Rural maternity services: It takes a team to make it work
Dr Ayman Shenouda
Timing is everything - this is particularly true in healthcare - and in birthing services right now, it’s actually getting quite critical for GP obstetrics.
For the rural GP obstetrician, the discussion is no longer about a rebirth of rural obstetric services for rural areas but in has moved rapidly to the preservation of this critical role.
Two key discussions are occurring in obstetric care in Australia at the moment both lacking one vital component and that is valuing the key role of the GP obstetrician in providing this care.
The first, occurring at the national level, in setting national directions for maternity services prioritises access yet omits GPs almost entirely despite their reliance in rural and remote areas.
The other discussion involves a state-led shift in WA towards a new model of care which seems to locks GP obstetricians out completely.
We are seeing spot fires right around the country including in northern NSW but on a slightly different front in resistance of midwifery units to GP involvement.
Combined these are worrying developments and it is clear that major change looms unless we can work to reframe the discussion.
We have the solution
The vital role of the GP obstetrician has to now dominate the national discussion and the National Rural Generalist Pathway is the connecting policy thread here.
We are now at a critical point in building a future rural workforce which offers a single solution by factoring together all the required enablers in one.
The vital work done over the last twenty years has shown us solutions which brought together in one pathway will offer a sustainable way to address rural health needs.
It’s a model that will work – one that prioritises the skills needed – which are reflective of local health needs with the required training supports embedded.
This is a model that brings flexible models of care bridging the primary care and hospital care continuum – it’s based on community need.
And it provides a way to keep it sustainable by enabling a highly skilled GP workforce integrating primary, secondary and tertiary care skills.
But it is reliant on enabling infrastructure too and in keeping it sustainable and so much is connected to a town’s capacity to preserve procedural services like birthing.
State of play
Here’s a brief outline of the current state of play.
Round 2 of the National Strategic Approach to Maternity Services Consultation has just closed (20 November).
The Australian Health Ministers’ Advisory Council’s consultation draft Strategic Directions for Australian Maternity Services is structured around four values — respect, access, choice, and safety. Enabling access to services for rural and remote women is emphasised.
Our College has advocated strongly for the federal government to acknowledge the role of GPs when this strategy is finally released next year having previously outlined concerns about the marginalisation of general practitioners out of obstetric care.
Meanwhile, in Western Australia, the debate continues to heat up on hospital led changes to the obstetric care model in that State which is seeing GP obstetricians increasingly locked out.
The WA shifts
In WA we are hearing that this shift has been occurring gradually over a five-year period.
The move to a hospital system with very little GP involvement and reliant on the fly in fly out specialist with onsite junior staff is becoming more prevalent.
Local reports state that GP obstetricians are being excluded from being involved in intrapartum care with the new model using a salaried medical workforce and shift to midwifery-led care.
This model has resulted in a significant disconnect between the hospital staff and the local primary care workforce.
This being at odds with what the federal government is trying to achieve nationally through the NRGP in building a resilient rural GP workforce.
Choice for women
But perhaps the most important point is that with a new maternity model which favours salaried medical staff over GP obstetricians it is the patient that loses most of all.
With GP obstetricians unable to care for public obstetric patients’ the choice for women is now much limited as a result.
In these towns, the continuity of care role sits with GP obstetricians and carving this off piece by piece to a fly in fly out service model will come at a significant cost.
In other towns we are seeing services close - women and their families have to travel significant distances to access care for pregnancy and birth.
We know the risks that come with increased distance as well as the associated financial burden on already struggling rural families.
Delivering care close to the patient is what works. Rural communities depend on their GP obstetrician with more babies delivered by GP-obstetricians than specialists in rural areas.
A collaborative model
What is missing in these discussions is a real understanding of team care and what it takes to address patient need in small rural towns.
That is, what it actually takes to sustain a rural maternity service and those interconnective factors for why it matters so much for other services.
We know that it takes a collaborative approach and advanced clinical skills encompassing medicine, midwifery, nursing, Aboriginal health and allied health.
What’s important is understanding the role of the team and scope of practice enabling all to work together without comprising quality.
It takes the whole team to make this work. A sustainable model involves a coordinated team involving the obstetrician, GP obstetrician and midwives and a roster divided among all of them.
This is how the service is maintained and we only have to look at the success of places like Albury Wodonga to see how this model sustains their service – sharing on call and the prenatal and antenatal.
We also know the other sustaining factor here – that the maternity service often opens up ways for other procedural services to develop.
A vital skill set
GP obstetricians skilled in childbirth require support, not barriers, in retaining such a vital skill set.
At a national level, procedural training grants ensure they can maintain their skills yet on a state-level, at least in parts, this is not sustainable when access is denied.
These latest developments not only risk the provision of obstetric services in rural areas becoming even more of a rarity but there will be some very real flow-on effects for our discipline.
The attraction and retention of GPs to the region is closely tied to the GPO model and it is a skill set we need to nurture to preserve through the National Rural Generalist Framework.
It is about getting the right skilled workforce in place, supporting a collaborative team structure to secure and sustain birthing services across rural Australia.
The rural generalist model offers a way forward which will make a difference for rural patients - ensuring safe, affordable and accessible healthcare.
Building healthcare capacity in the Solomon Islands
Dr Ayman Shenouda
A recent visit to the Solomon Islands provided some new insights into what it really means to be resilient. It is one of the least developed countries in the Pacific Region, the population languishes in poverty yet they make the most out of limited resources.
The community here face significant health challenges and on multiple fronts. They lack even the basic health infrastructure, and universal access seems an almost impossible health policy goal. Despite this, I found the healthcare teams here work with courage and resolve.
Health system challenges
Persisting social disparities mean they face significant health challenges through what is termed the “triple burden” of disease. The community deals with communicable diseases alongside rising rates of non-communicable diseases combined with the threat of climate change which we know already hits hard too regularly.
The Solomon Islands suffer from significant resource deficits and the underdevelopment of infrastructure is driving inequalities. There is no CT scanner in the country – that places new meaning on what it is to be deficient in resources here. This is a country of over 620,000 people spread across more than 900 islands and it is without essential imaging diagnostic tools.
Coverage of services is very weak. This is partly because past development efforts have lacked the required multi-level coordination to support any sort of integrated health system. Almost half of all health expenditure comes from donors which is mostly put to disease management with little left for service system development. [i]
The Good Samaritan
My visit to the Solomon Islands was unexpected and prompted by a local MP who approach me following some donations I made to the hospital in Tetere. They were relatively small contributions in the form of blood pressure and haemoglobin machines. From this visit, I learnt that while small they were vital and are the sorts of supports that help to develop capacity and reliability.
