Literature Review – Telehealth Uptake in Rural and Remote Australia

Introduction

Telehealth moved from the margins of the Australian health system to its mainstream in the space of a single month. In March 2020 the Australian Government added whole-of-population telehealth items to the Medicare Benefits Schedule (MBS) in response to COVID-19, and the arrangements were made a permanent feature of Medicare from January 2022 (Department of Health and Aged Care 2023). The reform carried particular weight for the roughly seven million Australians living outside the major cities, who experience shorter life expectancy, higher rates of potentially preventable hospitalisation and substantially lower access to general practitioners than metropolitan residents (AIHW 2024). Because rural workforce shortages have proven resistant to two decades of incentive programs, telehealth is now routinely promoted as a partial remedy for clinician maldistribution rather than a mere convenience.

This review synthesises empirical and policy literature published between 2015 and 2025 on telehealth uptake in rural and remote Australia. Sources were identified through MEDLINE, CINAHL and Australian government repositories, with priority given to studies that report outcomes by remoteness area under the Australian Statistical Geography Standard (ASGS). The review is organised into four themes: patterns of access and utilisation across remoteness areas; clinical effectiveness in mental health and chronic disease care; enablers and barriers to uptake, including cultural appropriateness for Aboriginal and Torres Strait Islander communities; and workforce and funding sustainability. The principal empirical studies informing the review are summarised in Table 1, and the closing sections synthesise the evidence, identify gaps and consider policy implications.

Table 1: Summary of key studies on telehealth uptake in rural and remote Australia

Access and Utilisation Across Remoteness Areas

The utilisation literature reveals an uncomfortable paradox: the communities with the greatest need for virtual care have recorded the weakest uptake of its richest modality. Snoswell et al. (2020) analysed national MBS claims and found that telehealth grew from a negligible base to more than one third of general practice attendances in April 2020, but that telephone consultations made up the overwhelming majority of these services. Subsequent monitoring confirmed that the telephone share remained higher, and the video share lower, in outer regional, remote and very remote areas than in the major cities (Department of Health and Aged Care 2023). Patient experience data show the same gradient from the demand side: although a substantial minority of Australians now use telehealth in any given year, reported use of video consultations declines steadily with each step along the ASGS remoteness classification (ABS 2023).

This gradient inverts the original policy logic. Before 2020, MBS telehealth rebates were largely confined to specialist video consultations for patients in eligible rural locations, an explicit compensation for distance; the universal items introduced during the pandemic have instead been used most intensively by metropolitan patients consulting nearby practices. AIHW (2024) reporting helps to explain why. The supply of full-time-equivalent general practitioners per 100,000 population falls consistently with remoteness, and rates of potentially preventable hospitalisation in very remote areas are around two and a half times those of the major cities. Utilisation therefore tracks the availability of clinicians and digital capability rather than underlying need. The pattern echoes the pre-pandemic conclusion of Bradford, Caffery and Smith (2016) that rural telehealth services endure only where they are embedded within local health services rather than introduced from outside to replace them.

Clinical Effectiveness

Mental health

Mental health provides the strongest effectiveness case for telehealth in rural Australia, partly because the workforce it substitutes for is so scarce. The distribution of psychologists and psychiatrists is even more heavily skewed towards the major cities than that of general practitioners (AIHW 2024), which makes virtual delivery structurally attractive. Titov et al. (2020) reported outcomes from a national digital mental health service and found that symptom improvement among regional and remote users was comparable to that of metropolitan users, with the absence of referral requirements and travel identified as central to engagement. Telehealth items under the Better Access initiative have similarly extended psychological therapy to towns without a resident psychologist. Two cautions temper this picture. Digital services enrol self-selecting users who already possess adequate connectivity and confidence, so cohort outcomes cannot simply be generalised to the remote populations with the lowest digital inclusion, and most published evaluations remain observational rather than controlled.

Chronic disease management

The chronic disease evidence points in the same direction while underlining the need for local clinical scaffolding. In a controlled evaluation in regional Victoria, Rasekaba et al. (2019) found that telehealth-supported management of gestational diabetes achieved glycaemic outcomes comparable to conventional face-to-face care while sharply reducing travel demands on women in outlying towns. Reviews of Australian programs reach similar conclusions for diabetes, heart failure and respiratory disease, provided that virtual consultations are paired with local nursing or allied health support for physical assessment and monitoring (Bradford, Caffery & Smith 2016). Effectiveness, in other words, is conditional rather than intrinsic: telehealth substitutes safely for the consultation, not for the clinical system around it.

