1 October 2020

Drastic changes needed to protect rural general practice

ACRRM Education RACGP Remuneration Rural

Katherine, the fourth-largest town in the Northern Territory, is set to lose its last private GP service at the end of the month.

With no GPs willing to step up, health groups are searching for more creative solutions.

The town’s last GP service, Gorge Health Clinic, caters mostly to the Northern Territory’s non-Indigenous population, with more than 7000 patients on its books.

For the past decade this general practice has co-existed with the care offered to local residents through three Aboriginal health services, and the Katherine District Hospital.

Perhaps surprisingly, the closure is not because there’s a shortage of doctors in Katherine, but instead because doctors are not willing to work in private practice.

The National Rural Health Commissioner, Associate Professor Ruth Stewart, says the situation in Katherine demonstrated the absence of economic and professional incentives for doctors in certain regions to leave salaried state-funded positions for private practice.

“There are doctors working in Aboriginal Medical Services, there are doctors working for Territory Health, but it’s private general practice that is really struggling to find staff and partners,” Professor Stewart tells The Medical Republic.

But when it comes to Katherine’s GP shortfall, Peta Rutherford, CEO of the Rural Doctors Association of Australia, has urged the Northern Territory PHN and the local general practice training network, to step up to the challenge.

“The PHN’s ability to support general practice outside of the two main centres in Northern Territory is pretty easy, considering there are only two,” she says.

While it isn’t the PHN’s responsibility to buy the clinic in Katherine, the network could help facilitate other creative approaches to supporting the practice.

Beyond simply subsidising more attractive salary packages for GPs, perhaps the PHN could invest in some creative solutions to make the professional experience of working in Katherine more valuable.

“It’s about being willing to think outside of the box,” Ms Rutherford says.

But the need to incentivise doctors into general practice is not unique to the Northern Territory – it’s a problem that has plagued much of rural and regional Australia for the last decade.

One major lesson could be to allow senior and junior doctors to share appointments.

This system is one that sees registrars work and complete training across both the hospital and private practice setting. And this flexible arrangement is one that many senior doctors also enjoy, allowing them to balance their interests in both in-patient and out-patient care.

“It gives a really good variety of clinical work and allows for continuity of care,” Ms Rutherford says.

“For a rural generalist it often provides general practice skills, emergency skills, and an advanced skill area.”

Another benefit of joint appointments is that junior doctors can retain their accrued leave entitlements from working in the state-based health system, while exploring a career in general practice.

While managing a rural hospital in Kingaroy, Queensland, Ms Rutherford saw the benefits of offering joint appointments first hand.

“We managed to recruit a lot of junior doctors by doing that,” she says. “[Losing these entitlements] is very much a disincentive to choose general practice as a career for a trainee doctor.”

Making the workforce arrangements more flexible won’t solve the entire problem though. Communities and PHNs will need to rethink the necessity of big capital investments by GPs.

The state may allocate funding to support the general practice by recognising it would reduce hospital costs, or it could be that the local PHN and communities themselves find ways to ameliorate those upfront costs, says Ms Rutherford.

After destructive floods in Charleville in southwest Queensland, the local council decided to fund the construction of the general practice and charge nominal rent for GPs to practise there.

Another example is Emerald, located in the Central Highlands region of Queensland, where the community secured $5 million in federal funding for a super clinic.

Now the community-owned clinic employs GPs, with the long-term doctor holding a senior role within the practice.

This approach allows the community to invest and build the resources of the practice, making it more enticing for GPs who want to go rural, but not for their whole career. Some doctors might live rurally for seven years, before making a decision to leave based on their partner, or their kids’ schooling, Ms Rutherford says.

“And that’s not just in medicine, that’s in a lot of professions. You’ll move jobs, and people are less and less likely to stay in the one job for 30 years.”

Sharing the care

Karalyn Huxhagen, spokeswoman for the Rural Pharmacists Network of Australia, notes other ways primary care providers were left to fill in the gaps.

When the general practice in the regional Queensland town of Clermont closed, the pharmacy established a telehealth-type area consult room and formed a partnership with a one of the telehealth GP practices, Ms Huxhagen tells TMR.

This allowed patients to have a consultation, after which the pharmacy performed tests, such as blood pressure testing, blood glucose testing and oximetry, that were requested by the GP.

“The GP would counsel the patient on what they wanted, and they would send that prescription back to the pharmacy,” she says.

But a major concern of general practice closures was the potential loss of patient records.

This problem arose in a NSW town after a GP left, and the townspeople worked with the local council to use one of the town’s buildings to form their own health hub. This building housed the residents’ patient records, as well as a physio and other allied health workers. The community was then able to bring in locum GPs for stints at a time, which helped prop up allied health.

Once a GP practice leaves an area, it’s very hard for allied staff to generate enough business to keep afloat, given they rely on GP referrals for their income, Ms Huxhagen says.

A meeting held last week in Darwin by the Northern Territory General Practice Education organisation, and attended by key stakeholders including the RACGP and ACRRM, discussed the need for bespoke models that would enhance retention of doctors in certain regions.

But trying to find the right model to support remote general practice is a “wicked problem”, says RACGP rural chair Dr Michael Clements.

“The whole point of the community-controlled health service is that each individual service gets to define its own way of managing problems,” he says. “But perhaps what we need to do is have a database of models of engagement across the country that practices can choose from. Because there’s not one solution that’s going to work for every town.”

Dr Clements says the RACGP will be developing supervision pathways more tailored to remote practice.

“We don’t normally allow trainees to spend their whole training in one practice,” he says. “But the Northern Territory is different. Sometimes the doctor might need to be working in a community where they have lots of supervision and colleagues around them, that are just not a GP supervisor.

“There are also times where a GP might need to be in a remote environment but be supported by telehealth and video links.”

One of the meeting’s other discussion points was the idea that incentivising doctors to work in rural and regional centres begins from the moment they start medical school.

This is why a focus in recent years has been the inception of rural medical programs such as that offered through Flinders University and James Cook University.

The retention of graduates from the first three cohorts of the Northern Territory Medical Program have been positive, with up to 75% now working in the Northern Territory.

Dr Clements says rural exposure early on showed that medicine in the bush can offer a fascinating, thrilling and rich general practice experience.

“We all need to see what we can do to expose people to [these experiences] through their training, because we know that once they’re there and experiencing it, retention will be good.”

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