title: Rationing is a reality in rural physiotherapy: a qualitative exploration of service level decision-making.
abstract: BACKGROUND
  Deciding what health services are provided is a key consideration in delivering appropriate and accessible health care for rural and remote populations. Despite residents of rural communities experiencing poorer health outcomes and exhibiting higher health need, workforce shortages and maldistribution mean that rural communities do not have access to the range of services available in metropolitan centres. Where demand exceeds available resources, decisions about resource allocation are required.
  
  
  METHODS
  A qualitative approach enabled the researchers to explore participant perspectives about decisions informing rural physiotherapy service provision. Stakeholder perspectives were obtained through surveys and in-depth interviews. A system theory-case study heuristic provided a framework for exploration across sites within the investigation area: a large area of one Australian state with a mix of rural, regional and remote communities.
  
  
  RESULTS
  Thirty-nine surveys were received from participants in eleven communities. Nineteen in-depth interviews were conducted with physiotherapist and key decision-makers. Increasing demand, organisational priorities, fiscal austerity measures and workforce challenges were identified as factors influencing both decision-making and service provision. Rationing of physiotherapy services was common to all sites of this study. Rationing of services, more commonly expressed as service prioritisation, was more evident in responses of public sector physiotherapy participants compared to private physiotherapists. However, private physiotherapists in rural areas reported capacity limits, including expertise, space and affordability that constrained service provision.
  
  
  CONCLUSIONS
  The imbalance between increasing service demands and limited physiotherapy capacity meant making choices was inevitable. Decreased community access to local physiotherapy services and increased workforce stress, a key determinant of retention, are two results of such choices or decisions. Decreased access was particularly evident for adults and children requiring neurological rehabilitation and for people requiring post-acute physiotherapy. It should not be presumed that rural private physiotherapy providers will cover service gaps that may emerge from changes to public sector service provision. Clinician preference combines with capacity limits and the imperative of financial viability to negate such assumptions. This study provides insight into rural physiotherapy service provision not usually evident and can be used to inform health service planning and decision-making and education of current and future rural physiotherapists.
authors.affiliation: Discipline of Physiotherapy, College of Healthcare Sciences, James Cook University, 1 James Cook Dr, Douglas QLD 4811, Townsville, Australia. Robyn.Adams@jcu.edu.au.
authors.forename: Robyn
authors.initials: R
authors.lastname: Adams
authors.affiliation: Discipline of Physiotherapy, College of Healthcare Sciences, James Cook University, 1 James Cook Dr, Douglas QLD 4811, Townsville, Australia. Anne.Jones@jcu.edu.au.
authors.forename: Anne
authors.initials: A
authors.lastname: Jones
authors.affiliation: Discipline of Physiotherapy, University of South Australia, Adelaide, Australia. Sophie.Lefmann@unisa.edu.au.
authors.forename: Sophie
authors.initials: S
authors.lastname: Lefmann
authors.affiliation: Discipline of Physiotherapy, College of Healthcare Sciences, James Cook University, 1 James Cook Dr, Douglas QLD 4811, Townsville, Australia. Lorraine.sheppard@jcu.edu.au.|Discipline of Physiotherapy, University of South Australia, Adelaide, Australia. Lorraine.sheppard@jcu.edu.au.
authors.forename: Lorraine
authors.initials: L
authors.lastname: Sheppard
mesh_terms: D000328:Adult; D001315:Australia; D003657:Decision Making; D003695:Delivery of Health Care / Q000706:statistics & numerical data*; D005260:Female; D015276:Health Care Rationing / Q000706:statistics & numerical data*; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D026741:Physical Therapy Modalities / Q000706:statistics & numerical data*; D019035:Rural Health Services / Q000706:statistics & numerical data*; D012424:Rural Population / Q000706:statistics & numerical data; D011795:Surveys and Questionnaires; D014505:Urban Population / Q000706:statistics & numerical data