Early effect of the COVID-19 pandemic on the North American cardiothoracic surgery job market.

Background: The present study aims to report the early effect of the coronavirus disease 2019 (COVID-19) pandemic on the cardiothoracic surgery job market in North America. Methods: The Cardiothoracic Surgery Network (CTSNet) job market database was queried, and patterns from January to May for 2019 versus January to May 2020 were compared for trends in job postings and job seekers. Results: Our study is comprised of 395 cardiothoracic surgery job postings, of which 98% were positions located in North America and 63% were academic. The negative impact of the pandemic on the cardiothoracic surgery job market was greatest in the cardiothoracic/cardiovascular combined subspecialty, followed by congenital and adult cardiac surgery, whereas general thoracic surgery experienced an increase in proportion of jobs available. Despite an increase in views per job posted in 2020 vs. 2019 (532 vs. 290), employer views of job seeker curriculum vitae declined over the same time period in 2020 (January, 380 views/month to May, 3 views/month) compared to 2019 (January, 100 views/month to May, 54 views/month). Conclusions: An analysis of job postings from CTSNet suggests a decline in job availability in the North American cardiothoracic surgical job market following declaration of the pandemic with acknowledgement that there is month to month variability and a supply-demand mismatch. The COVID-19 pandemic has had an unprecedented impact on our field, and the ultimate consequences remain unknown.

Strategies to optimize aged care volunteer recruitment and retention: A systematic review.

Population aging and resource constraints in aged care indicate an ever increasing need for volunteers in this growing sector. Volunteers in aged care have different expectations and experiences, as they typically form longer and closer relationships with residents, and perform important social support functions that may otherwise not be delivered. Tailored strategies to recruit and retain these volunteers are needed. The aims of this review were to identify the motivations and expectations of aged care volunteers, and to examine strategies that foster their recruitment, retention and role satisfaction. A systematic review of MEDLINE, PsycINFO, CINAHL, Embase and Cochrane Library was conducted. Selection criteria included qualitative and quantitative studies published in English, with no date restrictions. Volunteering roles were restricted to residential aged care services. The 18 studies eligible for review presented consistently strong themes across volunteer motivation, recruitment/retention, and satisfaction/involvement. Implications for policy and practice relate to the importance of setting clear role expectations, matching volunteers' skills with roles, ongoing training and support, and the need for operational frameworks that support volunteers with administrative processes, communication and complaint resolution. Improved volunteer management that enables the consistent provision of social support in this setting stands to improve residents' quality of life.

Decision-making in home care package spending.

OBJECTIVE: To understand the motivations and drivers of spending decisions made by home care package recipients, in the context of high levels of unspent funds. METHODS: Qualitative study using 30 semi-structured interviews with 38 home care package clients and/or client representatives in rural and urban Victoria conducted between December 2018 and March 2019. Interview transcripts were analysed to determine themes. RESULTS: Spending decisions were influenced by assessment and entry experiences, knowledge and understanding of package funds, availability and acceptability of services, and attitudes to spending. CONCLUSION: Clients need confidence in their individual funds and their use in order to maximise the potential benefits. Clear, consistent communication at all stages, and additional supports to build consumer capability, will enable clients to better understand packages and their application. This in turn will optimise the capacity of home care package recipients to maximise their health and well-being.

Mediastinal metastatic melanoma: an unusual case presentation of recurrent melanoma.

Mediastinal malignant melanoma is rare as both primary and metastatic lesions. We present the case of a 50-year-old man with diagnosis of recurrent melanoma of the mediastinum. Our patient was previously treated for cutaneous melanoma in 2001 with surgical excision. He presented with symptoms of exertional dyspnoea, dull chest pain and non-productive cough for 12 weeks. CT revealed a large heterogeneously enhancing mass, measuring 10.7×7.6 cm, centred within the aortopulmonary window which abutted the adjacent pericardium. Open biopsy of the epicardial mass was performed via left anterior thoracotomy. Immunohistochemical stains performed on the mass were positive for CD99, focally positive for CD56, SOX10, S100 and WT-1. A diagnosis of metastatic melanoma was established. The patient was started on pembrolizumab with pending BRAF testing. V600E and V600K mutations in exon 15 of the BRAF gene were codetected, and the patient was treated with dabrafenib and trametinib.

