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GENERAL practice in rural Australia is on life support, says a leading rural GP, and the development of a National Rural Generalist Pathway is a critical step in its revival.
“It doesn’t matter where you go in Australia, general practice is struggling,” says Dr Ewen McPhee, president of the Australian College of Rural and Remote Medicine (ACRRM). “We simply aren’t seeing the translation of doctors into general practice, the subscription to general practice is falling across the board. But we know that rural generalism can turn that around. To maintain rural vitality, we need a rural generalist program nationally.”
Dr McPhee was commenting on a Perspective, published in the MJA, outlining the importance of a National Rural Generalist Pathway in truly achieving universal health coverage in Australia.
“We may have universal health insurance and world class hospitals, but without a health workforce that is appropriately skilled and distributed for equitable access in rural areas, universal health care is not a reality in our country,” wrote Emeritus Professor Paul Worley, National Rural Health Commissioner, and co-authors.
They wrote that Australia faced a dual dilemma of persistent health inequalities for its rural citizens and oversupply of city-based specialties.
“The current medical education system, focused on metropolitan tertiary hospitals, means that rural communities need to rely on a downstream trickle of doctors,” they wrote. “We can learn from the success of urban teaching hospitals and intentionally re-imagine our rural health services as locally led continuous rural teaching health service networks, developing their own doctors, creating relevant evidence for best practice, and producing high quality, cost-effective and sustainable health care.”
Royal Australian College of GPs President Dr Harry Nespolon said the RACGP believed that implementing the Pathway was an essential first step towards securing high quality health care in rural Australia.
“The development of the Pathway so far has been built on the knowledge and expertise of many different stakeholders involved in healthcare training and healthcare delivery in rural areas, and the evidence from many research papers exploring this issue in Australia. It draws on understanding gained from successful state and local pathways and builds a consistent national approach to tackle the issue of the maldistribution of GPs,” he said.
“The Pathway has a focus on flexibility, adapting to local needs, having a broad range of relevant skills and an increased time during training spent in a rural setting.”
Dr McPhee, a GP in rural Queensland, said a National Rural Generalist Pathway would seek to provide doctors who are interested in living and working rurally with an extended scope of practice to meet their community’s needs.
“These are areas where patients need specialist skill sets – such as obstetrics, anaesthesia, paediatrics, or Aboriginal health – but it’s very unlikely that you are going to find a specialist [who will] move to those areas, because of low volumes of patients,” Dr McPhee said.
“What this program does is to set up a framework of professional qualifications, where doctors are recognised as rural generalists, and a framework for how they might be remunerated and supported in those roles.”
Speaking in an exclusive InSight+ podcast, Professor Worley said doctors’ groups were working on addressing funding disparities.
He said rural generalists with procedural skills, such as obstetrics or surgery, were able to access procedural item numbers, but this was not the case for rural generalists with additional skills in consulting specialty areas.
“In the surgical area, you take a lesion off a person’s skin, whether you are a plastic surgeon or a rural generalist surgeon, you can use the same item number. Where that hasn’t happened is in the consulting specialty areas.”
Professor Worley said rural generalists who undertook additional training in psychiatry, emergency medicine, aged care or palliative care have not been able to access the same item numbers as their specialist colleagues.
“That doesn’t make logical sense in our current system, and the two GP Colleges[ and the [Rural Doctors Association of Australia] have been able to agree that that principle now needs to apply in consulting specialties as well as [for] procedural items.”
Professor Worley said the financial implications to the federal government of such a change would not be significant, but the implications for rural communities would be “profound”.
“You will then get a generation of rural generalists deciding to train in aged care, in palliative care, in mental health, in drug and addiction medicine knowing that they are not choosing to be the sacrificial lambs in terms of their incomes compared to training to do rural generalist obstetrics practice, or rural generalist anaesthetics practice.”
Professor Worley said a National Rural Generalist Pathway also had the potential to address some of the disruptions that young doctors now faced in general practice training, where they were required to move between practices and locations.
“It is one of the big issues that the rural generalist pathway seeks to overcome by having regionally based training for the entire length of the pathway,” he said. “It gives you the opportunity, if you need to and if you wish, to be able to have your family [and friends] based in one place … and build a life at the same time as you are building your career.”
Dr Elise Ly grew up in Melbourne and hadn’t heard of rural generalism when she graduated in 2005. She has now practised as a GP obstetrician in rural Victoria for 7 years and wouldn’t have it any other way.
“Rural generalism was what I naturally always wanted to do, but I didn’t quite realise it until I dabbled in a few other areas,” she said, adding that a posting to Cooktown in Far North Queensland under the John Flynn Placement Program first opened her eyes to the potential of rural practice.
Dr Ly said the National Rural Generalism Pathway would provide great benefit for rural generalists and the communities they serve.
“A streamlined pathway would provide support and advocacy for junior doctors to be able to become rural generalists, and the benefits of that are enormous; not just for the doctors, but also for rural Australians.”
She said the development of a Pathway is one part of a puzzle in addressing the inequities of access to quality health care in rural Australia.
Dr McPhee told InSight+ that the next step in establishing a National Rural Generalist Pathway was recognition. He said ACRRM and the RACGP had joined forces to apply to the Australian Medical Council (AMC) for recognition of rural generalism as a specialist discipline within the specialty of general practice.
“This is an important part of the work because without national recognition, it is hard to create a national identity and the correct framework around it.”
Dr Nespolon said in addition to working with ACRRM on the recognition of Rural Generalist medicine as a sub-specialty of general practice, the RACGP was developing a new RACGP Rural Generalist Fellowship which would replace the Fellowship of Advanced Rural General Practice.
