Trials and tribs of rural generalism and how to fix ‘em

5 minute read

As the ‘poor cousin in the medical fraternity’, rural general practice needs better support to avoid a ‘burnt out, bitter and twisted’ workforce.

LHDs should maintain remote hospital services to allow rural GPs to maintain their acute skills, while preserving community general practice as the “bread and butter” of rural generalism, says the head of Rural Doctors Australia NSW.

RDA NSW president Dr Rachel Christmas yesterday told the Special Commission of Inquiry into Health Care Funding in NSW of the well-established struggles of the rural generalist and the possible solutions.

Dr Christmas works as a rural generalist in Temora, a town in the northeast Riverina area of NSW, which is home to about 4000 people.

The job – as for many rural generalists – involves providing community-based general practice care, hospital-based care and supervising future rural generalists.

Currently, Dr Christmas only has one registrar in her practice, demonstrative of the “long standing trend” that rural generalist registrars are few and far between.

The only other practice in town has not been able to get training off the ground.

“General practice is undersubscribed nationally and rural general practice is undersubscribed again,” she said.

“The reasons being myriad: general practice has long been a poor cousin in the medical fraternity.

“It’s not remunerated as well as other specialties and I think rural general practice is seen as an intimidating, big, hard job to do.”

Compounded by the disincentive of living in a small rural town as a young person – difficulty meeting a partner or finding work for family members – rural generalism continued to scare the masses, said Dr Christmas.

“I think people are worried that if they go out and do this job, that they’re going to end up burnt out, bitter and twisted, with no work-life balance,” she said.

But, despite the difficulties, there were methods to incentivise, she added.

Rural generalist trainees needed to know that facilities in small towns would have the resources to allow them to practice good medicine and upskill.

Dr Christmas used her own experience as a rural generalist with obstetrics training to provide an example.

Due to the limited facilities in Temora’s local hospital, most deliveries are sent to larger hospitals in Wagga, meaning deliveries per year sit at around 10, said Dr Christmas.

“Because the volume is so low, my confidence starts to drop and the confidence of the nursing staff starts to drop,” she said.

“What we need is a system where we can say, ‘okay, I’m going to be supported to go back to Wagga [Base Hospital] to do a week in the labor (ward), get my skills up again, get talking with people again, see how things are being done’.”

According to Dr Christmas, this needs “systematic” support which involves a well-maintained relationship with larger hospitals, as well as help with coordination – for example, someone to employ a locum to cover GP services in smaller towns when required.

Dr Christmas concurred with the committee that it may be useful to assess at an LHD level which areas may benefit from a GP having particular specialisations, and ensure skill maintenance and/or training was facilitated.

“It’s a very complex organism,” she said.

According to Dr Christmas, much of this relies on funding, most of which is block, not activity-based, which dissipates motivation.

“If [LHDs] are not accountable, if we’re not saying, ‘you need to run these services, we have KPIs around how many people are being operated on in those peripheral hospitals’, then there’s no impetus to make it happen,” she said.

But, while it was important to maintain hospital-based skills that often formed an intrinsic part of rural generalism and might attract many to the job, the “bread and butter” of the work was in community general practice, which also needed to be made attractive, added Dr Christmas.

“We have to be careful not to be training hospitalists,” she said.

“To make general practice viable, we need a healthy GP workforce, including upskilled nurses in general practice who are allowed to bill for services through the MBS,” said Dr Christmas.

The Albanese government’s rural bulk-billing incentives, providing higher rebates for rural doctors were a “significant improvement”, but general practice was continuing to deliver “marginal” profits, she said.

Dr Christmas said that it was likely state health districts would start employing more GPs to provide services in remote towns through models like the single employer model, which was growing in favour across the country.

The model generally involves salaried generalist registrars – paid by the state – that move between hospitals and community-based training.

Part of the GP’s billings go to the local practice, the RDAA recommends 50%, while the rest goes to the state to offset the salary.

This allows registrars to retain leave entitlement.

Dr Christmas said the benefits of such a model could be significant beyond registrars, getting primary care to where it might otherwise be unavailable and reducing the costs and responsibility of a private GP.

But while the single employer model was “certainly a model that has some appeal”, an alternative hybrid model where GPs retained some autonomy but were salaried by the state to work in hospitals sounded “fabulous”, said Dr Christmas.

“The trouble is, you may not have a full day’s work at the hospital,” she added.

While the hospital would take the risk for this, “what happens is you’re taking a GP out of the town, who’s being underemployed in the hospital, and not seeing people in the community”.

When the strain on GPs in rural communities was already significant, this might not be prudent, she suggested.

State-funded models could also lack some of the “continuity” of a private GPs and could “devalue” local practices, fostering “resentment”, as state-based GPs would be salaried for regular hours and would be able to provide entirely free services to patients.

For a state-funded GP model to work, it should replicate the “wholesale service” currently supplied by rural generalists and would require identification of local priorities and flexibility.

Funding models for rural generalists require a certain amount of “experimentation” as there’s not “one-size-fits all” solution, said Dr Christmas.

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