Introduction by Croakey: The general practice workforce crisis has been the focus of much recent public and political debate; however, many other areas of the health and aged care workforce are also under extreme pressure.
Emergency medicine specialist Dr Simon Judkins recently conducted an informal survey of half a dozen colleagues regarding emergency department workforce concerns in regional and rural areas in Victoria.
He reports below that there is widespread disappointment about the lack of attention to these pressing concerns in the Victorian election context.
(And for other rural health matters, follow #RMA22 for news this week from the Rural Medicine Australia conference co-hosted by the Australian College of Rural and Remote Medicine and Rural Doctors Association of Australia.)
Simon Judkins writes:
“Unfortunately, there have been no applications for the Consultant job we have advertised. We will go around again and keep our fingers crossed. It’s incredibly disheartening – we are busting a gut out here. It’s a great place to work, but we are really struggling to provide the level of care and expertise this community needs and deserves.”
This was how a rural Emergency Department Director described the response to a recruitment ad for staff in their ED.
This pretty much sums up what is happening in many rural health facilities at the moment. ED Directors, nursing managers and others in different parts of our health system are working hard to try to find staffing solutions.
We keep advertising, calling, using locum agencies – at an incredibly high cost – trying to work through the challenges of recruiting health workers from interstate and overseas, and we keep our fingers crossed that change will come soon.
Every health service in all states and territories has been experiencing a staffing crisis that has been exacerbated in recent years by the pandemic.
While there have been some significant investments in our health system in response to the pandemic, these generally have been very focused on metropolitan services.
And with the massive hit that healthcare workers and systems have taken during the pandemic, rural healthcare – which started from a position of neglect and chronic under-resourcing – has fallen further behind.
Just as we have seen the health and wealth gap increase over recent times, we have also seen the metropolitan and rural divide widen in health. While it is recognised that city and suburban health services have been impacted significantly, the further away from the CBD you get, the harder it is.
To get a feel for what the issues are, I spoke with about a dozen clinicians working in regional and rural EDs across Victoria.
I asked about how significant the challenges are and how much support they have seen (or haven’t seen) to support a transition out of the current critical state.
I also asked what focused investments are needed to enable them and the wider rural health systems to build back better.
Clearly, conversations like these are sensitive, so I have de-identified the individuals and the services they work for. It’s a disappointing situation where, to be heard, you feel like you need to be anonymous. But, of course, those concerns are understood and respected, especially when many employment contracts and conditions can make it difficult for those at the frontlines to speak up safely.
The conversations focused on where investment is desperately needed in regional and rural health, in relationship to EDs and the issues impacting care.
Although there have been a couple of announcements regarding some new developments, and a recent tweet from the Victorian Health Minister regarding investment across different areas, the feedback to this news has been very guarded.
Under-investment in hospitals and ED capacity was a very common theme, many developments are very slow to progress and, those that have progressed have run out of money, delayed by COVID, and associated cost increases.
Not fit for purpose
“We are living through the longest renovation rescue one could ever imagine,” one of the clinicians told me. “It’s a chaotic work environment every day.”
Another tells me that the service they work in is recognised by all as way past its use-by date and, despite all attempts, nothing has been announced regarding redevelopment.
“We see a large and growing number of patients, our department is tiny and not fit for purpose. And yet, while we have seen a large number of announcements about Royal Melbourne Hospital, Melton, Maroondah and Monash, we have been seemingly ignored.”
But it is more than just the buildings. For many years, rural facilities have been asking for several other infrastructure investments to improve access to care, resources, and information-sharing.
One colleague said: “Lack of IT infrastructure and support is a big issue which is not receiving enough attention. While we see huge investments in IT support at tertiary hospitals, rural facilities, which could reap the largest benefits from good IT systems, have virtually nothing.
“What we do have is poorly structured, bits added here and there over time, with no coordinated approach. There does not seem to be any plan for an integrated IT system to assist in information gathering, accessing health records, and assisting referral process/ patient transfers. The longer we wait, the further we will fall behind.”