The Good Samaritan hospital is on the coast in Tetere in Guadalcanal province which is about 40km from Honiara. The caseload here is overwhelming. The hospital is basic with about 30 beds, that provides mainly chronic disease management, emergency medicine and obstetrics. There is one doctor per 60,000 population, two midwives and two nurses. But with that they perform miracles here - this team provides obstetric care averaging 170 delivers a month.
This is a population facing serious health problems yet you would be amazed by how well they cope with very little. The four most common conditions leading to critical illness are malaria, diseases of the respiratory system including pneumonia and influenza, diabetes mellitus and tuberculosis.[ii] Screening programs are grossly underdeveloped which increases critical care demand.
Most facilities are short staffed and without basic equipment. From Tetere it is one hour to Honiara for Xray or just to do bloods.
Despite the many challenges, the team use their clinical skills to the highest levels to provide the best care for their patients. It is the practical supports that they need the most and I think as a community of GPs we are well placed to do more.
Improving critical care
It is clear that the underdevelopment of healthcare infrastructure compounds inequalities.
In Pacific Island countries, including the Solomon Islands, there is a high need for basic critical care resources. Equipment such as oximeters and oxygen concentrators are needed as well as greater access to medications and blood products and laboratory services. [iii]
A cross-sectional survey study examining critical care resources in the Solomon Islands found that inadequate resources from primary prevention and healthcare contribute to the high degree of critical illness. This study suggested that the solution lies in simple therapies and context-appropriate resources to mitigate the high burden of morbidity and mortality.[iv]
Therefore, the emphasis should be on the development and acquisition of simple and inexpensive tools rather than complicated equipment. This helps to prevent critical care from diverting resources away from other important parts of the health system. [v]
This makes perfect sense in these resource-poor contexts and certainly, the healthcare team in Tetere provide a stunning example of making it work with almost nothing at all.
Empowerment is key to improving health service development in the Solomon Islands. The focus needs to be on strengthening the health system and improving access to services but bringing health care to these areas is no easy task.
It needs a partnership which filters right down to the community level. The Ministry of Health and Medical Services (MHMS) is really working hard towards enabling these partnerships to ensure a more planned approach to funding health services.
Australia is the largest provider of Official Development Assistance (ODA) to the Solomon Islands, providing almost two-thirds of overseas aid in 2016-17. We are the lead donor in the Solomon Islands health sector, with Australia’s main bilateral assistance provided through the Health Sector Support Program (HSSP) (equates to AUD 66m over four years to 2020). [vi]
Since 2008, the MHMS, with their development partners including Australia, has led a sector-wide approach (SWAp) to the delivery of health services in the Solomon Islands. The overall program goal for HSSP3 is to improve the access and quality of universal health care in the Solomon Islands. The current funding supports the Solomon Islands National Health Strategic Plan 2016-2020 and provides direct budget support, performance-linked funding and technical assistance.[vii]
What more can be done?
It is clear that Australia is doing its fair share for the Solomon Islands. There is now alignment in terms of ensuring best outcomes from this funding. This will certainly help build health services for this nation. But there is always more to do and GPs, in particular, can make a significant difference.
We need strategies to work through how best we can support our disadvantaged pacific neighbours from a community of GPs. Education partnerships being key and the RACGP already contributes in this way particularly in Papua New Guinea.
From my recent visit to the Solomon Islands, I have seen how the community there through their own resilience can achieve so much. Those working in Aboriginal Health would be familiar with what it takes to support patients in low-resource, laboratory-free settings. It would be great to share some of these learnings and provide more support for the Solomon Island communities.
[i] World Health Organisation. Article. Health closer to home: transforming care in the Solomon Islands. March 2017. Available at: http://www.who.int/features/2017/health-solomon-islands/en/
[ii]Westcott M, Martiniuk AL, Fowler RA, Adhikari NK, Dalipanda T. Critical care resources in the Solomon Islands: a cross-sectional survey. BMCInternationalHealthandHumanRights.Mar1,2012.doi:10.1186/1472-698X-12-1.Availableat: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3307438/
[vi] Commonwealth of Australia. Independent Performance Assessment. Solomon Islands – Health Sector Support Program. Specialist Health Service. May 29, 2017; revised 24 July 2017.
Dr Ayman Shenouda
Announcing the Collingrove Agreement following the rural and regional health forum in Canberra on Friday 9 February 2018 from L–R: ACRRM’s Dr Michael Beckoff, National Rural Health Commissioner Professor Paul Worley, Minister for Rural Health Bridget McKenzie, RACGP Rural Chair A/Prof Ayman Shenouda.
A milestone agreement
Those who have been part of this journey will understand the significance of the Collingrove Agreement. Although I think on this topic, even the most casual observer will be across the division that has chocked us for so long.
It’s been a long and often dusty road but we’re now steered in the right direction and towards developing a national rural generalist pathway together.
Finding that common ground was relatively easy in one sense.
You see, the one thing I’ve noticed having travelled extensively over the past four years as Chair of the RACGP rural faculty is that patience, passion and persistence is a common trait of rural GPs or any GP for that matter.
From Longreach to Carnavon or Katherine to Goolwa and everywhere in-between and regardless of which camp they belonged – ACRRM or RACGP - there lies a great determination and commitment for their patient and rural community. An unbreakable connection which binds us all in addressing rural health disadvantage and securing a healthier future for all.
Navigating slightly rougher terrain
But in finding that common ground between the two GP colleges - while the destination remained the same - the road itself was indeed rocky. So rocky in fact it required an all-terrain vehicle for all involved and sometimes perhaps a tank may have been a slightly better choice!
Still, despite years of division, I think it was that same spirit that made the Collingrove Agreement possible.
An easy headline it may have seemed to those filtering the news last Friday, but the “RACGP and ACRRM collaborating on national generalist pathway” was truly momentous. And certainly, for those around the table at Collingrove Homestead in the Barossa Valley, South Australia, collaboration soon became the only solution.
Sharing a picture for history’s sake of those present on those momentous couple of days 11-12 January 2018.
