Introduction by Croakey: The Federal Government has announced a package of measures that it says will give general practices in towns throughout regional, rural and remote Australia “more options and a larger pool of doctors to recruit from”.
From the beginning of next year, regional and larger rural towns will have automatic access to the Distribution Priority Area (DPA) classification, which identifies locations with a shortage of doctors – making it easier for them to recruit international medical graduates and those under bonded service requirements, such as medical scholarship holders.
As well, the Government will provide “a significant incentive” for eligible doctors and nurse practitioners to practise in rural, remote or very remote areas of Australia, by eliminating all or part of their Higher Education Loan Programme (HELP) debt, subject to them meeting eligibility criteria.
The Rural Doctors Association of Australia (RDAA) has welcomed the announcement on the HELP debt, saying it could save junior doctors more than $100,000 each. However, the RDAA would monitor the impact of the DPA changes closely for unintended consequences “like the possibility of it draining doctors from remote communities to less-remote locations”, President Dr Megan Belot said in a statement.
“We also can’t afford to lose focus on training more Australian trained doctors, and creating the pathways and incentives needed to entice them to work in rural Australia,” she said.
The Australian College of Rural and Remote Medicine (ACRRM) welcomed both measures as “important steps to help address workforce maldistribution issues in rural and remote Australia”.
ACRRM President Dr Sarah Chalmers said the College looked forward to more initiatives being introduced in the lead up to the Federal Budget, which is expected in March 2022.
However, a powerful reality check is delivered in the article below by Mark Burdack, CEO of Rural and Remote Medical Services in NSW, who lives in Orange in the Wiradjuri Nation.
History shows the folly of narrowly focused incentives for the health workforce, and governments need to take more holistic, place-based approach to addressing rural communities’ concerns, he argues.
“We need to build an understanding that rural workforce shortages are in part a result of the failure to invest in community development in rural and remote communities because we continue to treat the problem as exclusively a ‘health workforce’ issue,” he writes.
Mark Burdack writes:
The Federal Government has announced a new package of individual incentives to get more Australian medical graduates to work in rural and remote communities. From January next year medical graduates can get their HECS debt paid off by the Government if they work for part of their career in rural and remote towns.
Given that individual incentives have done little to address the fundamental problems that lie at the heart of rural doctor shortages over the last 20 years, rural and remote people are likely to reserve their judgment on this latest plan.
For 20 years we have defined rural doctor shortages as exclusively a health workforce issue, and targeted an array of benefits to individual GPs and health practitioners through the health system.
Yet, over that same period we have seen the number of Australian medical graduates wanting to become GPs plummet to 15 percent, despite the fact that more than 85 percent of people rely on having access to a GP every year.
According to the NSW Rural Doctors Network, we have lost 600 GP/Visiting Medical Officers from rural and remote communities in NSW in just the last ten years.
Every year rural and remote communities welcome Australian medical trainees with open arms, only to see most relocate to the cities when they complete their training.
Undermining primary healthcare
The gap in health outcomes between people living in major cities and rural and remote towns continues unabated, and these towns are now almost completely reliant on an increasingly unaffordable fly-in, fly-out locum medical workforce that is contributing to the increasing fragmentation of care.
A rural locum GP/VMO can earn anywhere between $2,000 to $4,000 a day to work in a rural and remote hospital, which is pricing many rural and remote primary healthcare centres out of the market.
Yet it is primary healthcare that our communities need the most.
Very few rural and remote primary healthcare centres can generate this level of revenue through Medicare each day, particularly given the need to spend more time with chronically ill patients and small populations.
In some parts of rural NSW, hospitals are no longer collaborating as they once did with rural primary healthcare centres to attract and retain permanent GP/VMOs by sharing costs.
This has created an artificial market that forces primary healthcare centres to compete with well-funded local hospitals for the same locums, pushing up the price of services for everyone.
As the Christmas season approaches, 285 GP vacancies in NSW are currently advertised on the web site of NSW Rural Doctors Network.
Rather than this crisis bringing the sector together to find solutions, some have used this situation to argue to the NSW Parliamentary Inquiry into ‘Health outcomes and access to health and hospital services in rural, regional and remote New South Wales’ that rural and remote communities can no longer expect locally delivered healthcare and that the GP/VMO model is no longer viable.
But this simply shifts responsibility for the problem from governments to rural and remote communities.
In Australia, governments are responsible for ensuring equitable access to healthcare, regardless of where they live in the country. If there was a shortage of doctors in Coogee, would governments tell the local community that it’s their problem and they should lower their expectation of having local GPs and functioning hospital?
This approach also fails to recognise that the current situation is due in part to poor medical workforce policy decisions designed in our cities without any input from rural and remote people.
Learn from history
Focusing on incentivising individuals in the “health workforce” has not solved the rural health crisis in the past, so there is good reason to doubt that this new initiative will be any more effective.
