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THE health care workforce in rural and remote Australia is “close to the top of the cliff”, according to one of the country’s leading rural health academics.
Professor Jennifer May, Director of the Department of Rural Health at the University of Newcastle, told InSight+ in an exclusive podcast, that it had “taken a long time to get here”, but that it was no surprise.
“We have to be very realistic about what the road is ahead,” said Professor May.
“From my point of view, living and working in rural Australia, we’re not in a very good place at all. It feels a little like [we’re] getting close to the top of the cliff. The ageing of our rural workforce is very obvious.
“The scope of practice of that rural workforce, both in terms of general practice and in terms of specialists and the generalist nature of the work that they have done, is not being replaced.
“In that sense, we’re sitting in a very difficult place. It’s certainly a place that if I project 10 years forward, I don’t see the workforce there to take it on.”
Professor May and Professor Anthony Scott, Professorial Fellow at the Melbourne Institute: Applied Economic and Social Research at the University of Melbourne, have written an editorial for the MJA that accompanies a four-chapter MJA supplement, called Building a sustainable rural physician workforce.
The supplement focuses on physicians who work in rural towns and cities and provide outreach and services to smaller communities.
The first chapter – “Characterising Australia’s rural specialist physician workforce: the professional profile and professional satisfaction of junior doctors and consultants” – by Associate Professor Matthew McGrail, Head of Regional Training Hub Research at the University of Queensland Rural Clinical School, and colleagues, reports that physicians who choose to remain rural have similarly high rates of professional satisfaction to their urban colleagues.
The second chapter – “General physicians and paediatricians in rural Australia: the social construction of professional identity” – by Associate Professor Peter Hill, from the University of Queensland’s School of Public Health, and colleagues, describes the “detrimental effects of rigid accreditation processes and the role of a pervasive culture of undermining” of rural practice and generalism, rather than them being valued within college structures and by health service employers.
The third chapter – “Sustainable rural physician training: leadership in a fragile environment” – by Associate Professor Linda Selvey, from the University of Queensland’s School of Public Health, and colleagues, discusses the importance of the fundamental role of leadership in showcasing and championing positive rural practice.
The fourth chapter – “Principles to guide training and professional support for a sustainable rural specialist physician workforce” – by Dr Remo Ostini, an Adjunct Senior Research Fellow at the University of Queensland Rural Clinical School, and colleagues, outlines eight foundational principles that should be used to guide policy.
Essentially, the sector needs students and junior doctors to have positive experiences in rural settings, and for GPs and generalists to have a career pathway that includes remuneration for experience, support for family, spouses, and children, and leadership that values generalism, the authors wrote.
“There are multiple stakeholders, and that epitomises our current problem,” Professor May told InSight+.
“The federal government obviously has responsibility for community care – for general practice – and also for medical student numbers.
“Our employers, our local health districts have major responsibility in most of Australia for training. And we have professional specialist training colleges, [which] lead the educational attributes and attainment of fellowship.
“It really requires all those three groups to be working on song with communities, if we are going to have a functional model of training in the health system,” she said.
“One of the difficulties over time has been the unintended disinvestment by one or other of those organisations, not realising that there are a whole lot of straws on the camel’s back, and when they fall out, the service will disappear.
“So it is no one’s full responsibility, but all of us have an important part to play.”
One key concept was the privileging and support of generalism, Professor May said.
“We need to buy in to the fact that as a medical workforce in general, we want [generalism] to be one of the hallmarks of how we think about our workforce.
“Now, I have to say, right at the moment, I don’t think as a medical community we are invested in that vision,” she said.
“While ever we’re not, while ever we don’t see the intrinsic value of treating people as locally as possible, to the widest scope of practice that is available, then I think we are going to struggle.
“We are asking for the whole system to pivot.”
The National Medical Workforce Strategy, which is in the final stages of review, “potentially provides a mechanism by which such principles can be used to implement new nationally coordinated policy”, May and Scott wrote in the MJA.
To InSight+, Professor May said:
“Without doubt the themes of that Medical Workforce Strategy must include the geographic distribution of our workforce, and generalism as a concept, and also the support and wellbeing of the medical workforce.
“I’m confident that much of the impact of the Strategy will be around its capacity to influence as opposed to its capacity to mandate.”
Continuing to communicate about the maldistribution of the rural medical workforce was critical, Professor May said.
“The fact that we’re talking about generalism, and its importance to the medical workforce, is incredibly important valuable.
“That discourse is primary to anything changing.
“If we leave the medical workforce as it is at the moment, we are going to get stellar performance from that health service in certain areas, yes.
“But we are going to leave a large amount of our population behind with easily preventable and avoidable harm that will come to them because of the distributional issues that underlie our workforce.”
