Insurance Scheme (NDIS) is here, and it has been hailed as "the greatest change to Australian social policy in a generation" (Sydney Morning Herald, 2012). The change from mainly government-based services to a market-based system presents many opportunities and challenges for consumers, service providers, and clinicians, but at this stage of its rollout, it remains to be seen whether or not it will allow for people with disability in rural and remote Australia to achieve choice and control in their lives.

The issues

Several years ago I was working as a speech pathologist providing disability services to people in rural and remote Australia. I had a referral for a family in a remote area with a young daughter who lived with cerebral palsy. I had been planning the trip – about a four-hour drive from the regional hub in which I practised – when I was approached by my manager. “We can’t provide a service to this client. I need you here in the office so you can work with the clients closer to home,” she said.

It was difficult for me to reconcile this. I could certainly see more clients if I minimised my travel time, but it was at the expense of someone in need – a victim of circumstance. When government services withdraw from rural and remote areas as we transition to the NDIS, there is the very real chance that some people will be left without the opportunity to access specialist allied health services. They’ll have their own money from the NDIS, but nothing to spend it on.

People living in rural and remote Australia don’t have the same opportunities to access services as people living in big cities. There simply isn’t the population base to support the range of specialist services that some people need to access. Physiotherapy, occupational therapy, speech pathology, and early intervention services are examples of services that can play an integral part in supporting families and assisting in the development of kids with disabilities. 

Some solutions

To overcome these issues, we need to develop service-delivery models that give families in rural and remote areas access to disability services without forcing those people to compromise or to forego assistance. Solutions may comprise elements of the following:

Telepractice

• Telepractice is a therapy service that is delivered in-part or in-whole via remote telecommunication. This may comprise elements including (but not limited to) Skype, video sharing, instant messaging, email, and telephone.
• Telepractice can eliminate travel time, and increase choice in service providers outside the local area.
• An emerging area of inquiry, telepractice in lifelong disability has not been investigated extensively. However, Boisvert et al. (2010) found promising results in assessing and treating autism spectrum disorder through telepractice.

Allied Health Assistants (AHAs)

• AHAs are certificate-qualified individuals who can implement interventions under the guidance of an allied health professional, remotely or in-person.
• AHAs can have an in-depth knowledge of local community needs at the same time as having a broad knowledge of allied health services.
• The combination of an AHA and clinician brings expertise in the local community, and expertise in clinical practice, as well as providing a more regular and timely service to individuals, since the clinician need not be physically present at all times.
• In their submission to a 2015 Senate Inquiry, Lincoln and Hines recommended the development of an AHA workforce in rural and remote areas. Read more here (PDF)

Fly-In-Fly-Out (FIFO) Practitioners

• FIFO allied health practitioners who specialise in disability have the potential to empower rural and remote communities, and build capacity amongst generalist allied health practitioners, educators, and allied health assistants.
• Wakerman and colleagues supported the use of outreach (FIFO) services in their 2008 systematic review of primary health care delivery models in rural and remote Australia.

NDIA has acknowledged that telehealth may be an option for increasing service availability. However, there are potential cultural, attitudinal, and practical barriers to delivering telehealth. Providers may be reluctant to offer telehealth services or to supplement therapist intervention with allied health assistant support. Although the emerging evidence in these areas of practice is largely supportive of those approaches, the literature is sparse, and many established therapists and organisations are reluctant to offer alternatives to the traditional model of therapy support.

This could potentially perpetuate the shortage of therapists in rural and remote communities. Also, it is easy for misconceptions to arise over the roles and skills of professions supporting therapists such as local area co-ordinators, allied health assistants, and Aboriginal health workers. We need to continue an open discussion and consultation process, as well as continue to develop an evidence base of the kinds of support that can be effective, and communicate those models effectively to people with disability, their families, and NDIS providers.

Conclusion

Solutions have to be developed place-by-place, and according to the wishes of individual families. This requires creativity, flexibility, and insight from families, policy makers, service providers, and allied health professionals. This will give the NDIS the best chance of succeeding in providing choice and control for every family who accesses it, not just those within the boundaries of major metropolitan centres.

Further reading

• Implementation of DisabilityCare Australia in rural and remote areas: Roundtable report
  National Rural Health Alliance and National Disability and Carer Alliance
• The Road to NDIS: Lessons from England About Assessment and Planning
  Purple Orange, Julia Farr Association
• Submission to the consultation on the Proposed NDIS Quality and Safeguarding framework (PDF)
  Wobbly Hub Rural Research Team, Faculty of Health Sciences, The University of Sydney

References

1. The Sydney Morning Herald. (May 2012). PM introduces NDIS bill to parliament. Retrieved on 17 May 2016 from: <http://www.smh.com.au/breaking-news-national/pm-introduces-ndis-bill-to-parliament-20121129-2ah1j.html>
2. Wakerman, J., Humphreys, J., Wells, R., Kuipers, P, Entwistle, P. & Jones, J. (2008). Primary health care delivery models in rural and remote Australia – a systematic review. BMC Health Services Research, 8, 276.
3. Boisvert, M., Lang, R., Andrianopoulos, M. & Boscardin, M.L. (2010). Telepractice in the assessment and treatment of individuals with autism spectrum disorders: a systematic review. Developmental Neurorehabilitation, 13(6), 423-432.

Feature image by the author.