Enablers and Barriers to Uptake

GP endorsement and hybrid models

The clearest enabler in the qualitative literature is endorsement by a trusted general practitioner. Javanparast, Roeger and Reed (2021) found that South Australian patients accepted telehealth readily when it was delivered by their own GP within an established clinical relationship, and preferred hybrid arrangements in which virtual consultations sat alongside periodic face-to-face care. That preference is now institutionalised: MBS rules generally require a face-to-face attendance at the practice within the preceding twelve months before GP telehealth rebates apply, subject to limited exemptions, and the RACGP (2023) reports that most practices continue to offer telehealth as a routine complement to in-person consulting rather than a replacement for it.

Connectivity and digital literacy

Barriers cluster around infrastructure and capability. The Australian Digital Inclusion Index shows that digital inclusion declines with remoteness, with affordability stress, mobile-only access and lower digital ability all concentrated in remote communities (Thomas et al. 2023). Where households depend on satellite broadband, latency and data limits degrade video consultation quality, and the older age profile of many rural towns compounds the digital ability gap. Under these conditions the telephone is a rational default rather than an inferior preference, yet successive adjustments to telephone rebate settings since 2020 have made it the least secure element of the funding architecture (Department of Health and Aged Care 2023).

Cultural appropriateness for Aboriginal and Torres Strait Islander communities

For Aboriginal and Torres Strait Islander communities, appropriateness depends on who delivers telehealth as much as on the technology itself. Caffery et al. (2017) found that telehealth improved access and appointment attendance where it was delivered through Aboriginal community-controlled health organisations, with Aboriginal Health Workers co-facilitating consultations to support trust, communication and clinical follow-up. The same review warned that telehealth introduced from outside as a substitute for face-to-face outreach risks eroding trust and entrenching relationally poor care. The structural constraint is stark: remote First Nations communities record among the lowest digital inclusion scores in the country (Thomas et al. 2023). Culturally safe telehealth therefore presupposes investment in community infrastructure and workforce, directed through the community-controlled sector in line with the shared decision-making commitments of the National Agreement on Closing the Gap.

Workforce and Funding Sustainability

The sustainability literature converges on the proposition that telehealth complements, but cannot substitute for, a rural workforce. O’Sullivan, McGrail and Russell (2022) argue that rebate design determines whether telehealth strengthens or hollows out thin rural markets: where consultations leak to metropolitan or telehealth-only providers, local practices lose the routine work that cross-subsidises complex, procedural and after-hours care, worsening the viability problems telehealth was intended to relieve. Used differently, telehealth can extend the reach of rural generalists through telesupervision and virtual specialist support, an approach embedded in ACRRM training pathways. Funding stability is the second condition. Practices calibrate their telehealth offering to rebate settings, and repeated revisions to telephone items have generated planning uncertainty across the sector (RACGP 2023; Department of Health and Aged Care 2023). Sustained uptake therefore appears to depend on predictable blended funding that rewards hybrid, relationship-based models rather than episodic virtual contacts.

Synthesis and Gaps

Four findings recur across the reviewed studies. First, uptake follows infrastructure, workforce and funding settings rather than health need, producing an inverse pattern in which the most remote communities use the least video telehealth. Secondly, clinical effectiveness in mental health and chronic disease is genuine but conditional on integration with local services. Thirdly, relational continuity, and especially GP endorsement within hybrid models, is the pivotal acceptability mechanism. Fourthly, for Aboriginal and Torres Strait Islander communities, community control is the precondition for culturally safe delivery. Figure 1 illustrates how these determinants interact to shape equitable uptake.

The gaps are equally consistent. Much of the utilisation literature reports a binary metropolitan and non-metropolitan split that conceals large differences between inner regional towns and very remote communities. Economic evaluations rarely count patient travel time, out-of-pocket transport costs or income forgone, which understates the value of telehealth precisely where distances are greatest. Few studies have been co-designed with Aboriginal and Torres Strait Islander communities, leaving cultural safety inferred rather than measured. There is also little longitudinal evidence on whether the permanent MBS arrangements have shifted utilisation trajectories in remote areas since 2022, and direct comparisons of the quality and safety of telephone and video consultations remain scarce.