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Letter to Greg Hunt and all health ministers a few weeks ago –
Only one bothered to reply and that was just fluff as usual …
I believe action must be taken by yourself and state ministers, to stem the tide of burgeoning bureaucracy in the health system, and also reorganise the regional rural and remote regulations, requirements and reimbursements and so on.
One critical area is the supply of rural doctors (often “Locums”) as no one wants to go to these places. It is becoming almost impossible to get permanent staff to some regional and remote areas of Australia.
I have been doing locum jobs for 15 years, and in this time the amount of “paperwork” required has grown exponentially, to the point where I feel it is simply not worth the time and trouble to do them any more.
In 2006 only 8-12 pages was required PER JOB, even if for just a weekend.
Now in NSW it has exploded to over 64 pages, plus notarised copies of all degrees and registrations, FOUR types of notarised ID, lots of questionnaires, proof of all immunisations for a lifetime, and 12 online “learning” modules! Dumbed down content and insulting to most doctors I am afraid. And a police criminal check, usually a NEW one as they expire regularly. Also a “working with children” check , why they are not combined makes no sense, just more time, forms and fees. Plus they are SEPARATE for each state (!) which is ridiculous considering their function is to prevent child abuse, when all a perpetrator needs to do is move to another state – which has still occurred even recently.
It would take 2 days to complete this redundant information which is actually available elsewhere – AHPRA etc – supposed to make it more efficient and easier but the complete opposite has happened. I have had to submit unchanged information up to 50 times previously, even to the SAME hospital worked at not long before! Don’t they keep any records of this kind of thing? If not, then why bother collecting it??
Along with this onerous imposition, the supply of multi-skilled generalists is rapidly declining as we are all retiring early – like myself, partly because of the above.
Older doctors have also grown up in a time where super-specialisation hardly existed. These days, for example in my own field of anaesthesia, many won’t or cannot do obstetrics, or children. Or even if they can, or have done enough previously, they are not currently “accredited” for these, thus “forbidden” to do it, meaning kids have to fly long distances for a simple procedure. A chicken and egg situation really, classic catch 22 in action.
“Not allowed” to do things (by administrators) also means you obviously deskill rapidly, lose confidence and never do it again. Hence you can’t do Locums really. Both these areas are higher risk and involve a whole lot more night call, as does any emergency work too of course.
Why bother with all this if you can have a quiet civilised life doing private practice in the city, with minimal night or weekend call and a MUCH greater income as well. Culture, coffee, good schools , great food etc – why go to the middle of the desert with none of these, for less money and way more stress. Actually locum RATES have also NOT increased since 2006, in fact have gone DOWN in most places! Why ?? I suspect the “extra” has all gone to scrutinising pen pushers, risk “managers”, and form creators, as well as the huge number of locum agencies who get a large fee for trying to source people and navigate through the festoons of documents. Though it ends up being the doctors who have to do it themselves again and again, until – well, NEVER again, sorry. Bizarrely NO ONE cares, including yourself it seems.
Doctors aren’t going to bother with rural work ESPECIALLY with all these hurdles and hoops being continually created, in an insane system with no forethought to the consequences of their desk bound mania for complicating everything beyond belief. Any business would have gone broke years ago with this mentality. You, and we, are supposed to be IMPROVING productivity and efficiency not deliberately thwarting it, wasting massive amounts of clinical time and frustrating everyone on the coalface, as well as patients.
The size of patient documentation and risk management checklists etc has also blossomed way out of control over the years in a similar fashion – from a page or two to dozens now. GO check it out yourself, I can show you if everyone else is too cowed to do so. A nurse can take up to TWO HOURS to “admit” a patient, something that would have taken a few minutes years ago. Ironically nurse numbers have been tragically cut meantime, making them work harder and harder for historically low pay, yet still feel the brunt of any bad outcome = nowadays automatically an“error” or “mistake” for which a scapegoat must be found and ritually sacrificed on the altar of politics and media. Even publicly humiliated or sanctioned (AHPRA), as its always a nurse or a doctor’s “fault” – not the system – which it usually actually IS. Not something that most online “learning” modules will solve either, nor electronic medical records, nor more copies of documents.
Smaller places NEED competent, confident practitioners who can manage everything that comes through the door. In may places there is no cardiologist, neurologist, gastroenterologist, dermatologist, ENT surgeon, and many others. Very few doctors feel comfortable to manage most complex patients so they just send them to a seriously overburdened tertiary hospital. Usually flying long distances on RFDS etc where they could have been treated locally – or not even sent at all ,as they have terminal illness sometimes PLUS dementia and in their 90s. Palliative care and geriatrics anyone? Hell no, not even good (or any?) GPs now in many places, usually locums also with no skin in the game, just a bum on a seat.
