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?”