Table 6 Methods of rationing used by physiotherapy participants

Selection

A3:Priority one is the ICU sort of work: your very early stage orthopaedic patients, your day one gut surgeries, day one strokes, that sort of stuff and then right down the bottom of the list is mobility aid assessments, mobility reviews. [ED is] an artificial priority …it wouldn’t come up as a first thing that we would do, but because of the funding, it’s one that’s going to be maintained regardless of what is happening anywhere else.

A3: Sub-acute [care program]: at the moment, their core area is fractures over 65, so they do ortho-geriatrics.

A9:I’ve only got a certain amount of time…it’s an awful situation to have, but this is the one I have to spend more time with …to know where am I going to get the best outcome … you can’t treat them equally and that’s always been a frustration I think.

A1: Yes acuity and being in hospital and getting people out of hospital because anybody in health that is looking at dollars, looks at length of stay and it’s the only thing that counts.

Denial

A9: [when we had less than half our staff] we had set wards [as the priority] and we closed outpatients.

A1: [staff cuts] severely curtailed our ability to provide outpatient services. We’ve had to basically can [cease] any outpatient rehabilitation service.

A1:When [the paediatric physio leaves], there will be a gap because I can’t pick up [paediatric] neuro type or the disability, I can’t do it. I can’t do everything to that level.

Deflection

A3: [Physio X’s] job is to try and help flow them out to peripheral [hospitals], even if they’re from here they might go out to [a peripheral rural hospital] where staff there can continue their exercises and help them not weight-bear and then once they’re able to weight-bear, then they are appropriately brought back to rehab.

A3:Three out of four of our patients come from outside of [this Regional city] so that’s the other thing…what’s available at the other end very much determines how easily we can move people on.

A9:That’s right; so sometimes people need to be transferred to [Metropolitan centres] for anything more complicated.

A6: Well the in-patients, we have no influence who comes in as an in-patient. So our influence is then on who we send out the community, who we send to rehab…

A3:Sometimes we are sending referrals out into the ether knowing that the town that that knee replacement patient is from, doesn’t have a physio, and there’s nothing that I can do except send that referral through, knowing there will be receipt at the other end and registered as a need, but I can’t do anything else.

A6: Out-patient wise, we have quite a lot of private practices within the area and they’re able to take all third parties and anyone with private insurance or if our waiting list is too long, we suggest other people go along and at least get initial treatment…

A3:We channel those [private or compensable patients] to private, but there’s a lot of demand

B5:they might come through [to the practice] and say “I've had a stroke” and I’ll think I’ll be more than happy to look at you…but I look at them, assess them and think, I really don’t have the services here, or the rehab equipment here to do that for them, yeah I refer them off [to the public service].

Deterrence

B5:I think Case Managers put so much strain and stress on you, you’re trying to get someone better and they’re declining treatment and those sorts of things. …you’re getting someone back to work and then all of a sudden they stop the services and then the client goes backwards and returns to being off work…

Delay

A3: Certainly there’d be waiting lists for Paeds…and general out-patients definitely.

A9: Okay so with our acute that’s under 2 weeks…so they usually get them in within a couple of days; and certainly if anything comes across from ED …that’s on the spot stuff, and then we have 2 to 8 weeks – so your sub-acute and they probably take 2 weeks to get in.... and then greater than 8 weeks we usually go a month.

A7: I must provide the care for the acute inpatients and ED services – that is my core. I can do that and then there are the outpatients that can be sorted into waiting lists.

Dilution

A3:Absolutely, [the post-acute service] are able to see people for six weeks post op or post hospital stay but they’re limited to 25 kms from here. So if you live in [this regional city] you get a great deal, you get six weeks of home visits essentially but as soon as you’re one metre out of that 25 kms, all you have is musculoskeletal outpatient [physiotherapy at] your local facility.

Interruption

A9: Out by day 5 or 6

A3: [still send to a town that, at the moment doesn’t have a physio] Of course we do, but I can’t send them home with the same level of input as if they were local. There are lots of towns with no private practice …or because there’s no one at [the rural hospital] for three weeks. So you kind of just have to move them on anyway and the ability to bring them back, I can’t do that, we’re restricted.