Previous attempts to address rural doctor shortages have failed. Will the latest strategy be any different?
A push is under way to build a force of homegrown rural generalist GPs to fill workforce gaps in areas where medical migration and bonded schemes have failed to provide lasting solutions to the problem.
The strategy, to be developed as the first priority for the new Rural Health Commissioner, comes as the government has identified general practice as one of three top areas for future workforce planning, along with anaesthetics and psychiatry.
“Even after 20 years of fiddling around the edges, we still have a maldistribution of workforce,” Dr Ewen McPhee, president of the Rural Doctors Association of Australia (RDAA), told The Medical Republic.
“We’ve tried bringing doctors from other countries, both through the 457 (employer-sponsored) and skilled immigration programs, putatively to address the inequities in health and access for rural people.
“Of course, what we are seeing is the same equity and access issues.”
With GPs already in oversupply in urban settings such as western Sydney, and record numbers of medical graduates coming through the university system, it was time to find solutions beyond funnelling more doctors into the system, the Queensland GP said.
“When do we shift from just pumping out numbers to addressing the issues that exist in specific specialties that will never get fixed by themselves? We need to be responsive to need.”
Dr McPhee said selecting the right trainees would be crucial, favouring candidates with rural backgrounds and “rural intent”.
“We pick the person who wants to serve the needs of a community. We train them, we groom them, we build them up – very much like what we would like to achieve with our Aboriginal and Torres Strait Island people,” he said.
“We need explicitly to build our own capacity,” he said. “When we invest taxpayers’ money in people, we want them to be the right people and we want to support them into the places where they need to be.”
In December, the federal government promised $4.4 million over four years to establish the new role of Rural Health Commissioner, an initiative suggested by the RDAA and sealed by then rural health minister Fiona Nash in the week before the 2016 election.
“The commissioner will lead the development of the first ever National Rural Generalist Pathway, which will address rural health’s biggest issue – not enough health professionals in rural, regional and remote Australia,” then health minister Sussan Ley said.
As a statutory appointment, however, the post cannot be filled until parliament passes enabling legislation.
To date, workforce shortfalls resulting from a patchwork of health systems and the dwindling availability of GPs with procedural skills have made rural communities increasingly dependent on locums and fly-in fly-out services.
Dr Les Woollard, a long-serving procedural GP in the northern NSW town of Moree, described the decline over decades of generalist training and VMO roles in his state as amounting to “system failure”.
As we spoke, on a recent Tuesday afternoon, Dr Woollard was stepping aside from VMO duties at the Moree hospital. But he had been unable to find a replacement GP obstetrician, despite advertising the job for six months.
“I’ve been doing it for 35 years and nine months. I retired from anaesthetics yesterday, I have just 15 hours more tomorrow on obstetrics call. And on Thursday I retire from the emergency department,” he told The Medical Republic.
This meant the prospect of having only two people – one of whom being the on-call surgeon – running an obstetrics roster that once had nine doctors.
“It is unsustainable,” Dr Woollard said.
“When you advertise for six months and you get no reasonable applicants for a pleasant town in northern NSW with a reasonable population base and airlines to Sydney and Brisbane, you’ve got to understand it’s a failure of the system.
“It has failed country people. Why haven’t they fixed this? It’s the health ministers’ responsibility.
“I don’t see (politicians) coming around to look at the obstetric units around NSW … How much money do they put into training someone for a specific job who can deliver a baby, give an anaesthetic – and as we did the other day – intubate and ventilate a patient who nearly died on us?”
In recent state elections, he added: “Greyhounds got more attention.”
As defined by the Australian College of Rural and Remote Medicine, rural generalist medicine is a broad scope of care that includes comprehensive primary care, in-patient and/or secondary care, emergency care, and specialised skills in at least one discipline (e.g., emergency medicine, Indigenous health, internal medicine, mental health, paediatrics, obstetrics, surgery or anaesthetics); and hospital and community-based public health practice.
ACRRM President, Associate Professor Ruth Stewart, said a decline in emphasis on procedural work in GP training was one of the factors precipitating the breakaway from the RACGP by rural doctors who formed ACRRM in 1997.