Prevalence and nature of resident-to-resident abuse incidents in Australian residential aged care.

OBJECTIVES: To determine the prevalence of resident-to-resident abuse (RRA) in aged care facilities and to explore the nature, contributing factors and outcomes of abuse incidents. METHODS: Retrospective cohort study of residents in 13 aged care facilities between 1 January and 31 December 2017, using data extracted from organisational incident reports. RESULTS: A total of 169 RRA incidents were recorded, representing 0.56 incidents per 1000 bed days. 7.6% of residents were targets, and 6.9% exhibited aggression, in one or more RRA incidents over one year. In the majority of incidents (152, 89.9%), the aggressor had a cognitive impairment. Impacts on targets were mostly minor. The most common aggressor intervention was behaviour management (142; 84.0%). CONCLUSIONS: Resident-to-resident abuse was found to be lower than in other reports. Typically, it involves residents with cognitive impairment and does not result in serious harm. Managing behavioural symptoms associated with cognitive impairment is critical in preventing and managing RRA.

Aging in Australia: country of birth and language preferences of residents in aged care facilities.

Objective There is a need to better understand the use of aged care services by people from culturally and linguistically diverse backgrounds. The aim of the present study was to describe the prevalence of people living in residential aged care facilities (RACFs) who were born in non-English-speaking countries and/or have a preferred language other than English and to describe service utilisation rates. Methods The present study consisted of a secondary analysis of data from the Australian Institute of Health and Welfare National Aged Care Data Clearinghouse. Data were analysed by country of birth, preferred language, state or territory and Aged Care Planning Regions within Victoria. Results Nationally, over 30000 (18.3%) RACF residents were born in a non-English-speaking country. In Victoria, almost one in four RACF residents (23.9%) was born in a non-English-speaking country, and approximately one in eight (13.1%) has a preferred language other than English. Most Victorian RACFs (72.4%) have at least one resident with a preferred language other than English. Approximately one in four residents (26.1%) with a preferred language other than English are the sole speaker of the language in their facility. Conclusion All RACFs need to effectively address the needs and preferences of their residents, including those who were born in a non-English-speaking country or prefer to speak a language other than English. What is known about the topic? The number of older people from a non-English-speaking background continues to increase, but little is known about the prevalence of this cohort living in RACFs and how aged care providers are responding to their needs and preferences. What does this paper add? The present study provides detailed, service- and policy-relevant information, demonstrating a substantial degree of diversity among people living in RACFs, with wide distribution across facilities and regions. The findings confirm the need for a systematic, sector-wide approach to addressing linguistic diversity and developing inclusive practices. What are the implications for practitioners? All RACFs are required to develop policies and procedures in order to cater to the needs and preferences of residents who were born in non-English-speaking countries and/or who prefer to speak a language other than English.

Person-centred services? Rhetoric versus reality.

National and jurisdictional governments are increasingly using commissioning in health and community services. This includes the devolution of functions such as service planning, resource allocation, and regionalised approaches to intake and service delivery, to non-government organisations. The aims of this paper are to reflect on the experiences of commissioning as a not-for-profit health provider, and to identify some important early lessons. This analysis highlights the importance of a rights-based approach in which consumers, carers and communities actively participate in the design, implementation and evaluation of service systems, not just individual service needs; and that pays special attention to the most disadvantaged and the most vulnerable. The mechanisms and approaches used by cohealth to implement these principles are described. Service users need to be supported to develop advocacy capacity individually and collectively, in order to make informed choices about their own service needs and about the system more broadly, to ensure accessible and appropriate services.

The Adoption of Roles by Primary Care Providers during Implementation of the New Chronic Disease Guidelines in Urban Mongolia: A Qualitative Study.

