FormalPara Key Points

  • Innovations in system strengthening and creating formal networks can assist in bridging the health inequality gap faced by Indigenous communities.

  • Telehealth-enabled models of care can provide cancer care closer to home.

  • Health inequalities need to be standing agenda items at team meetings of all layers and streams of health providers and of all committees and working groups for them to be systematically addressed and improved.

Indigenous people from regional, rural, and remote (RRR) Australia live in small communities that usually lack the infrastructure critical for effective healthcare delivery. Care delivery issues are compounded by difficulties in attracting and retaining healthcare workers and providing specialist services in stand-alone centers. RRR communities rely on advocacy and support from their colleagues, government departments, and politicians. This calls for a networked approach to healthcare delivery, whereby small communities are linked with larger regional and rural towns and tertiary care facilities, allowing care delivery and workforce planning to be addressed holistically rather than relying on siloes [1].

To create this networked approach to enable equitable health systems, a culture of collaboration, purpose, and values alignment needs to occur across all layers of the system, from the political sector to the frontline workforce [2]. It also requires collective leadership and governance so that Indigenous communities do not have to rely on champions. Co-designing models of care with communities can instill a sense of ownership.

Telehealth-Enabled Cancer Care Systems

Telehealth has been established as a tangible model of care to create networked systems across the world, especially in response to the COVID-19 pandemic [3, 4]. Over the last two years, the world has seen the rapid growth of telehealth models as part of government agendas to address health inequities and keep communities safe from the pandemic. Telehealth has been used for consultations in primary and specialist care settings, shared-care models, remote supervision of chemotherapy and biotherapy administration and other medical procedures, clinical trials, preventive education for patients and their families, and remote education and mentoring of health professionals [5]. A hallmark of these models is the collaboration between health professionals and organizations that form the foundations of networked systems.

Telehealth models are welcomed by communities and health professionals for their many benefits. In a study by Mooi et al., health professionals listed professional support and networking, on-the-job learning of specialist topics, family involvement in care, and shared-care models with local health professionals as some of the key benefits [6]. While people prefer care closer to home, they expect the same quality of care as enjoyed by their metropolitan counterparts.

Clinical Consultations

Telehealth has been widely used to provide clinical consultations, including new and ongoing reviews. When a face-to-face consultation is offered to RRR patients at a larger center, they may need the help of an escort and may not be able to suddenly drop their day-to-day business for that visit. In most cases, only one escort can travel with a patient, who may or may not be familiar with the healthcare setting at a larger center. Telehealth can enable timely reviews closer to home [7].

New consultations via telehealth can be useful for triaging patients and coordinating the necessary activities when patients travel for in-person care and reviews. While physical examination has been cited as an issue, this has been addressed through shared-care models with rural GPs, junior doctors, physicians, and healthcare students in placements.

Examples of Telehealth Models

Several models of telehealth have been adopted by health professionals to provide care closer to home—depending on the nature of the care required, site capabilities, the type of available technology, and family and health professional support. Regardless of the availability of care they can receive closer to home, a few patients elected to travel to larger centers for privacy reasons (being from a small community) and due to the unavailability of family members for support, being away from home. For consultations, local support can be provided by nurses, health workers, medical and nursing students, and family members. Occasionally, when technology permits, consultations have been provided at home, with other family members attending in person or virtually. For chemotherapy administration and complex medical care, partnership with general practitioners and other professionals with specialized skills is necessary.

Chemotherapy and Biotherapy Administration

Multidisciplinary remote supervision models offer the opportunity to provide chemotherapy and biotherapy closer to home right across the country. For example, the Queensland Remote Chemotherapy Supervision (QReCS) model sets out governance for safety and the quality of services [8]. These models are underpinned by a collaboration between nurses and medical and pharmacy professionals through telenursing, telemedicine, and telepharmacy mechanisms. This model is adopted or adapted for remote chemotherapy and biotherapy delivery in Queensland, Northern Territory, New South Wales, South Australia, and Western Australia.

