Rural communities deserve access to high-quality GP-led care. The challenge now is ensuring we have the courage and leadership to build the systems that make that possible.
“In this world, nothing can be said to be certain except death and taxes,” said Benjamin Franklin in a letter to his friend Jean-Baptiste Le Roy in 1789.
He wasn’t the first to say it. He pinched it from Defoe’s The Political History of the Devil (but let’s not go there.) It’s since become a catchcry for modern life, its myriad uncertainties and the two great swords of Damacles- death and taxation.
As an optimist, I read into it that almost anything else can fought for, saved, rescued, advocated for.
As a realist I read into it that everything else will need to be fought for, saved, rescued, advocated for.
Such is the situation with Australian rural general practice.
I understand why rural GPs are worried
In six years as chair of Victoria at the RACGP, I have spoken to hundreds of GPs, practice managers and registrars; concern about the viability of rural practice is real and needs to be treated with respect.
Rural GPs face enormous workloads, on call demands, fewer opportunities for personal leave, can be professionally isolated and are at high risk of burnout.
We’ve been saying it until we are blue in the face and I’m going to say it again now: Medicare rebates have been so poorly indexed over 25 years, many rural practices make a loss when they perform procedures on their patients because the costs of equipment and staff are higher than the rebates they receive for providing care.
Let that sink in.
Some GPs are paying out of their own pockets to perform procedures on patients because of inadequate MBS rebates.
When I ask them why they do not charge a fee to at least cover the equipment costs, they just state flatly that patients now believe gap fees are outlawed and many become angry or simply refuse to pay.
When we turn the discourse to funding, the immediate riposte is the “greedy doctor” narrative that generates resentment from the public who now expect everything in general practice to be done for free.
The fact is, expert generalists deserve to be remunerated for their lifetime of training, the extraordinary levels of responsibility they shoulder, the long hours of on call, their skills and knowledge and the risks they take in operating businesses in difficult circumstances.
I have never read an article or political commentary that derides greedy pharmacy owners. That particular stiletto seems only to get lodged in the backs of doctors. And while self-sacrifice still seems to be synonymous with virtue in medicine, a GP can’t put their kids through school only banking virtue.
Rural GPs are also spending disproportionate amounts of time on administration, compliance and regulation requirements. Australia has a very proud history of high standards in medicine, but every hour spent on paperwork is an hour not seeing patients and not generating an income.
The system urgently needs to ask which administrative activities beget quality and which are needless enemies of productivity, morale and efficiency.
Rural practices are also perennially challenged by attracting and retaining adequate workforce. We often read about doctors not being willing to go rural, but in fact the issues that hamper them are often structural and systemic.
A rural town may not have adequate housing, childcare, schools, employment for non-medical spouses and opportunities for non-medical pursuits. It can also be very difficult for rural GPs to take leave and to access ongoing professional education. And even the most self-sacrificing GP will think twice before committing to a roster of endless on call because no adequate back up is available.
What we need is to attract, train and retain rural GPs and to do that we need to retain the entire medical family.
And while we often hear nostalgic and misty-eyed praise of the rural GP of the past who worked six days a week, saw 60 patients a day, was on call for months at a time, and required a full-time stay-at-home spouse in order to survive, we have to be brave and recognise that that model of medicine is not sustainable, reasonable or safe.
It’s an anachronism.
Rural practice remains one of the most rewarding careers in medicine
Despite these challenges, most rural GPs love their work, love their communities and espouse the satisfaction and value of their profession. They really love rural Australia.
For many doctors, the appeal of rural practice lies in the clinical autonomy, enormous variety and scope of practice and deep connection to their patients.
Rural GPs deliver the full continuum of care, treating generations of families and whole communities, performing myriad procedures, often with admitting rights at local hospitals. They often have advanced skills in obstetrics, anaesthetics, general surgery, palliative care, emergency medicine, paediatrics.
These people are the Swiss Army Knives of the medical world and can deploy their skills in a variety of settings. Forget the super-subspecialised non-GP specialist: if you find yourself in a survival situation the best thing you could ask for is an Australian rural GP.
Any doctor whose emergency skills include liaising with the local vet to keep the supply of atropine flowing ain’t no ordinary clinician.
But while rural GPs report high satisfaction and love of their work, they are also the most likely of all the medical professionals to experience burn out. It is the huge and relentless workload followed by administrative and systems barriers they cite as the leading problems.
The challenges are real, but they are not unsolvable
I’ve spent a lot of time talking rural and visiting rural practices over the last six6 years. We can’t make rural GPs immortal, and we can’t stop their requisite yearly homage to the Tax Man, but we absolutely can keep their profession from demise.
Rural generalism is now a recognised specialty of medicine which is bringing recognition, respect and a protected title to the profession. More trainees than ever are enrolling in RG pathways and taking up advanced skills.
To consolidate on that trend, we need rural health services to create positions for RGs to use and retain their skills. Country hospitals need to welcome RGs with open arms so that the vision of the Collingrove Agreement can be realised: highly trained GPs working in local general practice and utilising advanced skills in local hospitals and community settings, thereby bridging the gap between the two.
The Single Employer Model seeks to realise that opportunity but applies only to some trainees. Its intent must be replicated in permanent positions post fellowship.
We must also remunerate a GP’s advanced skills in recognition of their value and the huge relief those skills bring to the health system at large fiscally, logistically and geographically.
Rural training and workforce pipelines can only flourish, however, if there are adequate supervisors available to support incoming trainees.
Alongside RACGP’s huge success in recruiting more registrars into rural practice is the repeated call to properly remunerate supervisors for the time, effort and commitment they make to teaching the GPs of the future.
You can’t do everything for the love of it, and we can’t keep rewarding people who do more by giving them less. We also have a precious opportunity to make the trainees of today into the supervisors of tomorrow if we get that model right.
Significant positives in the world of rural health include the many grant opportunities, RG support, government focus on rural medicine, financial incentives loadings and local workforce solutions that GPs can consolidate on to meet the needs of their communities.
But remember what brings GPs the greatest satisfaction and protection from burnout: autonomy and relief from unnecessary red tape.
Rural GPs must be left with the autonomy to bill and to practice medicine independently. Handcuff them to funding restrictions, limit their ability to innovate and build bespoke multidisciplinary teams, or preclude them from using their skills and capacity independently and their communities will suffer and they may walk away.
Finally, more than 50% of GPs in Australia are international medical graduates. Many IMGs have committed their lives to the service of rural communities. In fact, Australia’s health system would have collapsed decades ago were it not for our IMG community working in general practice and every other specialty.
Their story has been woefully overlooked in the story of our health system. Many of our own systems make entering our country and flourishing in medicine orders of magnitude more difficult than it needs to be for IMGs.
We have also an urgent need to create attitudes of celebration and gratitude for their service to replace darker narratives that have long existed.
Rural practice is worth saving
Four adjectives come to mind when I think of rural GPs: resilient, erudite, hard-working, redoubtable. I do not think: indefatigable, impervious, replaceable, dispensable.
I know that the future should not be designed from Canberra alone, but our federal funders are key stakeholders in our vision for a robust, equitable and sustainable rural general practice. In the modern age of co-design, the very best thing we can do is ask our rural GPs and their patients what is needed to secure their collective futures and to act on that advice.
Rural communities deserve access to high-quality GP-led care. The challenge now is ensuring we have the courage and leadership to build the systems that make that possible.
Dr Anita Muñoz is a GP and chair of the Victoria Faculty, Royal Australian College of General Practitioners.