(1) BACKGROUND: In 2011, new chronic disease guidelines were introduced across Mongolia. No formal advice was provided regarding role delineation. This study aimed to analyse the roles that different primary care providers adopted, and the variations in these, in the implementation of the guidelines in urban Mongolia; (2) METHODS: Ten group interviews with nurses and ten individual interviews each with practice doctors and practice directors were conducted. Data was analysed using a thematic approach based on the identified themes relevant to role delineation; (3) RESULTS: There was some variability and flexibility in role delineation. Factors involving teamwork, task rotation and practice flexibility facilitated well the guideline implementation. However, factors including expectations and decision making, nursing shortage, and training gaps adversely influenced in the roles and responsibilities. Some role confusion and dissatisfaction was identified, often associated with a lack of training or staff turnover; (4) CONCLUSIONS: Findings suggest that adequate ongoing training is required to maximize the range of roles particular provider types, especially primary care nurses, are competent to perform. Ensuring that role delineation is specified in guidelines could remove confusion and enhance implementation of such guidelines.

Service distribution and models of rural outreach by specialist doctors in Australia: a national cross-sectional study.

Objective This paper describes the service distribution and models of rural outreach by specialist doctors living in metropolitan or rural locations. Methods The present study was a national cross-sectional study of 902 specialist doctors providing 1401 rural outreach services in the Medicine in Australia: Balancing Employment and Life study, 2008. Five mutually exclusive models of rural outreach were studied. Results Nearly half of the outreach services (585/1401; 42%) were provided to outer regional or remote locations, most (58%) by metropolitan specialists. The most common model of outreach was drive-in, drive-out (379/902; 42%). In comparison, metropolitan-based specialists were less likely to provide hub-and-spoke models of service (odd ratio (OR) 0.31; 95% confidence interval (CI) 0.21-0.46) and more likely to provide fly-in, fly-out models of service (OR 4.15; 95% CI 2.32-7.42). The distance travelled by metropolitan specialists was not affected by working in the public or private sector. However, rural-based specialists were more likely to provide services to nearby towns if they worked privately. Conclusions Service distribution and models of outreach vary according to where specialists live as well as the practice sector of rural specialists. Multilevel policy and planning is needed to manage the risks and benefits of different service patterns by metropolitan and rural specialists so as to promote integrated and accessible services. What is known about this topic? There are numerous case studies describing outreach by specialist doctors. However, there is no systematic evidence describing the distribution of rural outreach services and models of outreach by specialists living in different locations and the broad-level factors that affect this. What does this paper add? The present study provides the first description of outreach service distribution and models of rural outreach by specialist doctors living in rural versus metropolitan areas. It shows that metropolitan and rural-based specialists have different levels of service reach and provide outreach through different models. Further, the paper highlights that practice sector has no effect on metropolitan specialists, but private rural specialists limit their travel distance. What are the implications for practitioners? The complexity of these patterns highlights the need for multilevel policy and planning approaches to promote integrated and accessible outreach in rural and remote Australia.

General practitioners' perceptions of different practice models: a qualitative study.

Ownership of general practices is changing, but perceptions of GPs about ownership and the factors influencing their decisions about this are not well understood. The aim of this study was to explore GPs' perceptions and attitudes towards different practice models. GPs (n=138) in the Southern Adelaide-Fleurieu-Kangaroo Island Medicare Local region participated in semi-structured interviews, which were analysed thematically. Thirty-nine per cent of participants were practice owners, and 64% were working in a practice with six or more GPs. Factors driving practice ownership were flexibility, autonomy and financial reward. Factors discouraging ownership were increased responsibility, time commitment and the potential for financial burden. Some interest in future practice ownership was evident, but concerns were also raised about the knowledge and skills required. Strategies are needed both to support GPs who do wish to be practice owners and to facilitate a range of practice models to ensure continued delivery of accessible, quality primary medical care to patients.

Implementation of clinical guidelines on diabetes and hypertension in urban Mongolia: a qualitative study of primary care providers' perspectives and experiences.