The choice of chemotherapy delivered at rural sites will be determined by site capabilities, the availability of support for complications, and the nature of the chemotherapy conducted. Usually, complex regimens that cause complex reactions are not suitable for rural sites unless support mechanisms are available. Two North Queensland studies reported patient and family satisfaction with these models and the safety of remote chemotherapy supervision. A review by Deloitte demonstrated that the models offer a good return on investment [9, 10].

Clinical Trials

The Australasian Teletrial model has leveraged telehealth and telechemotherapy experiences to transform the way clinical trials are delivered to regional, rural, and Indigenous communities [11]. Based on positive pilot results in Victoria, New South Wales, and Queensland, the Medical Research Future Fund (MRFF) set up Australian Teletrial and NSW/ACT RRR programs to roll out this model across the country [12]. The aim is to transform Australia into a networked clinical trial system so that communities can gain access to some or all aspects of clinical trials closer to home. The pilot study showed that clinical trial clusters can be developed through collaboration between health professionals, regulatory officers, and managers. This program also offers an opportunity to streamline regulatory processes so that the workforce can focus on care delivery without wasting time on unnecessary and duplicative processes. Safety and quality are ensured by documentation about the nature of the collaboration, with supervision plans and legal requirements covered by cluster subcontracts.

Prevention Initiatives

One of the key benefits of telehealth models for Indigenous communities is that family members can attend consultations together with their loved ones [6], giving them the opportunity to learn about the illness and methods to prevent recurrence. One successful example is My Family’s Anti-Tobacco Education pilot, which demonstrated that the model was feasible and accepted by families and patients to manage tobacco-related head and neck cancer [13]. In this model, the specialist who is caring for a patient with a smoking-related illness becomes a mentor for the close and extended family of the patient after receiving consent. The specialist uses test results and medical images of the patient to explain the impact of smoking on their loved one. By combining a few in-person visits with virtual visits, the specialist supports family members to decide to quit. Once they have decided to quit, they are helped by primary care physicians who are a part of the group. The success of these models depends on the willingness of specialists and a stable primary care sector.

Rural Capacity Building as a Key Outcome

While providing services to patients is the key focus of telehealth on a day-to-day basis, sustainability is required to achieve long-term outcomes. Experiences in Mt Isa (Queensland) have highlighted the platform that telehealth models offer for system-building initiatives to ensure sustainability [14]. Through a networked approach between Townsville University Hospital and Mt Isa hospitals, Mt Isa acquired a new cancer center; employed more nursing, pharmacy, and medical staff dedicated to cancer care; and provided the most complex systemic therapy regimens locally. Recently, Mt Isa has become a hub for remote communities such as Cloncurry, with some cancer services (such as pump disconnection) now performed locally under remote supervision from Mt Isa. Mt Isa was also activated as a satellite site for the MONARCHE trial (comparing hormonal therapy with Abemaciclib and hormonal therapy in early breast cancer), though no recruitment occurred given the trial’s short duration. Through the Teletrial model, Mt Isa has become a routine part of the Townsville cluster.

New Culture of Implementation

Current siloed approaches continue to perpetuate the disparities in outcomes, access, and resources faced by RRR communities. Staff turnover, of both managers and frontline workers, as well as the critical shortage of staff with leadership talent, compound the issues. New approaches to leadership, culture, and governance are needed, as outlined by Health Q32—the Queensland Government’s 10-year health plan [1, 2]. As a minimum, these communities need to be integrated into statewide systems rather than being treated as isolated entities. This requires a mindset of integration and collaboration at all levels of the system and with primary care, regardless of the territorial status of the health services. This methodology enables a whole-of-system approach to manage workforce distribution, training, access, handovers, ward reviews, treatment, and resource allocation. This culture of collaboration and integration requires purpose-aligned teams, a culture of co-design, and workforce-enabling operational behaviors, policies, and procedures. It also requires the monitoring and enabling of these activities at local and system levels.