Dr Ly was keen for the word to get out about rural generalism as a rewarding career path. She said there was still a perception, particularly among young doctors in urban tertiary hospitals, that rural generalism was a poor cousin to the more established specialties, and AMC recognition would help to address this.
“There is so much to love about being a rural generalist,” she said. “There are opportunities to travel and to choose your own adventure. There are opportunities to contribute to equity in our own country, and to see patients holistically and go on a journey with them.
“I look back and think why wouldn’t you choose rural generalism?”
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David An immediate task of the Rural commissioner, the Federal Government and ACCRM is to immediate recognize professionally the Gps who have already often as sole practitioners provided services which which have been more recently described as the rural generalist over a long period of time. If the doctor has worked in a rural and remote community for 5 years, has acquired skills in an emergency department in a major regional hospital, has acquired skills and an extended scope of practice. If these requirements are met then these doctors should be grandfathered in as rural generalists which include the APRHA recognition and a non restricted provider number. Fairness and equality is required not only for patients but for gps.
Describing the Australian healthcare system is a system is an oxymoron. What passes for a system, structures, the processes, and the hierarchies have never evolved beyond its 19th-century origins.
In the present day the most important level is Primary Care, and the most important practitioner is the Primary Care Physician/General Practitioner.
In the early 1970s, when I first arrived in England, I had to work as a locum in London so that my family and I could survive before I found my first hospital appointment. In the course of that locum I did stints in General Practice, Hospital A&E Departments, and even as a Consultant in Outpatient Departments of some of the great hospitals.
Having spent a year in general practice in Australia, I found London Metropolitan general practice and nightmare. 10 minutes were allocated for a “consultation”. It took me some time to learn that I was not expected to take histories, examine people, and reach medical diagnoses. I was there to provide sickness certificates, write prescriptions, and refer anything else to A&E at the nearest hospital.
When I was the locum RMO or registrar in said hospital, I was extremely busy dealing with referrals consisting of only a few words: “abdominal pain… Headache” et cetera. When I became the registrar at the Nunnery Fields Hospital in Canterbury, I met real general practitioners.
What reminds me of this experience from the past is that this is where Primary Care is heading in Australia.
We have better models and examples to follow. I find that the best quality General Practice, and the best Aged Care is to be found in one-practice country towns. This is a credit to those general practitioners and not the system, which fails to recognise the value that we are getting for a pittance, while we pay proceduralists and super specialists generously for only being very good at one thing.
I must hasten to add, that I would not be alive today without the quality care that I have received from super specialists and proceduralists. The workman is worthy of his hire, and we heap great responsibility and unreasonable expectations on general practitioners in many areas while failing to value their input.
In discussing the quality of the healthcare provided in residential facilities with some of the NGOs they have been offended by my remarks, and have pointed out that they provide high-quality healthcare. None of them have been able to show me where on the organisational chart the general practitioner appears.
This discussion is always tinged with the idea that GP proceduralists are invaluable ‘because of the relative lack of specialists in rural or regional areas (read: they’re not the best but we’ll take what we can get). The truth is, GP’s, procedural GP’s, multi-specialty generalists – call them whatever you like – should be regarded as independent medical practitioners with a valuable subset of skills unmatched by any other specialty. Their value shouldn’t be elevated or diminished based on the postcode in which they work.
There is an increasing number of regional centres that are losing the contribution of GP Obstetricians and GP anaethetists not due to a lack of GP numbers but rather a rise in the number of traditional specialists. What we’re then left with is more doctors, each with a narrower skillset leading to increased care fragmentation and patient dissatisfaction without an appreciable rise in clinical outcomes – maybe even the opposite.
Ever-narrowing scope of practice guidelines, GP-VMO contracts controlled by risk-adverse administrators and a few over-bearing, competitive specialist ‘colleagues’ are leading Australian healthcare down a dangerous path.
Let’s start, no actually, let’s resume treating GP’s like the backbone of the healthcare system they are trying to hold together.
I know it would be difficult for some to believe but I (like many a GP colleague) have actually delivered a baby, investigated a cough and managed some eczema all in the same day! 3 different body systems and not one referral. Who woulda thought it possible?
I work as a solo specialist Obstetrician & Gynaecologist in a rural area with a population of 40,000. The training of DRANZCOG Advanced rural generalists has resulted in a sustainable and cooperative obstetric service as well as contributing to the number of General Practitioners in our towns. The attraction of these doctors has maintained GP VMO services on the wards and the emergency departments within the hospitals. The theatres are staffed by rural generalist anaesthetists. This is invaluable to our community. I agree entirely that the range of rural generalist training should be extended particularly to mental health and paediatrics. An innovative model of care is required in rural areas to maintain GP VMOs within the hospital system providing services to our communities as well as attracting and sustaining specialist services.
It is clear that the work many rural GPs do in their consulting rooms is as significant & effective in improving the health & well-being of rural people but is not remunerated in the same way as procedural skills. There is no equivalent payment system compared to procedural grants for GPs eg doing Palliative care or mental health training.
When you look at all the consulting item numbers in the Medicare Schedule, it is clear that a specialist consultation is rebated differently to a GP item (even taking time spent into account). Is it time for consultation rebates to be the same regardless of specialty & that consultation, management & navigation of a patients health journey be seen as equally valuable as a procedural service?
Should all Colleges be reviewing their Fellowship training to have a “Rural Generalist” arm which acknowledges the broader skills & possibly even the combined skills required. Are Colleges acting as yet another set of silos rather than integrating skills to better serve our rural communities large & small. Fly in fly out is a valuable “bandaid” but not a solution.
I am very interested in helping out rural doctors,
as a locum as its too late in my medical life to
work F/T in rural areas.
If I could help, please be in touch. I’m capable of doing
minor surgical procedures O&G etc.