BACKGROUND: Hypertension and diabetes, key risk factors for cardiovascular disease, are significant health problems globally. As cardiovascular disease is one of the leading causes of mortality in Mongolia since 2000, clinical guidelines on arterial hypertension and diabetes were developed and implemented in 2011. This paper explores the barriers and enablers influencing the implementation of these guidelines in the primary care setting. METHODS: A phenomenological qualitative study with semi-structured interviews was conducted to explore the implementation of the diabetes and hypertension guidelines at the primary care level, as well as to gain insight into how practitioners view the usability and practicality of the guidelines. Ten family health centres were randomly chosen from a list of all the family health centres (n = 136) located in Ulaanbaatar City. In each centre, a focus group discussion with nurses (n = 20) and individual interviews with practice doctors (n = 10) and practice managers (n = 10) were conducted. Data was analysed using a thematic approach utilising the Theoretical Domains Framework. RESULTS: The majority of the study participants reported being aware of the guidelines and that they had incorporated them into their daily practice. They also reported having attended guideline training sessions which were focused on practice skill development. The majority of participants expressed satisfaction with the wide range of resources that had been supplied to them by the Mongolian Government to assist with the implementation of the guidelines. The resources, supplied from 2011 onwards, included screening devices, equipment for blood tests, medications and educational materials. Other enablers were the participants' commitment and passion for guideline implementation and their belief in the simplicity and practicality of the guidelines. Primary care providers reported a number of challenges in implementing the guidelines, including frustration caused by increased workload and long waiting times, time constraints, difficulties with conflicting tasks and low patient health literacy. CONCLUSIONS: This study provides evidence that comprehensive and rigorous dissemination and implementation strategies increase the likelihood of successful implementation of new guidelines in low resource primary care settings. It also offers some key lessons that might be carefully considered when other evidence-based clinical guidelines are to be put into effect in low resource settings and elsewhere.

Noncommunicable Disease Prevention and Control in Mongolia: A Policy Analysis.

BACKGROUND: Noncommunicable diseases (NCDs) are the major global cause of morbidity and mortality. In Mongolia, a number of health policies have been developed targeting the prevention and control of noncommunicable diseases. This paper aimed to evaluate the extent to which NCD-related policies introduced in Mongolia align with the World Health Organization (WHO) 2008-2013 Action Plan for the Global Strategy for the Prevention and Control of NCDs. METHODS: We conducted a review of policy documents introduced by the Government of Mongolia from 2000 to 2013. A literature review, internet-based search, and expert consultation identified the policy documents. Information was extracted from the documents using a matrix, mapping each document against the six objectives of the WHO 2008-2013 Action Plan for the Global Strategy for the Prevention and Control of NCDs and five dimensions: data source, aim and objectives of document, coverage of conditions, coverage of risk factors and implementation plan. 45 NCD-related policies were identified. RESULTS: Prevention and control of the common NCDs and their major risk factors as described by WHO were widely addressed, and policies aligned well with the objectives of the WHO 2008-2013 Action Plan for the Global Strategy for the Prevention and Control of NCDs. Many documents included explicit implementation or monitoring frameworks. It appears that each objective of the WHO 2008-2013 NCD Action Plan was well addressed. Specific areas less well and/or not addressed were chronic respiratory disease, physical activity guidelines and dietary standards. CONCLUSIONS: The Mongolian Government response to the emerging burden of NCDs is a population-based public health approach that includes a national multisectoral framework and integration of NCD prevention and control policies into national health policies. Our findings suggest gaps in addressing chronic respiratory disease, physical activity guidelines, specific food policy actions restricting sales advertising of food products, and a lack of funding specifically supporting NCD research. The neglect of these areas may hamper addressing the NCD burden, and needs immediate action. Future research should explore the effectiveness of national NCD policies and the extent to which the policies are implemented in practice.

Changes in Doctors' Working Hours: A Longitudinal Analysis.

The study examined changes in doctors' working hours and satisfaction with working hours over five time points and explored the influence of personal characteristics on these outcomes. Latent growth curve modeling was applied to Medicine in Australia: Balancing Employment and Life data, collected from 2008 to 2012. Findings showed that working hours significantly declined over time, with a greater decrease among males, older doctors, and doctors with fewer children. Satisfaction increased faster over time among specialists, doctors with poorer health, those whose partners did not work full-time, and those with older children. The more hours the doctors worked initially, the lower satisfaction reported, and the greater the increase in satisfaction. Findings are consistent with a culture change in the medical profession, whereby long working hours are no longer seen as synonymous with professionalism. This is important to take into account in projecting future workforce supply.

Job satisfaction among Australian doctors: the use of latent class analysis.

