7 February 2018

No crisis. Just challenges that can be met

General Practice Rural

This is an edited version of Dr Paul Mara’s address in November to mark the RDANSW’s 30th anniversary and the birth of a national movement.

After having my arm twisted severely, I agreed to apply for the job of Rural Health Commissioner.

At the age of 63 it occurred to me that this was the first job I’d ever had to apply for and I wasn’t real sure what to put in the application.

So I wrote about moving to a small country town with no money and a large overdraft having purchased a solo practice, with two kids and no idea what the next 35 years in rural practice would be like.

I added the long obstetrics nights, the anaesthetics and days on call without relief, difficulty with locums, the challenges and joys of working with a wife who was also a doctor, the farm, the cattle, the 60,000 trees, the two more kids, workforce projects and the viable models project, accreditation, and finally the awards and the testimonial to wife and family.

Then I thought, the job wasn’t about any one person but about the myriad of diverse communities out there, people in those communities and doctors who had taken up the challenge and often sacrificed to support those towns. So I wrote it all down: the towns I had visited, the people I had met, the doctors and nurses and health workers and researchers.

Dr Paul Mara

But underpinning it all was a common thread that had its genesis in the Rural Doctors Association and a dispute that lasted over a year and that changed the face of rural medicine.

So I told the story of the RDA.

How it was formed by two OTDs from the UK, Geoff Cutter and Chris Bowman. Geoff was working as a procedural GP in Bourke and Chris in Tumbarumba. The catalyst for the dispute was the removal of after-hours Medical Benefits Schedule loadings on which hospital payments in NSW small rural hospitals were based. We were all pretty much burned out and buggered, a disparate group of rural idealists, wanting to tough it out but with no support or sympathy from an unyielding bureaucracy.

I related the phone call from Chris wanting to form an association to fight the changes. I naively suggested that this was an issue for the AMA to address. I nevertheless agreed to go and meet Bruce Shepherd, then NSW AMA president, where I received my first and probably most enduring lesson in medico-politics. When we pointedly asked what the AMA was going to do about the government removing the after-hours loadings, he just as pointedly replied, “What are you going to do about it?”

It has to be remembered that in 1987-88 communication was essentially by landline and fax. There was no internet, no social media, no Twitter, no Facebook, no mobiles, no beepers or pagers. If you were on call you had to be by a landline.

Still, 100% of doctors in over 30% of towns across NSW resigned (as visiting medical officers), and, with a looming state election, communities and the press were on our side.

We had a number of meetings with the government. Geoff drove down from Bourke and met Chris and me, and we headed to Sydney. The only tape in the car was Alice’s Restaurant and we were still humming it when we saw the premier, Labor’s Barrie Unsworth.

There was to be no advance on offers already deemed unsatisfactory by the members, and so we walked across the road to the office of the shadow health minister, Peter Collins. There was a good feeling when I saw the certificates on the wall. Collins had been to my old school. He was sympathetic but with a looming election, I learned my second lesson in politics. He asked, “How long can you keep this going?”

So I wrote it all down there in the application, the words and music to Alice’s Restaurant, the certificates on the wall, the election and subsequent change of government, the negotiations to end the dispute, the RDA Settlement Package. Ultimately we won because the focus was not on doctors but rural communities.

I included all the presidents of RDANSW who had kept the flame burning, the iconic rural doctors who had dedicated years to their communities, and thoughts about rural generalism and medical migration.

The impact of the dispute and the formation of the RDA had ramifications that went beyond rural practice in NSW and also drove significant reforms in general practice. The first RDA conference in Mudgee hosted two delegates from Queensland, Col Owen and Bruce Chater. They went home and formed the RDA in Queensland and ultimately other states came on board. RDA became RDANSW.

The momentum continued. The Australian College of Rural and Remote Medicine was created. Rural workforce agencies were established. There was a rural family medical network.  Medical education and training was decentralised. Quotas were put on rural-origin students in universities, the rural incentive program created. Vocational registration, grants and loadings for procedural work and the practice incentives program all reflected the profile established for rural through the dispute.

Still, politics and bureaucracy failed to listen and tried to snatch defeat from victory with crazy policies such the implementation of the ASGC-RA classification system by the federal Labor government that saw small rural towns lumped in with major regional centres.

It took six years and a change of government to counter this scheme, with a combination of sustained political pressure, strong research from John Humphreys and his team at Monash, and a political ally with vision in our first Minister for Rural Health, Fiona Nash, who adopted the Modified Monash Model that reflected the reality of rural and remote.

All this went into the application, and eventually I came to the present and the current push for rural generalist pathways. The argument and imperative for a rural generalist pathway is couched in terms of the rural-urban practice difference, but in reality it is much more complex.

It took a month to finish the application. It was a thesis on the history and philosophy and personalities of rural practice.

I printed it out and it came to 523 pages and I looked at it on the desk and it occurred to me: How will I know if they actually read it?  So, buried on the 10th page, I said, “He attributes his choice of career in rural practice to a horse called Sospel”.*

Nostalgia is an unreliable mistress, but there are lessons we can take from the past.

