Australia is the only country in the world with two colleges representing GPs. How did this come about?
It’s 30 years since Australian rural doctors banded together in response to an insulting pay deal, and 20 years since a bitter split with the RACGP that some say has left a few hatchets unburied.
The split in 1997 led, of course, to the formation of the Australian College of Rural and Remote Medicine as the world’s only rural-specific college for GPs, an event that has made Australia the only country with two GP colleges.
In another distinction, the nascent rural movement’s leaders decided to keep their political body, the Rural Doctors Association of Australia, apart from the academic arm.
“That was absolutely deliberate,” Dr Colin Owen, who was RACGP president before leading the split to form ACRRM, told The Medical Republic.
“We believed we should separate them. On one side, we have the industrial-political, and on the other, education and standards. The RACGP has tried to be political over the years, and copped flak for it. But we realised our college could not do that.”
The RDAA and ACRRM are still reaching towards the goal of having rural generalist medicine recognised nationally as a distinct specialty, but in this anniversary year there’s no doubt their efforts are paying off.
“We have made a dramatic difference to the landscape of rural practice in Australia and have got up a real head of steam,” ACRRM President, Associate Professor Ruth Stewart, a procedural GP and educator now based on Thursday Island, told The Medical Republic.
“I think the opportunities at ACRRM are to take the rural generalist program and make sure it is implemented nationally, so there is equity of access to health service right across Australia, which is not there at the moment,” she said.
“This is not about doctors doing what they want; it’s about providing health services for the community in remote and rural Australia. That is our vision and mission.”
ACRRM’s focus was on developing training pathways for GPs to have the competence and confidence to work independently in remote communities and other situations with little support, she said.
At the coalface, this means equipping doctors with procedural expertise such as obstetrics, anaesthetics and surgery. Advanced training in emergency medicine and mental health is also part of the mix.
Queensland, which formally accepted rural generalist training as a medical discipline in 2008, leads the way with its Rural Generalist Pathway, based at the Darling Downs Hospital and Health Service in Toowoomba.
This Rural Pathway had 270 trainees in the pipeline in 2016, up from just 30 in the inaugural group in 2006. Intern commencements last year numbered 77, nearly double the 2014 intake of 45, according to Queensland Health.
Slowly, but steadily, evidence had emerged of the program’s success in expanding the rural medical workforce, as in the availability of doctors to train students on hospital placements, Professor Stewart said.
“Last year Charters Towers had enough doctors for the first time. Cloncurry, Mount Isa, Longreach, Winton – these places are getting doctors, but not because they are compelled to go there. It is what they have trained to do.”
ACRRM’s research and training models are the object of admiration in Japan, Canada and other countries struggling with medical workforce problems. In this anniversary year, the college will host an international rural medicine summit in Cairns in April.
Another sign that rural medicine in Australia is establishing a distinct structure to cater for a variety of needs is the change stirring in power circles.
In the coming months, the federal government will introduce legislation to honour its election commitment to appoint Australia’s first National Rural Health Commissioner. As a statutory position, it will have permanence.
“The commissioner will be both an advocate and a leader, making sure rural and remote health stays firmly on the government’s agenda,” Assistant Minister for Rural Health Dr David Gillespie told The Medical Republic.
Dr Gillespie, a NSW gastroenterologist elected to parliament for the Nationals in 2013, is only the second person appointed to a rural health ministerial role.
The first was the Nationals Senator Fiona Nash, who announced last June that the Coalition would get behind a national rural generalist program, promising “extra recognition and financial incentives” for rural generalists to help attract more medical professionals to the bush.
“Due to the limited availability of specialist doctors in rural and remote areas, rural GPs … require a significantly more diverse skills set, with the expectation of substantial after-hours service,” Senator Nash said.
“As a rural person who lives hours from a major city myself, I understand rural Australia requires more medical professionals and this pathway will help deliver them.”
At recent roundtable discussions in Canberra on the new commissioner’s role, Dr Gillespie outlined his broad responsibilities to provide strategies and recommendations to government.