OBJECTIVE: To identify patterns of job satisfaction among Australian doctors using latent class analysis, and to determine the relationships of these patterns to personal and professional characteristics so as to improve satisfaction and minimize medical wastage. METHODS: MABEL (Medicine in Australia: Balancing Employment and Life) data in 2011 were used. The study collected information on 5764 doctors about their job satisfaction, demographic characteristics, their health, country of medical training, opportunities for professional development and social interaction, taking time off work, views of patients' expectations, unpredictable working hours, hours worked per week, preference to reduce hours and intention to leave the medical workforce. RESULTS: Four latent classes of job satisfaction were identified: 5.8% had high job satisfaction; 19.4% had low satisfaction with working hours; 16.1% had high satisfaction with working hours but felt undervalued; and 6.5% had low job satisfaction. Low job satisfaction was associated with reporting poor health, having trained outside Australia, having poor opportunities for professional development and working longer hours. Low satisfaction was associated with a preference to reduce work hours and an intention to leave the medical workforce. CONCLUSION: To improve job satisfaction and minimize medical wastage, policies need to address needs of overseas trained doctors, provide continuing professional development and provide good health care for doctors.

Retirement patterns of Australian doctors aged 65 years and older.

OBJECTIVE: To investigate retirements over a 4-year period among Australian general practitioners (UPs) and specialists aged 65 years and over, and factors influencing retirement. METHODS: Data from Medicine in Australia: Balancing Employment and Life (MABEL) for the years 2009-12 were analysed for 435 GPs and 643 specialists aged 65 years and over at the time of entry to the MABEL survey. Discrete time survival analysis was used. RESULTS: The retirement rates were 4.1% (2009), 5.1% (2010), 4.2% (2011) and 10.4% (2012). Retirement was associated with: (1) the intention to leave medical work in 2009 and 2010; (2) working fewer hours in private consulting rooms in 2010 and 2012; (3) having lower job satisfaction in 2009 and 2011; (4) being older in 2009; (5) working fewer hours in a public hospital in 2012; and (6) working fewer hours in a private hospital in 2010. Doctors who intended to reduce their working hours were less likely to retire in 2009. CONCLUSIONS: Strategies to support doctors at the late career stage to provide their valued contributions to the medical workforce for as long as possible may include increasing job satisfaction and addressing barriers to reducing work hours.

Australian doctors' non-clinical activities: results from the Medicine in Australia: Balancing Employment and Life (MABEL) survey of doctors.

OBJECTIVE: The aim of the present study was to investigate non-clinical work conducted by Australian doctors. METHODS: This study was an exploratory descriptive study using data from Wave 5 of the Medicine in Australia: Balancing Employment and Life (MABEL) longitudinal survey, collected in 2012 from Australian medical practitioners (2200 general practitioners (GPs), 3455 specialists, 1270 specialists in training and 1656 hospital non-specialists). The main outcome measure was the number of hours worked per week in non-clinical work. Regression analysis was used to determine associations between non-clinical activities (i.e. education-related, management and administration and other) and personal and professional characteristics, including age, gender, job and life satisfaction, total clinical working hours, sector of practice (public or private) and doctor type. RESULTS: Australian doctors spend an average of just under 7 h per week, or 16% of their working time, on non-clinical activities. Doctors who worked more hours on non-clinical activities overall, and in education-related and management and administration specifically, were male, younger, had lower life satisfaction and generally spent fewer hours on clinical work. Lower job satisfaction was associated with longer management and administration hours, but not with time spent in education-related activities. Specialists were more likely to work long non-clinical hours, whereas GPs were more likely to report none. Hospital non-specialists reported relatively high management and administration hours. CONCLUSIONS: Further work is required to better understand the full range of non-clinical activities doctors are involved in and how this may impact future workforce projections.

Workplace aggression in clinical medical practice: associations with job satisfaction, life satisfaction and self-rated health.