Ultimately Shepherd forced us to take responsibility for rural practice and look in the mirror for solutions.

Chater always said, “Solve the problem but not the crisis”. This was the fairly cynical way of maintaining the focus on rural.

So what about the future? It is now time to stop talking about the crisis in rural medicine. Workforce supply has improved in major towns and regional centres. Rural practice is challenging but rewarding, and health professionals can make a real difference to those communities.

Difficulties still exist in finding sustainable solutions in smaller rural and remote communities but all of these problems can be solved with structural reforms and innovative models. We need to be bullish if we are to entice younger doctors to rural areas and not just talk about the problems.

We have reached peak incentives. The impact of throwing more money at doctors to entice them to go bush will be limited.

If we are to finally solve the problem of rural and remote medical workforce, we need to address the strong systemic drivers that support the geographical maldistribution. These include a training program that costs hundreds of millions of dollars to put even more doctors into oversupplied metropolitan areas. They include an open-ended fee-for-service remuneration system and a lack of any control on entrepreneurs or doctors opening a new practice wherever it suits. More incentives, concentrating on the differences between rural and urban practice, or a national rural generalist pathway will not solve those problems.

One of the first questions we were asked when we arrived in Gundagai, with two small kids in tow, a large overdraft and was, “How long are you going to stay?”. It’s interesting, but after 35 years the scepticism about the response has changed to some resignation. The question remains the same but with a slightly different emphasis. “How long are you going to stay?”.

At its heart, rural generalism is not about obstetrics and anaesthetics, as important and interesting as procedural medicine is. It is about the stories of our patients and communities. It is about how we, as rural doctors, nurses and health workers can impact on those stories and more about how we become part of the fabric of those stories.

Rural and remote medicine is not just about providing comprehensive medical services or continuity of care. It is about how we can grow our communities. You will have all seen the campaign from the Royal Australian College of General Practitioners: “I’m not just a GP, I’m your specialist in life”.

Behind the rhetoric of rural generalism or specialist in life, ultimately, we are talking about the same thing.

Could it be that for all the attempts at differentiation and highlighting the differences between rural and urban practice, now might be the time to work on what we have in common?

So there you have it.

There is no crisis in rural medicine, just challenges that can be effectively met through clarity of policy and sound policy initiatives.

It is the stories that define rural generalism. While it has been useful in the past to highlight the differences between rural and urban general practice, at their heart many of the issues are the same, and we will not solve the rural medical workforce problems unless and until we address some of the fundamentals in urban areas.

We have reached peak incentives. While better targeting of resources is necessary, just throwing more money at the issue will not lead to appreciable change.

We need to recognise that governments can only do so much. Their role should be in establishing the industrial, economic and structural framework that supports effective local action.

In the 1850s in Gundagai there was a major flood of the Murrumbidgee River that took out the town, at that time located on the river flat, and killed over 50 people. It was Australia’s biggest natural disaster until the Newcastle earthquake.

The heroes of the flood were two indigenous people, Yarri and Jacki Jacki who in the middle of winter, at night and in dugout canoes braved the raging waters to rescue over 20 people from their rooftops and trees.

In his book, Peter Luders, a long-time generalist vet in Gundagai, describes how Jacki Jacki had previously been seriously wounded in a dispute between local tribes. He was taken to the Gundagai doctor who shrugged his shoulders and said there was no hope and he was going to die. But Jacki Jacki was taken in and nursed by one of the settler’s wives and recovered.

I don’t know if Jacki Jacki’s actions during the flood were related in some way but I have a deep sense that what goes around comes around.

Finally, it is traditional when giving presentations such as this to firstly acknowledge the traditional custodians of the land and pay respect to elders past and present. Without meaning any disrespect, I have kept this dedication to last because I want us all to carry the story of indigenous disadvantage in our country, in our minds and hearts, as we go back to our towns and communities and continue to do what we can to close the gap.

* Dr Mara explains: 

When I was in my final year at school some of the boys thought it would be a joke to take me to the races. It was the Spring Carnival at Randwick. My mother dressed me up in a coat and tie and I had $4 to my name, which in those days was a lot of money. I paid $2 to get in and met my “friends” and asked what do we do now. They took me along the pre-race stalls and there was a horse with the interesting name of Sospel. 

I put $2 on Sospel and was immediately bagged. “Sospel was a nag. The only race it will win is to the knackery, it is 50 to 1, you are an idiot.”

So I sat by myself disconsolately in the stands, miserable at having blown all my life savings, and watched the first race. Sospel, of course, won. I walked home with $100. 

When I finished my final exams and got into medicine my parents bought me a second-hand car with the child endowment money they had saved, and with the winnings from Sospel I went bush for two months, hay carting, mustering sheep, shooting rabbits, swimming in rivers and loved the country and small-town country life. I resolved then to be a rural doctor.