“It certainly needs to be someone who can surround themselves with people with the opportunities to make things happen,” Dr Ewen McPhee, current President of the Rural Doctors Association of Australia, commented after the meeting.
“To some degree I believe it has to be someone who has worked in the rural and remote environment, rather than an administrator or a CEO. We want someone with that credibility across the whole spectrum.”
Dr Owen noted it would not be easy to find a candidate for the commissioner role with a health background who also understood the political system, but he welcomed the prospect of a new champion for rural patients.
“Before you can achieve anything in this politico-medical area, you need to have structures and access. What they are doing is putting those in place,” he said.
“The rural generalist movement is the best outcome we’ve had in the past few years,” he added.
“I think it will go national and make a tremendous difference to rural patients. And I think governments are supporting this because it’s in their best interests. If they can have more generalists performing procedures in rural areas in the primary system, it will save so much money for their hospital systems.”
Clearly, the cause has come a long way since the dark days of the NSW rural doctors dispute of 1987, when there was not even a list of rural GPs kept by the RACGP, the AMA or, indeed, by rural doctors themselves.
The dispute that created the rural doctor movement broke out when the NSW state government, apparently without care or consultation, slashed the after-hours rate for VMOs at rural hospitals.
At a stroke, the reward for rural GPs who got up in the night to attend to emergency hospital attendances plunged from $22 to $13-$15 per patient.
The state’s move was in lockstep with the federal government’s May 1987 mini-budget, which had axed the MBS after-hours loading with the intention of stopping city-based bulk-billing clinics reaping large profits for non-urgent consults.
But in an era when politicians spoke derisively of “greedy doctors”, the VMOs were so far off the political radar they were overlooked as collateral damage, and the NSW Labor government was unmoved by their plight.
“It was an insult. That got everybody’s backs up,” recalled Dr Geoff White, a GP in Manilla, northwest NSW, who later served as RDAA president at the time ACRRM was incorporated.
“Ambulance drivers – taxi drivers is what they were – were getting $100 for the first call-out and $150 for the second. A doctor would get $15 for the first patient, but if there was a second patient you’d get $26 for both.”
The rate had been cut earlier from $28, but was slashed again when no one important made a fuss, Dr White said. “Obviously, we didn’t want to walk away, but how else do you make them listen?”
The dispute, which took a year to resolve, taught the rural GPs they had to take hold of their own destiny.
“The college of GPs could not have been more unhelpful nor more antagonistic,” one of the lead negotiators, Dr Geoff Cutter, then a Bourke GP, told The Medical Republic.
“I spoke to the (RACGP) president at the time, Eric Fisher. He was abrupt, and basically what he said was, there is no role for the college in this, we are not a political organisation. Which I thought was laughable, because we all knew they were intensely political.”
The AMA was sympathetic, but AMA NSW president-elect Dr Bruce Shepherd advised the rural GPs they’d be better off standing up for themselves.
“He was a call-a-spade-a-spade type of bloke. He said he was sick of people calling the AMA and asking him to do something for them. He said, why don’t you get in touch with these other two guys who have called me, and do something about it yourself?” Dr Cutter said.
The others were Dr Paul Mara in Gundagai and Dr Chris Bowman in Tumbarumba. With Dr Cutter, they were nicknamed “the three musketeers” and were soon joined in the negotiations by Dr Bill Hunter of Moree.
To compile a database of names and addresses, Dr Cutter sat down with a map of NSW, circled the bigger towns and rang the hospitals. Within three or four weeks, he had spoken to most of the 480 rural doctors in the state.
“Morale among doctors was at rock bottom when we started,” Dr Cutter said.
The British immigrant GP – scorned by then NSW premier Barrie Unsworth in parliament as a “Pommy shop steward” – became the first president of the new Rural Doctors Association. The group began putting out newsletters and lobbying the media.
“With the government unwilling to negotiate, we decided the best way to do it was to collect signed, but undated, resignation letters,” he said.