OBJECTIVE: To determine the likely impact of aggression from internal sources (co-workers) and external sources (patients, patients' relatives or carers and others) on Australian medical clinicians in the previous 12 months. DESIGN AND SETTING: An exploratory, descriptive study using cross-sectional survey design, conducted in the third wave of the Medicine in Australia: Balancing Employment and Life longitudinal survey (1 March 2010 to 30 June 2011). PARTICIPANTS: 9449 Australian clinical medical practitioners, comprising 3515 general practitioners and GP registrars, 3875 specialists, 1171 hospital non-specialists and 888 specialists in training. MAIN OUTCOME MEASURES: Logistic regression was used to determine associations between workplace aggression exposure and intrinsic job satisfaction, satisfaction with life and self-rated health. RESULTS: In fully adjusted models, exposure to internal aggression was negatively associated with intrinsic job satisfaction (odds ratio [OR], 0.59; 95% CI, 0.53-0.66), satisfaction with life (OR, 0.67; 95% CI, 0.60-0.76) and self-rated health (OR, 0.86; 95% CI, 0.77-0.96). Exposure to external aggression was also negatively associated with intrinsic job satisfaction (OR, 0.75; 95% CI, 0.67-0.84), satisfaction with life (OR, 0.87; 95% CI, 0.78-0.98) and self-rated health (OR, 0.83; 95% CI, 0.74-0.92). CONCLUSIONS: The likely impact of workplace aggression on clinician wellbeing may extend to adverse consequences for care quality, safety and access. More concerted efforts to prevent and minimise workplace aggression are required.

Rural outreach by specialist doctors in Australia: a national cross-sectional study of supply and distribution.

BACKGROUND: Outreach has been endorsed as an important global strategy to promote universal access to health care but it depends on health workers who are willing to travel. In Australia, rural outreach is commonly provided by specialist doctors who periodically visit the same community over time. However information about the level of participation and the distribution of these services nationally is limited. This paper outlines the proportion of Australian specialist doctors who participate in rural outreach, describes their characteristics and assesses how these characteristics influence remote outreach provision. METHODS: We used data from the Medicine in Australia: Balancing Employment and Life (MABEL) survey, collected between June and November 2008. Weighted logistic regression analyses examined the effect of covariates: sex, age, specialist residential location, rural background, practice arrangements and specialist group on rural outreach. A separate logistic regression analysis studied the effect of covariates on remote outreach compared with other rural outreach. RESULTS: Of 4,596 specialist doctors, 19% (n = 909) provided outreach; of which, 16% (n = 149) provided remote outreach. Most (75%) outreach providers were metropolitan specialists. In multivariate analysis, outreach was associated with being male (OR 1.38, 1.12 to 1.69), having a rural residence (both inner regional: OR 2.07, 1.68 to 2.54; and outer regional/remote: OR 3.40, 2.38 to 4.87) and working in private consulting rooms (OR 1.24, 1.01 to 1.53). Remote outreach was associated with increasing 5-year age (OR1.17, 1.05 to 1.31) and residing in an outer regional/remote location (OR 10.84, 5.82 to 20.19). Specialists based in inner regional areas were less likely than metropolitan-based specialists to provide remote outreach (OR 0.35, 0.17 to 0.70). CONCLUSION: There is a healthy level of interest in rural outreach work, but remote outreach is less common. Whilst most providers are metropolitan-based, rural doctors are more likely to provide outreach services. Remote distribution is influenced differently: inner regional specialists are less likely to provide remote services compared with metropolitan specialists. To benefit from outreach services and ensure adequate remote distribution, we need to promote coordinated delivery of services arising from metropolitan and rural locations according to rural and remote health need.

Adoption, implementation and prioritization of specialist outreach policy in Australia: a national perspective.

The World Health Organization has endorsed the use of outreach to promote: efficient redeployment of the health-care workforce; continuity of care at the local level; and professional support for local, rural, health-care workers. Australia is the only country that has had, since 2000, a sustained national policy on outreach for subsidizing medical specialist outreach to rural areas. This paper describes the adoption, implementation and prioritization of a national specialist outreach policy in Australia. Adoption of the national policy followed a long history of successful outreach, largely driven by the professional interest and personal commitment of the workforce. Initially the policy supported only new outreach services but concerns about the sustainability of existing services resulted in eligibility for funding being extended to all specialist services. The costs of travel, travel time, accommodation, professional support, staff relief at specialists' primary practices and equipment hire were subsidized. Over time, a national political commitment to the equitable treatment of indigenous people resulted in more targeted support for outreach in remote areas. Current priorities are: (i) establishing team-based outreach services; (ii) improving local staff's skills; (iii) achieving local coordination; and (iv) conducting a nationally consistent needs assessment. The absence of subsidies for specialists' clinical work can discourage private specialists from providing services in remote areas where clinical throughput is low. To be successful, outreach policy must harmonize with the interests of the workforce and support professional autonomy. Internationally, the development of outreach policy must take account of the local pay and practice conditions of health workers.