This was agreed universally. Another colleague said: “We are still reliant on chasing paper, faxing, and referrals and medical reports. Things go missing. Doing good quality audits and case investigations are so difficult without a robust and effective IT system. We are working in the last century.”
So many pressures
Staffing, across the board, keeps everyone awake at night.
As one colleague said: “There has been a significant deterioration in the last 12 months. The workforce is heavily reliant on locums, who are more difficult to attract. Costs are escalating because of the competition. The staff we have are exhausted.”
“I feel like I can’t take leave,” says another. “I’m constantly filling in gaps on the rosters, so what will happen when I do go away? Who is going to come in to cover a sick call, or a locum shift when the person we were waiting for pulls out at the last minute ? If I leave, there is no-one.”
Another director tells me that: “I can’t get any of my administration work done as I’m constantly filling in gaps on the roster. This means I’m falling behind in all the other work I need to do to keep the place running.”
Ironically, this “other work” includes trying to recruit doctors to fill the gaps he is currently filling.
This is all amidst increasing presentations: “…access to community care is an additional problem, so more people are coming to us. The hospitals are full, so more are staying 24 hours. Staff are leaving or reducing hours; it’s a vicious cycle.”
Concerns were also raised regarding the increasing costs. One colleague told me: “We work in an area which is socially and economically deprived anyway. So, with worse access to GPs, less bulkbilling, greater out-of-pocket expenses for specialist care (and months waiting), more people are turning to the ED. They are very apologetic, but they have no other options.”
There are significant concerns regarding the retention and recruitment of staff in the primary care/GP sector where “it’s been almost impossible to recruit” and the impact on community and the flow-on effects to the local hospital and ED are very concerning.
“We really need to step outside the box to create incentives for more clinicians to move to regional and rural areas.“
Suggestions included offering more attractive packages (industrial/education/upskilling/family) that are significantly better than what’s on offer in metropolitan EDs.
Another rural clinician said: “Although emergency physicians and hospital doctors in subregional sites have the AMA EBA, this needs to include much better incentives for rural (loadings in the order of 10-25 percent). Smaller rural sites have no access to awards.
“Also, rural GPs working as VMOs desperately need a state-wide award which offers them some security and fair conditions, with scaled incentives which increaser with distance or isolation from metro centres…the devolving of governance to local sites has had a generally negative impact on working conditions.
“Currently, new services in metro areas like the telehealth providers, are acting in direct competition for limited staff. This will see many clinicians choosing to work from their living rooms, so why travel three or four hours from home and have to stay away from family? How can we compete with that when the pay-scales are virtually the same?”
Some colleagues suggested partnering with metropolitan health systems and having co-contracts with additional incentives for time spent in regional areas and contracts stipulate rotations to partnered regional areas at senior and junior levels. However, this would have to be supported by the large metropolitan facilities, which are also struggling to maintain their staffing levels.
Scaled financial incentives increasing with distance or isolation from metropolitan centres may help. This should not just be hospital-based but should be strongly advocated for GPs specifically as well.
Concerningly, most colleagues did not feel optimistic about whether the needs of regional and rural areas would be met.
Said one colleague: “Regional and rural care never receives adequate attention and funding, and this election has been no different. Unfortunately, rural medicine is not very sexy when it comes to elections, and it often just highlights the limited resources offered to small regional centres.
“We all have hoped that our politicians and policy developers will see beyond the outer suburbs of Melbourne, the borderline electorates and will start to actively engage with rural clinicians and providers about what will make a difference. But we need more than hope; we need a bit of help also.”
Dr Simon Judkins is a regular contributor to Croakey and works in rural Victoria.
See Croakey’s archive of articles on health workforce matters.
One of the big problems in recruiting in rural areas is the lack of other doctors. It can mean no time off. No one to discuss cases with. Terrifying to a younger doctor.
Overseas locums i have talked to consider they are very lucky if there is a hospital with specialists to talk to within an hour of their practice.
I understand that your premier has announced the biggest hospital development in Australia! Like it’s big and beautiful with lots more beds. I hope he will also have enough staff to use the beds.