“We collected them from the majority of rural doctors, and then we had the letters in our hand and we could say to the government, if you really won’t do anything we will date them and lob them in to you. Which is what happened.”
In the event, GP VMOs at a meeting at AMA House in October 1987 resolved to resign from more than 100 hospitals at 30 days’ notice, saying they would provide emergency care at no charge to needy patients in their private rooms where possible.
The standoff was resolved only with a change of government. The doctors’ grievances, along with proposed tighter gun controls, were two of the big election issues that saw off NSW Labor in 1988.
Meanwhile, Dr Owen had been representing rural medical superintendents in Queensland, demanding an award to improve pay and conditions. Enlivened by events in NSW, this group became the basis for RDA Queensland, formed in 1989.
In 1987, Dr Max Kamien had presented a landmark report on the recruitment and retention of country doctors in Western Australia.
The report, commissioned in response to rural doctors’ warnings to MPs in marginal seats before the 1985 state election, provided evidence that matched with the thinking of the fledgling movement.
“The Queensland and NSW people were politically quite active and pretty savvy, and now they had this WA data they could use,” Dr Kamien, now emeritus professor of general practice at the University of Western Australia, said. “The rural doctors made a case that their work was different – the content and the context of their work – from that of an urban or regional GP.
“Their motives were very pure. What they wanted was a training program that produced a doctor who could cope with that difference and who would provide the sort of care required by rural and remote communities.
“In working towards that case, they used data from BEACH studies that found there was only about a 10-12% difference in what they did – but that 10% came to 36 days a year, on which they were going to be in great anxiety and difficulty.”
The movement found a key ally in the form of Brian Howe, who was appointed health minister under then Labor prime minister Bob Hawke in 1990, and who provided funding for the first national rural health conference in Toowoomba in February 1991.
“That’s where we formed RDAA, on a Sunday afternoon in the back room of the Burke and Wills Hotel,” Dr Owen said.
“Brian Howe was extremely supportive. He believed that the rural doctors and rural people in Australia were the victims of social injustice… He was the first one who put it in those terms.”
Yet, while negotiations had been under way with the RACGP since 1990 on the idea of specific training and education for rural GPs, establishing a separate rural college was not on the agenda.
“RDAA believed the easiest way to set up education and standards for us would be to be part of a bigger organisation, which was the RACGP. That seemed to be the logical way to go,” Dr Owen said.
“The two things we agreed on were that we would set up a faculty of Australian rural medicine within the college and that there would be a fellowship awarded by the college which would be a fellowship of the faculty of Australian rural medicine.”
But after Dr Owen was elected RACGP president in 1994 on a platform to “cement” rural medicine within the college, those core agreements were voted down by urban-based representatives on council.
“Basically, I believe that the conservative members of the RACGP were in fear of the energy and enthusiasm of the rural movement at that stage, and they were especially fearful that the fellowship of the faculty of rural medicine would outshine the FRACGP because it involved extra training in extra areas,” Dr Owen said.
The rural activists rejected the counter offer – for a graduate diploma of rural medicine and a “rural faculty” – which they took to mean a downplaying of the rural medicine concept.
The decision to leave the RACGP – supported by two-thirds of the 1500 rural doctors in a plebiscite – was “an enormous risk” and caused much bitterness and resentment, Dr Owen said.
He believes the decision has been vindicated by the RACGP’s eventual move to upgrade the diploma to a fellowship of advanced rural medicine (FARGP) and a growing acceptance of rural medicine as a discipline.
“I think that’s accepted now. But in the mid to late 90s it was really hard going, we had a bad time politically. But I think the enthusiasm, energy, resilience and toughness of the rural doctors’ movement is what carried us through.”
Subsequently, further acrimony ensued on the rural doctors’ side when the AMA and the RACGP opposed ACRRM’s application to the Australian Medical Council for rural medicine to be approved as a specialty.
Nowadays, many doctors on both sides agree there may be advantages in having a single voice for general practice in dealing with government, and say they would welcome more cooperation between the two colleges.
But you don’t hear ACRRM doctors regretting their independence, either.