Securing the milestone agreement from L-R: Dr Melanie Considine, RACGP Rural Deputy Chair, RACGP Rural Chair A/Prof Ayman Shenouda, ACRRM Censor in Chief A/Prof David Campbell, our National Rural Health Commissioner Professor Paul Worley, ACRRM President A/Prof Ruth Steward and Dr Rose Ellis from the Rural Doctors Network.
A common goal
While the agreement itself is only four paragraphs long - the common ground here was significant. We had 7 million reasons to get this right.
It is about equity of access in meeting the health care needs of rural and remote Australians through a responsive needs-based solution.
Together we were determined to secure a strong, sustainable and skilled national medical workforce to meet the needs of these communities.
More than a definition
This is, of course, more than a about a definition but it was always a sticking point.
On one hand there were those focussed on the name or a tendency to favour a definition over others. On the other, we knew that developing skills around the ongoing care considerations are the areas that best serve the community.
And there’s the commonality – supporting doctors to acquire the skills to meet the needs of their communities. A dedicated and clear pathway for rural GPs to acquire those skills and utilise them in a way that is valued and recognised are important workforce factors.
This was the cohesion that brought the clarity to the definition.
So here is it -
“A Rural Generalist (RG) is a medical practitioner who is trained to meet the specific current and future health care needs of Australian rural and remote communities, in a sustainable and cost-effective way, by providing both comprehensive general practice and emergency care, and required components of other medical specialist care in hospital and community settings as part of a rural healthcare team.”
Beyond the definition, it is the careful design of the pathway itself that will make the most difference. It needs to be a lot of things but at its core it is about ensuring the right skill mix against demand with supportive elements offering flexibility and choice.
Key features which include a clear pathway for young doctors with flexibility that allows entry and exit at different stages. Ensuring adequate funding for the pathway itself alongside essential factors in establishing a critical mass of trainees but with enough flexibility for it to work within the varying jurisdictions.
It should also allow lateral entry for practising GPs and other rural doctors who want to acquire new skills to address the shifting need in these communities. Ever changing needs like mental health and palliative care and in dealing with the extra problems which depend on the health needs and context of the community.
The full range of competencies enabling them to deliver patient care closer to home in the primary and secondary care contexts. Or quite simply, training young doctors with the right skill set that makes them feel safe and supported to do their job which is addressing rural and remote community needs.
There’s usually some bleeding before healing
Despite years of focus, the disparity of health service delivery in rural and remote Australia remains a key policy failure. Much has been left to our overseas trained doctors who have been the backbone in delivering this care over this time. The lack of a solid training or workforce solution meant that the rural health system depended on individual efforts with very mixed results.
Sometimes I feel the split between the colleges had to happen for us to be able to reach this agreement. The Collingrove Agreement is the culmination of 20 years of hard work by both Colleges in building capacity to deliver a needs-based solution for rural health.
We’ve seen more collaboration over the past year than in the preceding 20 - through Bi-College Accreditation to this historic Collingrove Agreement. So, let’s keep it up!
A Rural Generalist Pathway Taskforce is being formed in the coming months to work through the pathway design. There may still be a long road beyond Collingrove Homestead but I think this time it will be the recently resurfaced type!
A significant step in securing a stable rural medical workforce
Dr Ayman Shenouda
A rural renaissance
It is great to see the Federal Government delivering on its commitment to increase the number of rural-based doctors in training.What we are experiencing right now in rural health can only be described as a rural renaissance. We have great leadership in our Rural Health Commissioner and now in our new Rural Health Minister making her mark and building on the great work of her predecessor.
More intern placements in general practice is great news for rural doctors and their communities. This is an essential step in securing the next generation of rural GPs by ensuring our trainees receive broad exposure through prioritising primary care and general practice. These programs really work as they provide trainees with that essential insight to community medicine.
Intern rotations in general practice
The Rural Junior Doctor Training Innovation Fund (RJDTIF) program provides primary care rotations for rurally based first-year interns. It builds on existing state and territory arrangements to provide primary care rotations in addition to hospital rotations.
Last week, Rural Health Minister, Senator the Hon Bridget McKenzie, announced a $1,304,967 Federal Government grant for the Murrumbidgee Local Health District to increase intern rotations throughout the region. I’m proud to be contributing with my practice in Wagga selected to participate and we will be rotating five interns a year through this program.
It was great to show Minister McKenzie around my practice and have a chance to discuss how to provide that valuable community exposure early. The Minister showed a deep understanding of what is required in placing policy priority on general practice. She shared my vision that every junior doctor should have a rotation in general practice as part of the first two to three years of training.
Quality training experience
In our practice, we have GP specialists, new fellows, GP registrars, interns and medical students working alongside nurses and allied health professionals. We aim to support the integration of vertical and horizontal teaching enhanced through a multidisciplinary team environment.
A strong teaching culture and established education networks also ensure we have the hospital and community partnerships to enhance exposure and demonstrate for our trainees the diversity of general practice. We’ve worked hard to build the required supportive infrastructure and systems to make this work which needless to say is also reliant on a solid business model.
Keeping them there
Targeted exposure strategies like these ensure trainees can develop the broad range of skills required. It provides essential rural exposure for interns to learn the complexities of delivering services in rural areas while in a supportive general practice setting.
My own experience with the PGPPP where I had 12 interns rotated in my practice really yielded results. From that cohort, about 70 per cent of them have chosen general practice as their training speciality. They loved the diversity and complexity general practice offered. It challenged them, kept them engaged and provided that important insight into the doctor-patient relationship.
A little on the policy journey
Addressing maldistribution has been dominant in the discussion at many Rural Health Stakeholder Roundtables in Canberra over recent years.
Certainly, greater exposure to general practice for junior doctors has been central to RACGP Rural advocacy around securing an integrated rural training pathway. Particularly in ensuring more emphasis on primary care and generalism early in medical education.
But really making generalism a foundation of junior medical training – a discussion made more difficult on the back of a defunded PGPPP. This was a significant policy obstacle when you consider that what we were pursuing was more of a supercharged PGPPP but specifically for rural areas.
We needed a solution that would boost the number of GPs as well as address the gap in the rural pathway by providing intern rotations in general practice and primary care. We knew there was a strong learner preference for rurally based internships. We also knew that potentially we had lost a cohort of potential rural GPs as the gap from the PGPPP hit hard and narrowed our opportunities.
A win for general practice
It certainly was a long policy process getting here. This is the why this program, which was the result of a long period of sustained advocacy, is such a significant win for general practice. It is clear much of the hard work over many years is starting to pay off particularly in rural health. This is a significant step forward in securing a stable medical workforce to address maldistribution.