For her, as a naïve kid from rural Victoria who was always going to practice in a country town, generalist medicine had always been the goal.
“I had a concept of a GP who ran a private practice, was a visiting medical officer at the local hospital, where they had a procedural practice, and lived in the community. I wanted to be that kind of doctor,” the GP, who practices on Thursday Island in Torres Strait, said.
“Learning about consulting and office-based skills was all very well, but we needed emergency skills and advanced lifesaving skills.
“In my clinical practice, I can move from delivering obstetric care to psychological care to chronic disease care, all for the one patient. It’s seamless care, and it is profoundly rewarding.”
The call to revive generalist GP training comes as the government searches for ways to reduce reliance on medical immigrants, many of whom move to the cities after serving their time in District of Workforce Shortage areas under a 10-year moratorium.
In advice to Ms Ley last year, the federal health department recommended that all medical disciplines be withdrawn from the Skilled Occupations List that helps immigrants gain work visas. Doctors were added to the list in 2004.
The Skilled Occupations List is another route of entry, after the 457visa category, under which organisations and practices sponsor thousands of overseas-trained doctors per year to work in areas of workforce shortage.
While the occupation list proposal was ultimately rejected by the Department of Immigration, it signals a significant shift in attitude and mirrors the advice of doctors’ groups, including the AMA and the RACGP.
“Uncoordinated decision making in the past has seen a ‘boom and bust’ cycle in medical training and resulting doctor numbers,” the department said in its report to the minister, revealed after a Freedom of Information request.
The report said there were enough domestic medical students already in the system to fill GP workforce needs, noting a growing mismatch between medical graduates and available vocational training places that could exceed 500 in 2018 and reach 1000 in 2030.
“The high cost of training and the continued reliance on immigration to fill workforce gaps mean that it is important … to ensure the potential benefits to the community of these doctors is fully realised,” it said.
“This may mean the development of pathways that help fill workforce gaps are considered.”
In Queensland, which accepted rural generalism as a medical specialty in 2008, the generalist pathway is well established, with enrolments nudging 80 per year and 270 junior doctors in the pipeline in 2016.
A NSW generalist program has grown quickly in numbers and scope since starting with 13 GP registrars training in anesthetics and obstetrics in 2013, with participants over the four-year program to reach 87 this year.
Similar programs in other states are in early development and only starting to gain traction, with graduates working towards fellowships with ACRRM or the RACGP.
The RDAA suggests larger states such as Queensland and NSW could support an annual intake of 80-100 trainees and smaller states between 20 and 50.
Anecdotal accounts suggest skills shortages are particularly a problem in regional hospitals in South Australia.
Dr McPhee said a coordinated national scheme could target specific primary-care needs without massive new investment.
“Money is already being spent, some of it effectively, a lot of it not. We need to realign that money to make the rural generalist pathway work,” he said. “We are too small a country to have five or six different programs.
“We still get contacted by small communities that have been trying to get a doctor for years. There is a rural generalist program in that state, but there doesn’t seem to be an explicit intent to recruit and retain (a doctor) for that town or region. They are paying lip service.”
Nevertheless, ACRRM CEO Marita Cowie said the states’ rural generalist programs were “clear signals of commitment”.
“They are at different stages of development, but there has been serious investment by some states in supporting the development of doctors with that (comprehensive) skill.”
ACRRM is continuing to press for rural generalist medicine to be registered as a specialty nationally, with increased compensation in recognition of the advanced skill set required.
“It gives it a status, and a specific recognition that it is not little pieces of other things, but it’s actually a comprehensive scope of practice that you can train for and excel in, like other specialties,” Ms Cowie said.
“It is different from mainstream general practice, and why wouldn’t you recognise that?
“It is a very broad, comprehensive scope of practice we are asking these docs to be skilled in, and in relative professional isolation, and geographic isolation in many cases.”
For these lofty objective to be met, where previous strategies have failed to keep Australian-trained doctors in the bush, advocates say the new program will also need policies to support nurses and allied health for rural roles.