Policy Implications

Three implications follow from the synthesis. First, equity cannot be managed if it is not measured: MBS telehealth utilisation should be publicly reported by ASGS remoteness area and Modified Monash category so that the inverse uptake gradient is visible and trackable. Secondly, digital inclusion is health policy. Affordability support, community connectivity upgrades and digital ability programs in remote areas, delivered wherever possible through community-controlled organisations, are preconditions for video telehealth rather than optional extras (Thomas et al. 2023). Thirdly, funding design should protect hybrid, relationship-based care: stable rebates for telephone as well as video consultations, safeguards against fragmentation by telehealth-only providers, and investment in telesupervision models that strengthen rather than bypass the rural workforce (O’Sullivan, McGrail & Russell 2022).

Conclusion

The Australian literature on rural and remote telehealth tells a consistent story. The MBS expansion permanently normalised virtual care, but uptake has been shaped by infrastructure, workforce and funding settings rather than by need, so the communities that stood to gain most have adopted the least capable modalities. Where telehealth is delivered within established clinical relationships, integrated with local services and, for Aboriginal and Torres Strait Islander communities, controlled by community organisations, the evidence on access and clinical outcomes is encouraging. Where it is introduced as a remote substitute for local care, it risks entrenching the very inequities it promises to resolve. The research agenda now lies in remoteness-stratified utilisation data, co-designed evaluation with First Nations communities and economic analysis that counts the patient’s journey, so that permanent telehealth matures into an instrument of rural health equity rather than metropolitan convenience.

References

Australian Bureau of Statistics (ABS) 2023, Patient experiences in Australia: summary of findings, 2022-23, ABS, Canberra.

Australian Institute of Health and Welfare (AIHW) 2024, Rural and remote health, cat. no. PHE 255, AIHW, Canberra.

Bradford, NK, Caffery, LJ & Smith, AC 2016, ‘Telehealth services in rural and remote Australia: a systematic review of models of care and factors influencing success and sustainability’, Rural and Remote Health, vol. 16, no. 4, pp. 1-16.

Caffery, LJ, Bradford, NK, Wickramasinghe, SI, Hayman, N & Smith, AC 2017, ‘Outcomes of using telehealth for the provision of healthcare to Aboriginal and Torres Strait Islander people: a systematic review’, Australian and New Zealand Journal of Public Health, vol. 41, no. 1, pp. 48-53.

Department of Health and Aged Care 2023, MBS telehealth services: post-implementation review, Australian Government, Canberra.

Javanparast, S, Roeger, L & Reed, RL 2021, ‘Experiences of patients with telehealth in Australian general practice during the COVID-19 pandemic: a qualitative study’, BMC Family Practice, vol. 22, no. 1, pp. 1-9.

O’Sullivan, B, McGrail, M & Russell, D 2022, ‘Rural workforce distribution and the role of telehealth: implications for equitable access to primary care’, Australian Journal of Rural Health, vol. 30, no. 5, pp. 570-582.

Rasekaba, TM, Furler, J, Young, D & Lim, WK 2019, ‘Telehealth support for the management of gestational diabetes in regional Victoria: clinical outcomes and service use’, Journal of Telemedicine and Telecare, vol. 25, no. 8, pp. 466-475.

Royal Australian College of General Practitioners (RACGP) 2023, General practice: health of the nation 2023, RACGP, East Melbourne.

Snoswell, CL, Caffery, LJ, Haydon, HM, Thomas, EE & Smith, AC 2020, ‘Telehealth uptake in general practice as a result of the coronavirus (COVID-19) pandemic’, Australian Health Review, vol. 44, no. 5, pp. 737-740.

Thomas, J, Barraket, J, Parkinson, S, Wilson, CK, Holcombe-James, I & Brydon, A 2023, Measuring Australia’s digital divide: Australian Digital Inclusion Index 2023, RMIT University, Swinburne University of Technology and Telstra, Melbourne.

Titov, N, Dear, BF, Nielssen, O, Staples, LG & Kayrouz, R 2020, ‘User characteristics and outcomes from an Australian national digital mental health service’, Internet Interventions, vol. 20, pp. 1-8.