National Rural Health Commissioner: Putting the rural health agenda back on track
Dr Ayman Shenouda
A rural champion
A visit this week to Wagga from our National Rural Health Commissioner Professor Paul Worley provided a great chance to work through some of our highest rural health priorities.
This new champion for rural patients is exactly what we needed.
He fits the job description well – independent, impartial and “a fearless champion” for rural health. He also has alongside him a strong rural health sector full of ideas for building a strong Australian rural health system.
Getting the agenda back on track
Rural patients are finally getting the focus they deserve and this is our chance to get the rural health agenda back on track.
I think we finally have the policy settings in place for this to occur. But it all has to be orchestrated in a way that sees very specific locational needs acknowledged and addressed.
This is where the new rural commissioner role comes in. We all have a key role here. There’s still a great deal of work which now needs to occur to ensure every instrument in this vital ensemble can be fully utilised.
It is those featured instruments – whether string, woodwind, brass or percussion – each with its own unique qualities that really need to shine. These are the ones that fill in a critical gap and vital if we are going to provide a performance worthy of rural Australians.
National Rural Generalist Pathway
The first task is the National Rural Generalist Pathway.
If we are to get this policy right we will need a broad policy lens with a commitment to needs-based planning encompassing all disciplines.
We know that a sustainable health workforce solution for rural Australia needs to factor in flexibility in policy design. By this, I mean allowing for an optimal skill mix which is capable of meeting the very specific service needs of that community.
Local needs analysis
It is clear that we need reforms that can address maldistribution to meet growing service demand. But to do this we need to look at what is really happening in these communities.
Skills planning through a rural generalist pathway solution must, therefore, encompass a much broader skill mapping exercise. This needs to be steered toward more integrated care and with a focus on the full multidisciplinary skill mix required to keep those services going.
We need to find ways to capture current skill depth so that this can be prioritised better in policy. Reinforcing the importance of primary care and coordination of care so that the policies can follow. But really plotting that essential skill mix required to support rural models of care.
Future supply and demand (against need)
It is about having that critical mass of health professionals to achieve a sustainable service environment.
This not only lifts constraints enabling more equitable access to services but creates a way to mobilise and build on peer support. In turn, reducing burn-out by formalising mechanisms for peer support-support networks. It provides safer working hours and leaves room for internal backfill for relief, as well as professional development or space to take on a supervising role.
There’s been plenty of workforce planning occurring – PHNs, LHNs, and RHWAs – but we lack that common formula.
No-one can see at a national level where the true hotspots are. We need to establish what constitutes a minimum workforce requirement or mix for a particular population size and then apply that across the country.
Matching and forecasting the needs is complex but we have evidence-based approaches to estimating health workforce demand. HWA did years of work around it. I think we must clarify this area of workforce policy as a first key step.
Once we have this formula then we’ll see a situation where training investment meets demand.
There is just not enough aligning in terms of training pathways with workforce planning. This is vital as you can’t have a situation where you have three GP anaesthetists and no GP-obstetrician.
This level of planning would also help in terms of succession planning and reassure those committing to these pathways that there is or will be a position for them. It provides a planned career pathway for them.
Broad skill depth
Broad skill depth is vital to addressing patient need in rural communities. We need to find a way to embed in workforce policy those skills most relied on in meeting this need.
I think the discussion is also broader than the training pathway itself. We have to have an equal focus on the requirements of the existing workforce in meeting shifting community need.
Training solutions need to enable private community-based practice. We really need to ensure we encompass a range of approaches factoring both procedural and non-procedural skills if we are going to align closely to need.
If we support the full skillset required then we are closer to reflecting within the training the full scope of skills practised in rural general practice to meet community needs. This is how we can ensure we produce the next generation of doctors with the skills needed to provide both primary and secondary care.
Past policies have had an impact on both recruitment and retention. It all comes back to securing that critical mass (of students). Early exposure which can establish that community connection early which can continue through to intern, prevocational and vocational training years.
We’ve always said that we need to invest in more localised training solutions to provide for that community connection and rebuild a teaching culture. The hubs are well positioned to facilitate that vital community connection and link the various stages of training in a rural setting across the full training continuum.
The training hubs provide that essential framework now but it is about facilitating those vital partnerships. This is how we can structure training against local healthcare need and service construct and build in those supportive factors so early exposure can be a positive experience.
Nurture rural intention
We need to nurture rural intention through targeted incentives and sufficient rural exposure strategies.
A strong commitment to rural should come with benefits. Capture those wanting to pursue rural through a nurtured pathway and supports which include an investment in mentoring. Truly support RMOs skills and career path aspirations and reinvesting in these years by getting back the PGPPP in its true form.
Newly developed policy offering primary care rotations through the new rural community-based interns is certainly acknowledged but it is a minimised model which really needs to be expanded.
Vertical continuity over time
Focusing more effort on areas that provide both a training benefit and meet a community health need is a way to secure an enduring rural benefit. Realising that a focus on the full multidisciplinary team is key to providing more integrated and improved patient-care strategies.
Building this capacity through vertical integration of teaching and learning which promotes shared responsibilities. It’s that continuity that is needed most – vertical continuity over time to allow for varied exposure which results in the more resilient doctor.
Flexibility is needed to ensure training reflects the local service context with an equal focus on community-based training. It helps develop that understanding of optimal care pathways providing continuity of care and a collaborative integrated care approach.
Team and teaching culture
Developing a strong team culture early has to also be a key focus. Those working in rural Australia know that it takes a dedicated team and an enduring local commitment to tackling the many challenges in delivering regional, rural and remote healthcare.
We need to ensure more exposure to multidisciplinary team environments as well as enabling hospital and community partnerships through supportive policy. This is where the pathway solution has to extend beyond a focus solely on medicine.
Improved support for supervisors has never had the policy focus it deserves. We need to increase the teaching capacity of rural communities while minimising the impact of burnout. Practice viability is a major consideration here.
All these factors need to be considered in terms of ensuring a rural GP can take on a training or teaching role. Succession planning and providing that easy entry, gracious exit is key and would lift the load for many already overcommitted.
A more sustainable future
In designing rural policies which can provide a more sustainable future, the focus clearly has to come back to addressing health disparities between rural and urban Australians. A resilient multi-skilled generalist workforce capable of meeting current patient need now and into the future is all part of meeting that key requirement.