The willingness of Government to put more funding on the table for rural and remote health is welcome, but the solution to the problem of attracting health and other professionals to live and work in rural and remote communities requires more than just individual financial incentives.
As we have seen before, increasing remuneration or benefits for one part of the national medical workforce simply inflates the market price for services across the country requiring greater incentives over time to maintain existing levels of service.
This is causing unsustainable growth in health budgets and creating a vicious cycle of cuts to local provision of rural healthcare, while fuelling increasing costs for locums, making it even harder to attract professionals to live and work in our communities.
A significant part of the problem is that rural health and medical workforce shortages are not fundamentally a health issue, and the solutions are well outside the expertise of the health sector.
These problems, whether it is teacher, doctor or nursing shortages, have arisen in part due to the policy of successive governments of ‘managed rural decline’ involving the withdrawal of traditional government services and supports from rural and remote towns, and centralising services in metropolitan and regional cities.
This has resulted in the loss of well-paying jobs and economic opportunity in these communities, contributing to the flow-on loss of local shops, services, healthcare and amenity.
Today rural community transport services in Lightning Ridge are delivered from an organisation located in Melbourne, and rural medical services in many vulnerable communities are delivered by a private company based in Sydney.
As a result, money that used to flow into rural and remote economies and generate jobs has flooded out of our communities taking with it the income that enabled local services to survive and prosper.
How are rural and remote communities expected to attract and retain a new teacher, doctor or nurse when there is no local supermarket, no local bank branch, the local club is closed, there is poor broadband access, housing quality is variable, medical practices cannot cover overheads and unemployment sits at 15 or 20 percent?
The more we let our rural and remote towns decline by withdrawing traditional social and economic supports that all other Australians expect and receive, the more we are being forced to use individual incentives to attract and retain doctors and other professionals to live and work in rural and remote communities.
This does not just impact of workforce attraction and retention. The removal of these social and economic supports is also contributing to an epidemic of chronic disease in rural and remote communities by denying rural and remote Australians the opportunity of a good education, employment and local opportunity which are well-known social determinants of health.
The more we pull out these supports, the more money we end up paying across the whole-of-government to fund interventions in these towns to address the adverse impacts on health, community resilience and economic capacity of poor decisions.
Sadly, these interventions are more and more likely to be delivered by large organisations that have “economies of scale” that are based in regional and metropolitan cities, effectively reducing the flow-on economic value of interventions for community development.
We need to build an understanding that rural workforce shortages are in part a result of the failure to invest in community development in rural and remote communities because we continue to treat the problem as exclusively a ‘health workforce’ issue.
There is emerging evidence, however, that shows that better integrated local approaches to addressing place-based determinants of health, and the place-based determinants of rural recruitment and retention, can be effective over time.
However, it will require a more thorough overhaul of our rural medical workforce programs.
Governments will need to return to a policy of supporting rural and remote towns and people by delivering services and jobs locally and increasing strategic investment in rural place-based community development to support attraction and address the social determinants of health holistically.
Rural health has hit the headlines of late following media reports about the deaths of the fathers of two prominent journalists which led to a NSW Parliament Inquiry into what is going wrong with our rural and remote health system.
The more than 700 submissions to the NSW Inquiry from rural and remote people, and rural doctors, highlight the extent of the anger in the bush about the centralisation and withdrawal of services and the lack of support for rural and remote development by successive governments at both a State and Commonwealth level.
A newly announced Senate Inquiry into rural GP services is likely to ensure that the failures of rural and remote health and workforce policy over the last few decades will remain in the headlines for the next year or more.
There will be no escaping the impact of the failure to effectively address the needs of rural and remote people. The deaths that sparked the NSW Inquiry have not gone away and will continue if we do nothing.
There is a positive opportunity from all this suffering to open up a new dialogue with rural and remote people about the solutions.
Rural and remote people know that our communities will continue to struggle with teacher, doctor, nurse and other professional shortages until we have a joined-up whole-of-government approach by the Commonwealth and State government, led by rural and remote people, to rebuild our towns as attractive places for people to live, work and be healthy
This year we learned much from the experience of Aboriginal and Torres Strait Islander people following the failure of the Closing the Gap strategy. If we want solutions to the problems of rural and remote health, we need to talk to the people who have a personal stake in getting to the right answers.
In response to the 12th Closing the Gap Report the Prime Minister said:
Despite the best intentions, investments in new programs and bipartisan goodwill, Closing the Gap has never really been a partnership with Indigenous people. We perpetuated an ingrained way of thinking passed down over two centuries and more, and it was the belief that we knew better than our Indigenous peoples. We don’t.
We also thought we understood their problems better than they did. We don’t. They live them. We must see the gap we wish to close, not from our viewpoints, but from the viewpoint of Indigenous Australians.”
This is the lesson we need to learn in addressing the appalling state of rural and remote healthcare in Australia.
It’s time for politicians and policy-makers to begin a new conversation with rural and remote Australians about how to fix the challenges in their communities.
See Croakey’s previous articles on rural and remote health.