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Table 1 Healthcare for John in Region A (fragmented care, with a workforce where sustainability issues are a constant concern and where local residents must rely on only intermittent specialist input, otherwise travel to the city for any acute and specialist care needs

From: Towards equity and sustainability of rural and remote health services access: supporting social capital and integrated organisational and professional development

Christine and John visit the GP once a month, usually when they head into town for shopping trips. The practice has served the region for many years; it is a 2-doctor clinic, but that often there is only one doctor because of staff turnover and difficulties in finding locums. Also, one of the GPs will be retiring early next year, leaving only 1 GP, unless they can attract another from outside the region. John receives twice weekly home visits from the local community nursing outreach; they help Christine to shower John on those days, with Christine doing sponge bathes in-between their visits. Otherwise, Christine provides virtually all of John’s hands-on care needs. They are on a waiting list for further support, as packages are limited. Whilst Christine has become somewhat of an expert in warding off skin problems and infections for John, she has found it increasingly tiring to maintain this role and look after the farm. Although she can call on members of the Lions club (and members respond well), and neighbours from time to time, she does not always want to burden them. Also, John had to be admitted several times to the hospital when his condition deteriorated. This is partially due to his lack of physical activity, diet and borderline diabetes condition.

Todd is a physiotherapist who is based in the larger regional centre about 1.5 h’ drive away. He and Ruth the occupational therapist from the region’s community health centre visited John to perform an initial assessment when John came home from hospital. They undertake a review visit separately every 6 months; though they find this increasingly difficult because their resources have been steadily cut over the past 2 years. There was a private physiotherapist but they moved, leaving Todd to cover the whole region. This means that he is on the road a lot and striving to also provide limited services at the community centre. Whilst the community nurses are able to contact John’s GP with any concerns, communication is limited. The primary care nurse at the general practice is part-time and her scope of practice is limited and does not include involvement in chronic condition care planning. Communication between the various health professionals involved in John’s care is limited more broadly, and was reliant on one-way referral to allied health by the GP initially.

Few health professionals in the region have taken on students in the past 5 years. With no links to tertiary education providers and ever growing pressures to see more people over larger distances, they just haven’t had the time. The GPs runs a small practice with few incentives to take on medical students. Their use of chronic disease care planning item numbers is limited. There is some access to telemedicine, although it seems that fewer health professionals are interested to settle in the community or undertake regular visits since this commenced a few years ago.