We really need to capitalise on the policy settings we already have in place. The strong planning role of the PHNs and LHNs in identifying local level need. The facilitation role of the new training hubs in ensuring a more positive rural training experience. Existing strong College pathways and well-developed rural skills training program with inter-professional partnerships to build from.
We now have that vital role in the National Rural Health Commissioner to ensure a more coordinated national policy and planning effort can occur. We’re well on our way in putting the rural health agenda back on track ensuring lasting change for rural Australians.
Source: RACGP 2014. New approaches to integrated rural training for medical practitioners. Final Report. Available at: https://www.racgp.org.au/download/Documents/Rural/nrffinalreport.pdf
Let’s not lose another rural obstetrics service
1 September 2017 Dr Ayman Shenouda
Decline of rural obstetrics services
It was disappointing to see yet another decision without due consultation to downgrade rural maternity services recently and this one was particularly close to home for me. Temora Hospital’s maternity services will be reduced with patients requiring maternity surgery under general anaesthetic moved to other district hospitals. Only a month earlier, in July, it was Emerald in Queensland that was in the spotlight due to a maternity service closure. But none of this is really new, is it? Nationally we’ve seen more than 50% of small rural maternity units closed since 1995.
In this latest downgrade, we’re told Temora’s maternity services for low-risk pregnancies will continue but caesarean births and gynaecological surgery will now be relegated to Cootamundra and Young hospitals. This just shifts the costs in my view and is not a sustainable solution for this community and could see broader impacts on other services too if works are not prioritised and essential staff leave. Surely, part of the cost equation has to also look at the costs transferred to the patient as well as the skills lost and broader safety aspects of NOT having a locally accessible service?
The NSW Health Minister Hon. Brad Hazzard MP says he was kept in the dark on the decision by the Murrumbidgee Local Health District (MLHD) and wants the service retained. There is at least some hope for this community with the Minister making clear his views on the matter. But why do we need to get to this level in the first place? Local level planning and consultation should have occurred on such an important issue and well before it got to ministerial intervention level and preferably not debated through the media in this way.
Impacts for the local workforce
Putting aside the clear impacts of this decision - including higher risk birthing outcomes - for one moment. What now for the three obstetric providers who have been providing this service? One GP obstetrician in the town stated in the Harden Murrumburrah Express that she did not want to see Temora become a victim of bureaucracy.
We know that driving decisions to close or reduce rural maternity services is often around doctor shortages, safety concerns or funding constraints. This decision according to media reports comes down to physical infrastructure costs. The issue is the obstetrics theatre room was deemed unsafe for surgery following an audit by the Australian Council of Healthcare Services.
Rural patients need viable maternity and surgery services near to where they live. And doctors who invest in training to ensure a service for their community need some certainty around service continuity. They most certainly need to be involved in local service decision making which certainly seems not to have been the case in the Temora downgrade.
A strong focus on policy
This is a decision which seems contradictory to what we’ve seen from NSW HETI in terms of its rural generalist pathway. There has been an expansion of training positions this year with 40 positions being made available.
It is also contrary to the focus nationally which has seen committed action over an eight-year period. There has been a strong policy focus in the form of a Maternity Services Review (2009), a National Maternity Service Plan (2010-2015) and the current development of a National Framework for Maternity Services.
We’ve seen such a strong policy response in recent years and it’s important that local level planning decisions work within these broader nationally set priorities. Both the National Maternity Services Plan (2010-2015) and new National Framework for Maternity Services (2017), which is still being finalised, have set specific priorities to secure more equitable outcomes for rural patients including in the areas of access and workforce.
Some great policy outcomes have resulted already including in terms of tools to inform planning and in areas of national data development.
The Australian Rural Birthing Index (ARBI) was a key outcome of the Plan which has provided an important index to help in the planning for maternity services in rural locations. The index can be downloaded here: http://ucrh.edu.au/wp-content/uploads/2015/07/ARBI_FINAL_PRINT.pdf .
While the AIHW-led National Maternity Data Development Project aims to enhance maternity data collection and reporting in Australia. Both are important national planning tools which aim to utilise a population based planning approach as the basis for demand driven evidence-based decision making.
Protecting rural services
Despite such a strong policy focus and commitment, it is evident that we still need to improve maternity services in rural and remote communities. There is clearly state-level support for the development of rural GP procedural skills. However, this needs to also extend to rebuilding rural hospital infrastructure when required to ensure service continuity. Here in NSW, we have a policy commitment to develop workforce capacity by expanding rural generalists being potentially compromised by a local level decision driven by infrastructure costs which have led to the downsizing of maternity services.
The critical role of procedural GPs – both GP obstetricians and GP anaesthetists – in providing maternity services in rural Australia is well understood. Decisions which see closures or a downgrade of services will have a direct impact on the long-term commitment of both current and future rural doctors. Let’s not lose another rural obstetrics service – operative obstetrics and gynaecological procedures are needed in Temora and funding should be found to upgrade the operating theatre.
 Rural Doctors Association of Australia. Maternity services for rural Australia. Manuka: Rural Doctors Association of Australian, 2006.
 The Daily Advertiser. Media Article: Minister ‘kept in the dark’. Published 22 August 2017.
 Harden Murrumburrah Express. Media Article: Temora Hospital theatre closure could see expectant mothers transferred to Cootamundra or Young Hospital. Published 21 August 2017. Available at: http://www.hardenexpress.com.au/story/4870112/obstetrics-theatre-room-closing-at-temora-hospital/
 Longman J, Pilcher J, Morgan G, Rolfe M, Donoghue DA, Kildea S, Kruske S, Grzybowski S, Kornelsen J, Oats J, Barclay L. (2015) ARBI Toolkit: A resource for planning maternity services in rural and remote Australia. University Centre for Rural Health North Coast, Lismore.
25 August 2017 Dr Ayman Shenouda
RECRUIT, TRAIN AND RETAIN
Getting the policy settings right
I don’t think there’s ever been a better time to secure the next generation of rural GPs. Now more than ever before we have the right policy settings in place. We need to seize this opportunity to ensure we select the right doctors for rural Australia.
Once we’ve overcome that first hurdle in getting them there, we need to then ensure those registrars who choose rural practice, that once secured, they remain there. But not only remain there that they continue to thrive. To do this we need to ensure the right supports are in place.
The policy momentum has been building for some time with the help of thousands of rural GP champions – possibly most now reading this blog – who have advocated for change over many years.