Often nothing significant is done for them in the city, sometimes leaving them to die alone, a long way from home. Vastly increased emotional and monetary costs from all this, and this should not happen but it does many times every day.
And psych? Even more dismal, massive numbers increasing all the time and often flown out for things that could be locally managed or with Telehealth and local mental health teams who have also been slashed.
As a lapsed country doctor and rural health academic, I agree and reinforce the fact that we have spent long enough identifying the problem(s) and making various recommendations. The solution is political and requires political will and leadership across all sectors of society. That depends on votes – and that means the rural and regional community.
The state of politics in Australia emphasises the rural-urban divide, explicitly with the Coalition and implicitly with Labour. This plus the “political left and right” divide is enough to ensure that nothing will be done to encourage our younger health (and other) professionals to populate the bush in sufficient numbers to make a difference to encorage politician to work across the divides to solve the “recruitment and retention” problem.
Perhaps the information and communication technologies plus the culture change initiated by COVID-19 may provide an impetus.
I am not sure whether to laugh or cry in response to this article .I have worked as a country gp / vmo for a very longtime This discussion has gone on all of my working life . I often wonder why country people pay the medicare tax they get very little for it compared to city folk. The argument about fixing it from a medical perspective simply has not worked Governments of both persuasions couldn’t give a toss
Talk to Barnaby about how country people are being shafted due to lack of medical services discrimated against etc It is always about votes for politicians regardless of their rhetoric . BARNABY needs to be involved informed of the impending crisis Shooters and Fishers etc Country voters need to ask their respective potential politicians how they will get doctors to their towns & vote accordingly
Yes there are a few of us ‘jaundiced’ rural practitioners willing to vent our collective spleen!
I am not sure if these ‘essays’ pertain particularly to Physicians who work in rural settings, or generalist family doctors in rural communities.
I am physician who tried to obtain a broad subspeciality exposure with a view to returning to my home town and practicing as a Generalist at the local hospital. Unfortunately, my experience, which included management of Acquired Brain Injury and Behavioral disturbance lead to a dispute with the hospital administration when I requested a patient with a frontal lobe full of contusions and in Post traumatic amnesia, have nurse specialist [ie 1 to 1 nursing] as the patient had already started roaming the medical ward and was interfering with other patients! [The tertiary referral center declined the patient…’nothing we can do for them’]
The nursing administration complained that this was a reprehensible abuse of the Nursing budget, I was summoned to the Medical CEO, denied any professional representation, and told that if I did not rescind my request for one on one nurse supervision I would be ‘sacked’
Never the twain shall meet…….
Lets face it, over the years that I have practiced Medicine there is increasing physician ‘bullying’ – Surgeons etc. are considered essential because that is where both public and private hospitals make their income. The Generalist Physician is relegated patients that no one else is willing to look after; patients that create ‘bed block’, who often represent and represent. Tertiary Center are not interested in helping out their Rural colleges!
The Generalist used to have a bit of a guaranteed income by being the ‘Clayton’s’ cardiologist! Now more and more waves of Cardiologist are moving to rural settings to be able set up ‘profitable practices’ .
We have sub specialists running the General Medical Wards, I despair at the number of patients who go without diagnosis and appropriate treatment when they fall outside of these Physician’s area of expertise. Its a bit of ‘dumbing down’ of Medical Care in the country [possibly to reduce health costs] leading to country folk receiving ‘second rate’ health care.
Sorry, I and my colleges have so much misadventure to be anecdotal about!!
This looming ‘cliff’ was already being highlighted for those who chose to look well back in the 1970s when I was a bonded state fellow who had survived at an undergraduate level on that particular type of scholarship. Bonded doctors were then controlled by iron fisted authoritarian health bureaucrats threatening future registration blocking in all states and NZ for anyone daring to break or even trying to renegotiate their bonds (some up to 7 years).
At least city general practice back then (pre-medicare) was widely viewed as a worthy long term career whilst rural practitioners with the right of private practice earned enough to offset all the same persisting obstacles and life-style demands listed above. It is the remnants of that particular hard working dedicated demographic cohort that are now retiring after decades of having had their intrinsic worth and importance being constantly and ruthlessly devalued by government treasury decisions (e.g. the unjustified constant recurring Medicare rebate freezes etc) as well as by the splintering of coordinated and holistic medical practice through licensing nurses and chemists to undertake hived off services deemed cheaper. (Ex Labor Health Minister Senator Roxon with the Nurses Union agrrement).
All the academic treatises above do miss the point and obscure the two key issues.
1. Primarily, it is now the poor level of remuneration that is pointing the way to the cliff’s edge. It is that exactly which defines your value in the eyes of the community and it should reflect the academic work (at least 10 years study) and dedication. Medicare has reduced highly professional medical care to being seen as ‘free’ and like everything free not valued.
