Capping city provider numbers may make it worse

A Nationals MP's plan to get more young docs to go rural would probably just make general practice less attractive.

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Putting a cap on the number of Medicare provider numbers available in metropolitan areas is the latest proposal from Nationals MP Dr Anne Webster.

For some rural doctors, it’s new lyrics to an all-too-familiar tune.

Dr Webster (PhD) – who represents the large, rural electorate of Mallee in Victoria – put the motion to cap provider numbers forward at the Nationals Federal Conference earlier this month, where it received support.

While she hasn’t put a firm number on the proposed cap, The Medical Republic understands it would be close to 100 active full time equivalent GPs per 100,000 people.

The current average in metropolitan areas is 121 GPs per 100,000 people.

“Desperate times call for desperate measures,” Dr Webster told TMR.

“And the situation that we are facing in regional Australia in terms of general practitioners, or the lack of them, is a crisis and we’re heading for disaster.

“While that sounds dramatic, the fact is – this is dramatic.”

While Dr Webster is not a medical doctor herself (she is a former social worker who wrote her doctoral thesis on adoption), her husband Dr Philip Webster has been a regional GP going on 46 years.

Around two-thirds of the GPs in the Mallee electorate are over 55, creating a looming succession issue as some look to retire.

“We know that of the medical graduates that are coming through the system, only 13% are choosing general practice,” she said.

“And significantly less are going into regional practice. That spells a disaster in anyone’s terms.”

Dr Webster told TMR her capping proposal would only be a short-term solution and acknowledged the need for positive incentives for doctors to move out to the bush to sit alongside the more punitive initiatives.

“I’m not averse to carrots, not in any way, shape, or form – we need a mix,” she said.

“But I think we’ve just got to have some courage and make some tough decisions, and our metropolitan friends need to understand the disaster that is occurring in the regions.”

The proposal has not been met with enthusiasm, but not because there’s disagreement that rural and regional Australia is in the midst of a primary care workforce crisis or because no one thinks that radical solutions are needed.

Instead, the pushback is about the type of motivation on offer and how that shapes the perception of general practice.

“The reality is that general practice is not seen as an attractive specialty in the current climate,” National Rural Health Commissioner Professor Ruth Stewart told TMR.

“And rural is less popular than metropolitan practice in any specialty.”

When you have a combination of one of the least popular specialties and one of the least popular places to practice, Professor Stewart said, “you have a pretty difficult conundrum”.

“Adding disincentives around a practice does not make that practice more attractive,” she said.

“Compelling people to do things that they don’t want to makes them dislike that thing that you’re compelling them to do.”

Manipulating GP supply via provider number is not a brand-new idea.

Various geographic Medicare provider number models have been proposed in the past, ranging from schemes that restricted the allocation of provider numbers in well-serviced areas to government-run provider number auctions, as well as a sliding-scale price system where rural provider numbers were free and metropolitan numbers came at a cost.

Compulsory rural return-of-service programs like the Bonded Medical Program and the 10-year moratorium for international medical graduates are two functioning versions of provider number manipulation.

“In the 1990s, whenever what was then referred to as geographic provider numbers was mentioned, there would be a decrease in interest in general practice and particularly in rural practice because of the perceived risk that people might be stuck in rural,” Professor Stewart said.

RACGP president Dr Nicole Higgins, who works in the regional Queensland town of Mackay, said the college also opposed the idea of a cap on GP provider numbers in metro areas.

Her reasoning, like Professor Stewart’s, was that it put general practice in danger of becoming even less popular.

“This may make general practice a less attractive specialty if junior doctors feel they won’t be able to work where they want to, and it could therefore exacerbate workforce challenges because fewer junior doctors will want to become GPs,” she told TMR.

“Instead, we should be pursuing options to draw more junior doctors and GPs to rural, regional, and remote areas, and that includes strategies to attract, sustain and retain a strong GP workforce, as well as cutting red tape holding back more international medical graduates from working in Australia.”

As Professor Stewart would tell it, there is ample reason to be hopeful that the positive incentives for going rural and doing general practice that have been baked into medical training over the last decade will pay off.

“[There is] quite a complex series of things to be done and you’re swimming against the current, but when everything is lined up it works really well,” she said.

“James Cook University has demonstrated that particularly in the alignment of the terms … [for the] medical school undergraduate program and the JCU general practice training program.

“There is a very high instance of the fellowed graduates of that program becoming rural and remote general practitioners.”