We now have the right set of policy conditions: an overall increase in medical school intake with quarantined placements for rural; a rural emphasis and exposure with a focus on generalism as a priority in the training; and, of course, the regional training hubs which will soon be in place to help link the various stages of training.
We finally have the makings of an integrated rural medical training pathway. This includes a priority on rural community internships – a clear gap which needed fixing – and soon with the regional hubs, training can be structured in a more coordinated facilitated way.
The hubs, in particular, will strengthen the efforts of the Rural Clinical Schools’ and help build the facilities and infrastructure and teaching capacity needed to make this work. For the trainee, it will help to provide the navigational supports that have been so lacking in the past from medical school to rural practice. Importantly, we have a focus on non-coercive strategies in securing the next generation of rural GPs.
Why enter, why stay, why leave?
We know that many factors influence rural intention and that it is getting those supports right and across the full training continuum that counts.
Ruralising the curriculum is a key one. Embedding more primary care early into the medical curriculum is essential and this has certainly been said often enough. But other simple things like placing a rural scenario in the exam would also help to formalise assessment to enforce primary care and emphasise the important role of the generalist.
Getting them in early and interact as often as possible is another key requirement. Nurturing your registrars once there requires a whole of community effort.
I think it is instilling that sense of belonging that is vital at this point so the emphasis then needs to be multifactorial. Positive exposure offering a mix of rural experiences including clinical and nonclinical competencies and of the latter leadership being a key one here, the ability to lead and work in teams cannot be emphasised enough.
Trainees want broad exposure and the opportunity for multiple levels of clinical learning through blended placements. Trainees need to be empowered to make informed career decisions and to obtain the skills they need in the local setting. A community with the right structures and partnerships in place can facilitate this well.
Next is community connection and engagement and getting that right. This really gets to the heart of the issue – this is why they stay – that sense of place and identity. Ensuring a strong rural connection is hard work in training terms but worth the effort in the long run.
This is all part of developing a professional identity and mentoring plays a key role here. Longer-term placements in and around the same community also help to build those lasting relationships.
While I think an intrinsic characteristic of most GPs is their altruism there are also limits. We need to formalise that mentoring point – and at every learning stage – so that rural GPs and broader teaching staff are able to commit their focus towards mentoring.
More funding for mentoring has to be part of the suite of incentives in support of rural intention. Formalising succession planning in this way would help to ease the pressure on those nearing retirement too. That’s the ‘gracious exit’ part that often gets forgotten but just as vital as ‘easy entry’ for rural.
A rural pipeline functioning well can support these broader retention outcomes in terms of supplementing supply over time through a constant stream of new entrants. This would help make rural practice even more attractive as it provides an exit strategy for rural GPs without having to make that lifetime commitment. Rural GPs could stay for a shorter period, up to five years, without causing the workforce disruption that currently occurs upon exiting. Rural practice could become a standard part of the GP journey with supportive policy offering more flexibility and opportunity to spend at least part of your career within a rural community.
Now finally, getting to the hardest bit. Once you have them, then the focus then shifts to keeping them there. And getting to the bottom of that is a whole new set of questions which tend to include broader impacts including those on family.
Factors including an adequate income, appropriate workload, locum provision, access to specialists’ advice and continuing education, spouse career opportunities and children education all come in to play. Again, it takes a whole community to help make this work.
Bringing it all together
Piecing it all together there are a lot of factors that need to come together to get rural recruitment, training and retention right. Ensuring we have the right set of incentives in place for those making the commitment is key to policy success including rewarding advanced skills, procedural and non-procedural.
In understanding intentions to practice rurally, we know that rural origin plus a rural clinical school placement is a significant predictor. But there are many ways to get there and we should keep an open mind as many get there by accident. I think I fit that last category having only come to rural practice at the age of 35 after commencing in a completely different specialty to being with.
In securing strong rural outcomes, it comes down to nurturing those with an interest and being able to bundle those known influences. We’ve certainly come a long way in securing the right supports and focus to realise a fully integrated rural training pathway. It’s a multitude of factors including supportive policy and a strong local commitment from each and every one of us, but not least the trainee to secure the next generation of rural GPs.
 RACGP. New approaches to integrated rural training for medical practitioners. Royal Australian College of General Practitioners. 2014. Available at: http://www.racgp.org.au/download/Documents/Rural/nrffinalreport.pdf
 Parlier AB, Galvin SL, Thach S, Kruidenier D, Fagan EB. The Road to Rural Primary Care: A Narrative Review of Factors That Help Develop, Recruit, and Retain Rural Primary Care Physicians. Acad Med. 2017 Aug 1. doi: 10.1097/ACM.0000000000001839. [Epub ahead of print]Availablat: http://journals.lww.com/academicmedicine/Abstract/publishahead/The_Road_to_Rural_Primary_Care___A_Narrative.98154.aspx
 RACGP 2014, op. cit. p.65.
 Humphreys J, Jones J, Jones M, et al. A critical review of rural medical workforce retention in Australia. Aust Health Rev 2001;24:91-102. [PubMed]
 Walker JH, DeWitt DE, Pallant JF, Cunningham CE. Rural origin plus a rural clinical school placement is a significant predictor of medical students’ intentions to practice rurally: a multi-university study. Rural Remote Health. 2012;12:1908.PubMed
5 August 2017
Dr Ayman Shenouda
Often a really good policy solution will in turn place more pressure on a part of the health system it relies. This isn’t necessarily a bad thing and is usually indicative of good policy spend. It is sometimes an outcome of optimal policy coverage as is the case for disease screening measures. The National Bowel Cancer Screening program, introduced in 2006, is an example of a policy working well.
We know that one in 12 Australians will develop bowel cancer by the age of 85 which makes it the second most common cause of cancer-related death in Australia after lung cancer. But, if detected and treated early the cure rate is around 90% which makes policy intervention through prevention and in this case, through screening measures, so vitally important. [i]
The is a great policy intervention which we’ve seen expanded under successive governments with broad coverage now currently available to Australians aged 50, 55, 60,64, 70, 72 and 74. Once fully implemented by 2020, all Australians aged 50 to 74 will be able to be screened every two years.[ii]
But as a result of this policy, we’ve seen demand increase for lower gastrointestinal endoscopies. This growth in demand means there is a need for the endoscopic workforce in Australia to be well planned in order to cope with future demand associated with expanded cancer screening, particularly with an ageing population. Service solutions to address current demand including nurse endoscopists are now being rolled out in Queensland and Victoria. But is this the right workforce response for Australia or is it more of a temporary fix to a growing system issue?