L'Organisation mondiale de la Santé a approuvé l'utilisation de services de proximité pour promouvoir: le redéploiement efficace du personnel des soins de santé; la continuité des soins au niveau local; et le support professionnel au personnel de santé local et rural. L'Australie est le seul pays qui possède, depuis l'an 2000, une politique nationale soutenue de services de proximité afin de subventionner la présence de médecins spécialistes dans les zones rurales. Cet article décrit l'adoption, la mise en œuvre et la priorisation d'une politique nationale de proximité spécialisée en Australie. L'adoption de cette politique nationale a fait suite à une longue histoire de services de proximité dont la réussite est largement attribuable à l'intérêt professionnel et à l'engagement personnel des professionnels de santé. À l'origine, cette politique soutenait seulement les nouveaux services de proximité, mais les préoccupations concernant la durabilité des services existants ont abouti à l'extension de l'admissibilité au financement à tous les services spécialisés. Les coûts des déplacements, des temps de déplacement, d'hébergement, du soutien professionnel, de personnel de remplacement dans les cabinets primaires des médecins spécialistes et de la location d'équipement ont été subventionnés. Au fil du temps, l'engagement politique national pour le traitement équitable des populations autochtones a entraîné un soutien plus ciblé pour acheminer les services de médecine mobile dans les zones reculées. Les priorités actuelles sont: (i) l'établissement de services de proximité en équipe; (ii) l'amélioration des compétences des professionnels locaux; (iii) la réalisation de la coordination locale; et (iv) la conduite d'une évaluation cohérente des besoins à l'échelle nationale. L'absence de subventions pour le travail clinique des médecins spécialistes peut décourager les médecins spécialistes privés de venir soigner dans les zones éloignées où le rendement clinique est faible. Pour qu'elle réussisse, la politique de proximité doit s'harmoniser avec les intérêts des professionnels de santé et soutenir l'autonomie professionnelle. À l'échelle internationale, le développement de politiques de proximité doit tenir compte du salaire local et des conditions d'exercice des professionnels de la santé.

La Organización Mundial de la Salud ha aprobado el uso de la difusión con el objetivo de promover la reasignación eficiente del personal sanitario, la continuidad de la atención a nivel local y el apoyo profesional para el personal sanitario a nivel local y rural. Australia es el único país que ha mantenido, desde el año 2000, una política nacional continuada en materia de subvención de la difusión de especialistas médicos en las zonas rurales. Este artículo describe la adopción, implementación y prioridad de la política de difusión de especialistas en dicho país. La adopción de la política nacional obedeció a un largo historial de difusión con buenos resultados, impulsado en gran parte por el interés profesional y el compromiso personal de los trabajadores. En un principio, la política apoyaba únicamente los servicios de difusión nuevos, pero la preocupación acerca de la sostenibilidad de los servicios existentes auspició una ampliación de la financiación a la totalidad de los servicios especializados. Se subvencionaron los costes y el tiempo de viaje, el alojamiento, el apoyo profesional, la asistencia al personal en los consultorios principales de los especialistas y el alquiler de equipos. Con el tiempo, el compromiso político nacional respecto al trato equitativo de los pueblos indígenas se tradujo en un apoyo más específico para la difusión en las áreas más alejadas. Las prioridades actuales son: (i) establecer servicios periféricos por equipos, (ii) mejorar las capacidades del personal local, (iii) lograr la coordinación local y (iv) llevar a cabo una evaluación cohesiva de las necesidades a nivel nacional. La ausencia de subsidios para el trabajo clínico de los especialistas puede disuadir a los especialistas privados de prestar servicios en zonas remotas, en las que el rendimiento clínico es bajo. Para resultar satisfactoria, la política de difusión debe armonizar los intereses del personal y apoyar la autonomía profesional. A nivel internacional, el desarrollo de una política de divulgación debe tener en cuenta los salarios y las condiciones locales de los miembros del personal sanitario.