Rural generalist the bush circuit-breaker

Healthcare in regional Australia is at a crossroads.

GP Sarah Koffmann, who returned to Bathurst, says there are opportunities to make a difference in regional centres. Picture: Graham Schumann

Healthcare in regional Australia is at a crossroads, with the biggest policy reforms this century and local innovation promising to fill the gaps in service delivery.

Having endured a prolonged doctor shortage, relieved only by imported medical graduates and the willingness of some to do more than they should, many communities face the prospect of having a stable workforce for the first time in decades.

Decentralisation is a challenge for all service delivery but in healthcare it is a life or death issue. People living in the bush have long had some of the poorest health outcomes, partly attributable to a lack of access to preventive, primary, specialist and acute care services. This is especially true in Aboriginal and Torres Strait Islander communities, where closing the gap has proved more difficult than hoped.

Stability of workforce would allow the health system to finally make inroads in the relative disadvantage suffered by some people in rural and remote Australia. The prospect of success, it seems, is in the hands of the doctors themselves.

The latest reforms seek to capitalise on the surge in Australian medical graduates. Rather than force them to work outside the well-serviced cities, there will be a broader range of incentives that make working in rural and remote areas more attractive. It is hoped this approach will bring lasting benefits.

National Rural Health Commissioner Paul Worley was appointed by the federal government 10 months ago with his first priority being to finalise the model for a rural generalist. The rural generalist — which Worley describes as a paradigm shift, even a circuit-breaker — is an emerging field of enhanced general practice, where a doctor is skilled to work across a broader range of settings and is more involved than a comparable city-based GP.

No longer will authorities simply try to get more doctors into areas of need, to replicate the situation in the cities. Instead, most rural and remote communities could be served by teams of rural generalists supported by visiting specialists.

Worley, who has strong backing from Regional Services Minister Bridget McKenzie, says the time has come to transform scope of practice for the benefit of the broader community.

“I think the time is absolutely right to be doing this,” Worley says.

“There is an overwhelming consensus that we need to be training our rural doctors in a way that equips them for the breadth of practice that they need to perform the services that rural and remote communities require.”

In some respects, the rural generalist model takes its lead from traditional bush doctors, some of whom have been willing, or simply compelled, to take on greater ­responsibilities.

That is particularly the case for maternity ser­vices, where the local GP may be involved throughout the family journey, especially if the birthing suite is suddenly too far away.

Bathurst GP Sarah Koffmann studied at the University of Sydney, then trained and worked in the ACT and the Northern Territory, before returning to the NSW central tablelands where she grew up. In Bathurst, Koffmann was able to complete her obstetrics training at the base hospital and also become a principal in the practice she first went to as a child.

She is on-call at the hospital at least one night a week and sometimes helps deliver the babies of women she sees as a GP, before following up their care in the practice. Koffmann is grateful for the opportunities Bathurst gives her own children, and the lifestyle they enjoy as a family, but says it is the local patients who make it all worthwhile.

“They are realistic in their expectations of modern medicine and often more accepting of life’s ebbs and flows,” she says of the 35,000-strong community.

“For me it is the human connection that I love so much about being a country GP obstetrician. I look after men and women who knew me as a child. I joke with the women that they used to change my nappy and now I do their Pap smears.

“The local mayor was my Year 7 geography teacher and stops to chat to me in the street as I bustle my kids off to the local eisteddfod. You can’t do the shopping without stopping to chat to someone you know.”

This personal approach, through continuity of care, helps deliver better outcomes for ­patients.

According to the Australian Institute of Health and Welfare, people living in very remote areas die 15 years younger than those living in major cities and also have 1.7 times the disease burden.

They also have a higher rate of potentially preventable hospitalisations — including through not having been vaccinated — but then have to travel further to reach hospital.

Even if a GP is available, access to specialists decreases the further you go from the cities, and that limits diagnosis and treatment ­options.

Worley says the new breed of rural generalists will need additional skills in other areas, such as mental health, aged care and palliative care, pediatrics and indigenous health.

“We are recognising a historic practice and expanding it to become relevant for the 21st century,” he says.

As training and workforce planning shifts its focus to west of the Great Dividing Range, a suite of reforms and demographic shifts promise to transform the health landscape. Medical students will be required to spend more time in regional and remote areas, and graduates will have more training opportunities there, as authorities try to entice them to go bush rather than force their hand.

In the last federal budget, it was announced a Murray-Darling Medical Schools Network, including Charles Sturt University, would result in 140 medical students studying in rural centres such as Bathurst and Orange.

That is another piece of the puzzle, helping to address the maldistribution that may linger after the doctor shortage is over, and will be accompanied by Medicare incentives and cuts to overseas-trained GPs in the cities.

Worley says the role of rural generalist — which is starting in medicine but also will be rolled out in other fields such as dentistry, nursing and midwifery — has proved attractive to medical students and graduates. Supported by technology, they can do far more than their predecessors, and certainly more than their counterparts in the city.

“Technology will enable them to not be confined to a single town but to have influence over an entire region, so their practices and networks extend over a region and they are no longer isolated geographically or professionally,” Worley says.

In the NSW budget in June, two-thirds of the hospital redevelopments or upgrades due to start this year, under a $550 million capital works program, were in regional areas. Federally, there are moves to expand telehealth services to help farm families cope with the drought, and the My Health Record potentially will help with the mobility of doctors and patients.

Doctors who are part of these communities, and committed to them, say they receive the same loyalty in return. Most important, strong doctor-patient relationships have been shown to improve quality of life, productivity and life expectancy, while also making best use of resources. For rural and remote Australia, the health prospects appear good.

Worley says, for some doctors, the call may come years after graduation, when they are trying to make their way in the city, perhaps struggling to find a specialist training place. He says rural and remote medicine is no longer a lesser option than city practice.

Koffmann says the GP workforce in Bathurst has benefited from more seasoned doctors doing succession plans.

But what is more remarkable of late has been the increase in new specialists, across a range of fields and able to serve the region. After talking to one of the new arrivals, she realised that living and working in the city made Bathurst look like the ultimate package deal.

“She pays half the amount on her mortgage per week than she did on rent in Sydney,” Koffmann says of the specialist.

“The house is twice the size. She walks to work and it takes four minutes. She says the town has everything she and her family needs. If there is something she wants that isn’t local there is always online shopping.

“What’s more, Sydney is easily accessible due to better cars, safer roads and a regional airline for those who can afford it.

“Sounds like an ad for Bathurst, doesn’t it?”