Here’s the policy background to the issue. The policy response to limited endoscopy capacity a few years ago saw the now defunct Health Workforce Australia (HWA) invest in a project to train nurses to perform endoscopic procedures. Expanding the scope of practice of health professionals was a typical policy response being keenly pursued at that time by HWA. This particular decision though saw unprecedented action with a policy preference to train non-medical endoscopists and build capacity from within nursing.
At the time, the medical press reported that doctors were calling for a moratorium on nurse endoscopy.[iii] From a resource perspective, it is important to also note that this was a decision undertaken within the broader context of increased medical graduates coming through and claims of impending oversupply.
The Advanced Practice in Endoscopy Nursing (APEN) program was modelled on approaches elsewhere including in the UK where the nurse endoscopist was well established. Although nurse endoscopy training and delivery of endoscopic services is not a new policy response: the first report of nurse endoscopy in the US was more than 35 years ago for flexible sigmoidoscopy.[iv] But I think it is important to work through policy alternatives for Australia particularly if one solution has limitations both in terms of efficacy and coverage.
The University of Wollongong evaluation of the HWA-funded APEN sub-project in 2014 highlighted some key points in terms of the validity of a nurse-led model as a workforce solution.
Firstly, it stated that one of the main drivers for the program was the need to respond to growing demand for lower gastrointestinal endoscopies arising from bowel screening. However, it also stated that only about a quarter of same-day colonoscopies are performed in public hospitals. A key detail that severely limits the ability of nurse endoscopists to meet this growing demand. The evaluation also stated that given full implementation was not achieved, that relative advantage in terms of effectiveness and cost effectiveness of the model could not be evaluated and could only be measured after trainees were qualified and working at full capacity. [v]
The Australian Medical Association of Queensland (AMAQ) in commenting on the Queensland roll out of nurse model to Cairns and Townsville, stated that medical endoscopists were more cost effective than nurses as surgery could be performed at the time of procedure.[vi]
Cost-effectiveness of the nurse-led model as a workforce solution has also been challenged in a study published in the World Journal of Gastroenterology in 2015. The study examined the available evidence on safety, competency and cost-effectiveness of nursing staff providing gastrointestinal (GI) endoscopy services. The study concluded that the empirical evidence that supports non-physician endoscopists is limited to strictly supervised roles in larger metropolitan settings and mainly flexible sigmoidoscopy and upper endoscopy for asymptomatic or low complexity patients. [vii]
This same study also stated that contrary to general beliefs, endoscopic services provided by nurse endoscopists are not more cost effective compared to standard service models due largely to the increased need for subsequent endoscopies, specialist follow-up and primary care consultations. It stated that studies measuring cognitive competency were limited and providing endoscopic services is more than mastering the technical skills required to safely advance the scope. Further, that making clinical decisions in the context of the patient’s full clinical picture is critical to delivering efficient and meaningful services.[viii]
In finding an effective solution, the most obvious question for me in terms of utilising the available workforce is around why we are not looking to general practice to address excess demand? Some of the pressure placed on endoscopy units in managing this increased demand can certainly be addressed by general practitioners.
General practice offers a particularly viable solution for rural communities in endoscopy. Keeping trained procedural GPs in rural areas should be made a priority and this is a good example of where support is needed to sustain local solutions where rural GPs fill a service gap like this. Access to diagnostic endoscopy is limited in rural and remote areas and service expansion by GPs provides significant patient benefits in terms of time and costs.
While savings including around reduced costly patient transfers are obvious to most, the investment in GP procedural practice where it offers a sustainable service model should be sufficient for policy makers. It would help to reduce the demand placed on regional tertiary services and could help make GP procedural practice more viable in the smaller towns. We know that rural GP proceduralists must be supported to consolidate their skills in the communities they serve and this is one service solution which can help realise this aim. It is a workforce solution that needs to be considered.
[i] Cancer Council Australia. Position Statement. Bowel Cancer. Available from: http://www.cancer.org.au/policy-and-advocacy/position-statements/bowel-cancer.html
[iii] Australian Doctor. Doctors call for moratorium on nurse endoscopy. 30 January, 2015. Available from: https://www.australiandoctor.com.au/news/latest-news/nurses-expand-scope-into-endoscopy
[iv] Spencer RJ, Ready RL. Utilization of nurse endoscopists for sigmoidoscopic examinations. Dis Colon Rectum. 1977;20:94–96. Available from: https://www.ncbi.nlm.nih.gov/pubmed/844404
[v] Thompson C, Williams K, Morris D, Lago L, Quinsey K, Kobel C, Andersen P, Eckermann S, Gordon R and Masso (2014) HWA Expanded Scopes of Practice Program Evaluation: Advanced Practice in Endoscopy Nursing Sub-Project Final Report. Centre for Health Service Development, Australian Health Services Research Institute, University of Wollongong. Available from: http://ro.uow.edu.au/cgi/viewcontent.cgi?article=1384&context=ahsri
[vi] ABC News. More gastroenterologists needed rather than using nurse endoscopists in hsopitals, AMAQ says. 18 Apr 2016. Available from: http://www.abc.net.au/news/2016-04-18/amaq-more-gastroenterologists-rather-than-nurse-endoscopists-qld/7336202
[vii] Stephens M, Hourigan LF, Appleyard M, et al. Non-physician endoscopists: A systematic review. World Journal of Gastroenterology : WJG. 2015;21(16):5056-5071. doi:10.3748/wjg.v21.i16.5056. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4408481/
Broad skill depth is what makes general practice unique and so central to addressing patient need. An essential part of that skill mix and key to addressing an aging population with more complex health care needs are non-procedural advanced skills.
The development of specialist clinical interests by GPs has always been a key feature of general practice. These are often the skills needed to meet identified patient need and provide an effective way to address access constraints, particularly for rural areas.
It makes sense then that in order to provide training to match demand that we don’t over emphasise or value certain skills over others. It’s also important to value the workforce you have as well as prioritise policy to support the next generation of GPs. This is the case for both urban and rural GPs we need to provide more opportunities in those extended skills or advanced skill areas identified and prioritised by the profession.
This is particularly important for practising rural GPs who need flexible training options so that they can acquire new skills to address unmet service need. And in meeting this need this requires an equal focus on both non-procedural and procedural skill acquisition.