2. Secondly, being actually respected as a dedicated person and recognised as a critical cog in medical practice in this country by politicians and not just a poorly remunerated semi-indentured and mendicant worker at the end of a massive bureaucratic food chain who can be treated as a constant source of cheap labour with no political blow-back to worry about whatsoever.
Stark Fact: The number of graduates opting for general practice as a career is now in free fall at only about 20%. Given this stark figure then the chances of country and region people ever being treated and cared for by adequate numbers of doctors in their communities will simply not happen unless a major political redress is made at a very senior Federal political level.
Political activism rather than never ending Committee reports and academic papers is what is required. Get the National Party and all other cross-party regional politicians to act or threaten their seats. The ‘Hunters and Fishers’ seem to have traction for whatever reason.
One of the greatest inhibitors to General practice anywhere, is the emphasis on Psychiatric problems in patients, for which treatment is very unrewarding , very time consuming, and very “hit and miss”.
Not many of our generation (graduates of the 60’s) were ever enamoured with Psychiatric medicine (4 lectures in 5th year ! )
One of the attractions to medicine, in “the good old days”, was that you had a physical problem eg. appendicitis, cholecystitis, fractures, obstetrics, etc., to name a few, and you could solve it, or at least you had a fair idea of what you were dealing with, and what to do with it.
Todays’ “entitlement generation”, and drugs, has made “bush”practice, unsustainable and unrewarding, clinically, financially and mentally (?).
The abuse of Doctors in ED, the treat me for “nothing”obligation foisted on one by the patients (not all ), the constant threat of litigation, soon tires one of the “joys”of bush practice.
Is it any wonder ??
RACS Represent, select, train, retain, and collaborate for rural practice is a big step in the right direction and Dr Bridget Clancy and her Rural Surgery Committee should be commended, however, there are many players who are benefitting from current restriction of training and subsequent outsourcing of medical workforce. The key is to find Australian trainees (including the unaccredited “ghost generation”) who are genuinely invested in solving the problem and ask them what they think is needed. After all, it is the younger doctors who will have to sort it out eventually if it doesn’t undergo much needed reform.
There needs to be a rapid and immediate expansion of the Integrated Rural Training Program, whereby Advanced Trainees do 2 of their final 3 years in a rural setting. Only with more trainees spending significant time in the country (and therefore not putting roots down in the city), do we have any hope of encouraging them to stay. Students training in the country may wish to return, but are forced back to Ivory Towers to train, where their Registrar positions are numerous. More appropriate training could and must be funded away from metro areas.
In a word, yes.
For years I have lamented the decline in numbers of general physicians, and the falling regard with which GPs are held. From 2002 to 2018 (ie. 16 years), I conducted a psychological medicine specialist clinic at Coober Pedy, 850Km north of Adelaide. Since October of 2018 when I had to relinquish my contract with the Rural Doctors Workforce Agency on the grounds of serious ill health, there has been no replacement. Which is sad as the longest serving local GP with whom I most often worked, in an occasion communication tells me, “the patients still miss their appointments with you.”
My wife and I, both >40 year veterans of rural health care as GPs, GP educators, GPR examiners, one a VMO the other an ACRRM senior examiner , are about to step off the precipice of that “cliff” into retirement leaving a town that is dire short of continuing experienced and trained to local standard GPs. Our practice’s efforts at succession planning have been thwarted by the very things mentioned. Downplaying of generalist medicine by narrow specialist colleagues and health services has redirected interested GP candidates back to hospital centred care. Even in GP with the increasingly fragmented role delineation and super specialisation at all levels for medical graduates such that they do know ” everything about nothing” instead of the once lauded role of GP “knowing nothing about everything” there is a barrier to a cradle to grave family medicine practice. Rural “down the street” even without VMO practice should at least be able to try to care for all comers and, if needed direct them to the specialist/narrowist advice of other area limited colleagues.
The process for helping local GPET associated registrars become selected and placed in suitably supported training sites is challenging but nothing compared to the hurdles of helping suitably trained and keen IMGs to find roles after the state and commonwealth authorities have established the direction and number of hoops to be jumped/stumbled through. We have struggled to coordinate the AWS, RMMR,DPA etc etc whilst missing out on good, coachable candidates courtesy to this somewhat opaque system. Twenty years of striving to maintain services and organise a succession plan leaves us exhausted with no relief in site despite forestalling retirement over the past 3 years.
We have been very fortunate and fulfilled by our work in our community but would prefer not to “die in the saddle” as there may be more to life.
Disreguarding medical directives is the greatest threat to a major outbreak !!