Doctors considered that rural people deserve the same healthcare access as urban people. They described how healthcare in RH areas struggle with patient safety issues related to long distances to base hospitals, and the need for safe transportation of severely ill patients requiring ambulance access. It was also discussed that even though many referred patients need transfer to a larger hospital because of their condition—that is, that they cannot be safely treated in the RH—some patients are referred because of practical issues related to long distances.

Ambulance access: as an ambulance could be gone for hours when transporting a patient to the base hospital, doctors described concern about what to do if another sick patient needed ambulance transfer in the meantime (rural ambulances are crewed by dedicated volunteers, consequently most rural areas just have one active ambulance at any one time):

As there was limited access to the local ambulance, any patient that could go safely to base hospital by any other transportation (eg, friend or family member’s care) would not be sent by ambulance.

Referral because of distance: RH doctors reported that local access to basic radiology and laboratory facilities was sufficient for most, although not all, acute situations. Some patients needed acute laboratory testing or radiology examinations to guide further actions, that were not available in rural areas. In such situations, the decision had to be made as to whether the patient needed referral to the base hospital for these investigations.

Among issues related to sparsely populated rural areas, limited experience of or training in handling different conditions, limited medical resources and limited medical staff were discussed. Related to these were discussions regarding vacancies among medical staff and recruitment initiatives like ‘rural practice for medical students’.

Limited experience of handling different conditions: doctors described a sense of insecurity when severely ill patients arrive at the RH. Although trained in emergency medicine, they do not often meet these patients in the clinic

I’ve put chest drains in people before. I’ve intubated people before, but not often. Doing those sorts of procedures, I’ll do it if my back is shoved against the wall, and I had to. It’s gonna make me really uncomfortable. Yeah. Some of that stuff is scary. (Doctor 10)

It was discussed that, since midwives took responsibility over the obstetric care in NZ in the 1990s, rural GPs have lost their competences to deal with obstetric complications. Only one RH doctor interviewed was a trained obstetrician. Consequently, in some regions, expectant mothers can have a long way to go to give birth.

… if a midwife is looking after that woman, identifies she’s in need of an emergency caesarean she has to call an ambulance or a helicopter to get them to (a big hospital) for an urgent operation, therefore the delay will be a minimum of probably an hour and a half. Probably more likely two hours. (Doctor 5)

Some patient groups are not admitted to all RHs, such as psychogeriatric patients and children.

Limited medical resources: all RHs were reported to have access to plain X-ray, and many of the RH doctors do point-of-care ultrasound examinations. However, with few exceptions, RHs do not have a CT scanner, consequently patients with stroke symptoms, for example, would be referred to a base hospital for diagnostics, which, including travel time, could take hours.

The availability of point-of-care lab tests were also reported to differ between RHs, and additional tests were wanted to improve patient safety.

Limited medical staff: the generalist rural health workforce across South Island was acknowledged as having high turnover rates of doctors. Some doctors reported a lack of nurses, physiotherapists, midwives and dentists as well.

Midwives, we had the one midwife who was … you know, her only, 24 hours a day, 7 days a week, 365 days a year. She was our only midwife here for years and finally she just had enough and said, "I quit. (Doctor 12)

Different reasons for this were discussed: living and working in the countryside does not suit everybody, “GPs either hate it and they leave, or they love it, and they can't leave.” (Doctor 12). Working in isolation far from hospitals could be frightening, especially for unexperienced doctors. And “…if you work there as a doctor, what does your partner do?” (Doctor 14).

Rural practice for medical students: one problem described was that urban-centric health professional training programmes do not support a rural healthcare workforce. Doctors appreciated the Rural Medical Immersion Programme run by the University of Otago (Dunedin), where medical students do part of their clinical practice at RHs. Doctors stated that students get closer to the patient work and take more responsibility when doing their practice rurally compared with in a university hospital.

It’s very different if you’re the first person to see the patient. And then you have to think about the patient and the diagnosis and that’s a bit. It’s not… You can’t just go and open the notes and say, “ah yes the registrar said it was this” (Doctor 15)

Perceived patient safety: many doctors argued that patient safety in RHs was as good as or better than patient safety in larger hospitals, providing patients needing a higher level of hospital care were not retained. Arguments for this were shorter decision paths in RHs and medical staff knowing the social context of the patients, which could favour discharge planning. Furthermore, in RHs patients are often seen by an experienced doctor sooner than in a big hospital.

I’ve been here nearly 10 years and I can’t think of a specific example of somebody who I’ve thought, “If that happened in central Auckland then they would be alive”, so that must be quite rare, I think it’s safe (Doctor 9)