We need an equal focus on both recruitment and retention strategies which in turn means factoring into the policy design both learning stage and time in career. To achieve this, we need targeted strategies to support both the existing workforce and those at an earlier learning and career stage.
Funding not only needs to be prioritised for skill acquisition but also for maintenance. Skill certainty is also crucial so that the GP can utilise the skills they’ve acquired to support their community. The return on investment is substantial and means that patients get the services they need and deserve.
Research led by RACGP Rural in 2013 helped to clarify the extent of advanced skills used and needed by GPs in rural and remote Australia. Not surprisingly the number of advanced skills acquired and used across most areas increased with rurality.
Mental health came out in front as the most commonly practised advanced skill in the study, followed closely by emergency medicine and chronic disease management. Of those skills GPs would seek to acquire to meet a community need, emergency medicine was the most prevalent, but this was followed by palliative care, paediatrics, and mental health.
Skills in emergency medicine were expectedly prominent with approximately 60% of respondents indicating that emergency medicine was relevant in rural general practice. However, only 38.7% had acquired it and 33.6% were currently using it. More broadly though, of those who had acquired an advanced skill, most were continuing to use that skill which was most reassuring.
The most important policy points from the study had to be the high prevalence of non-procedural advance skills as well as the continued reliance on emergency medicine in addressing need. There would be no surprises here particularly for those rural GPs currently overstretched to keep providing emergency and in-patient services. But also to those struggling to meet an increasing need in palliative care, paediatrics and mental health which extend to psycho-geriatric skillsets.
The policy requirement extends beyond providing training opportunity with a need to address system constraints which act as deterrents to working outside of the practice setting. Increased training opportunities need to be delivered in a supportive framework which enables skill utilisation facilitating service continuity otherwise it’s like doing half the job.
Capturing service complexity and rewarding GPs working across settings or in targeted areas of need offers a service solution in these areas. Investment in these skill-specific solutions based on need with a focus on GP-led models of care offer real solutions for health service viability.
We need to focus on enhancing health system interfaces where those non-procedural advanced skills factor strongly. In managing demand at the interface between primary and acute health care settings or various stages of illness – in palliative care or those with multiple chronic conditions for example – requires much more focus and across the full multidisciplinary team.
We need clear referral pathways which promote continuity of care for patients moving in and out of primary and tertiary care. The type of coordinated care planning made possible by that initial skill investment to enable an expanded role, but which is then further invested in terms of ensuring continued skill use across settings to provide for the required continuity of care.
15 July 2017 Dr Ayman Shenouda
The Federal Government’s $54.4 million investment to create 26 regional training hub sites nationally sees yet another significant rural health reform realised. Providing a more seamless transition from undergraduate training into rural practice, I believe the hubs measure is one of the most important reforms since the establishment of the Rural Clinical Schools nationally in 2000.
Having this policy realised is also a proud moment for me knowing that RACGP Rural was at the forefront of this reform having developed rural medical training pathway options for the Commonwealth through a major study undertaken in 2013.
What we now have with this policy is the level of integration we called for with the hubs being our highest ask. It’s also clear that other aspects of the full pipeline investment were informed by this study, which was one of the largest member-led rural consultations ever undertaken. Collectively these initiatives represent a significant rural training investment and it’s a great achievement for the sector.
It’s a substantial package, the three-part integrated rural pipeline package provides just short of $94 million over four years with the regional training hubs forming a key policy component. It also includes a rural junior doctor innovation fund and further investment to expand the rural specialist training program. Three new University Departments of Rural Health have also been committed for strategic sites across WA, NSW, and Queensland.
We’re also seeing some policy shifts here which are significant. Particularly in those key areas where we’ve been calling for change in order to address the policy gaps which impede integration. These are those junctions which occur from student to intern and intern to registrar which offer real opportunity in terms of being critical rural commitment points.
Firstly, in this policy, we see a clear focus on embedding more primary care earlier into the training. A new strategy to provide more internships that include rotations in general practice addresses a really significant problem where the lack of exposure to rural practice at this critical time impacts our recruitment goals. Factoring rural primary care rotations for rurally based first-year interns ensures this exposure across multiple settings. It doesn’t minimise the required hospital exposure but ensures essential exposure to community-based rural general practice.
While the early linkage of intern positions with specialist training positions is also evident through providing up to 100 new rural training places. We need to ensure our next generation of rural doctors are nurtured and supported once captured. This investment will go a long way towards supporting that aim by ensuring there is the capacity to provide high-quality rural placements.
We know there is a link between where a student ends up and where they completed their post-graduate studies. But even with the strongest rural interest and the best intentions, not everyone is suited and it takes a substantial personal commitment to make it work and stay.
We now have more capacity through this pipeline initiative to get those supportive elements right in order to provide a stable learning environment to equip trainees with the skillset they will need. Even more importantly it helps to ensure support can be sustained long enough to provide trainees with the skills and confidence required which makes staying much more likely.
The hubs provide for the right set of supports that will help us capture for rural the increasing domestic graduates coming through. It enables the university-hospital-community partnerships we need to set the right conditions to encourage more doctors to practise in rural areas.
This model facilitates a level of integration that will allow adequate clinical exposure in a rural area across all training stages. Most of all it provides a way to maintain a link to a specific rural community and to facilitate longer terms in rural areas.
What also needs to be emphasised here is a program of complete immersion. The step beyond rural exposure and a commitment towards longer placements. Community connectedness can only be achieved through longer placements in the same community throughout the full training continuum.
More cohesive and tailored training options will result. A more varied training experience will be able to occur, one which is appropriate to the learning stage but also flexible enough to be in line with community health needs.
Longer placements with multiple levels of learning are more effective allowing for the required immersion. It connects the trainee to the key players in the community, developing a network and connection to community through mentorship. Importantly they learn the value of rural general practice on their way through.
Policy success will, of course, be determined by improvements in the rural retention rate over time but I have no doubt the pipeline investment will work to build the right supports to make rural training a much more viable option.
These measures provide for the supportive and coordination factors as well as some much-needed infrastructure to make rural training work. It helps to formalise the networks needed to provide a pathway continuum for medical education and training from medical school to rural practice. All this combined provides a comprehensive policy solution which will translate into rural recruitment success and workforce retention over time.
Further reading: RACGP Rural developed a Position Statement to support policy implementation of the Regional Training Hubs.
The passing of legislation during the last sitting days in June to establish a new National Rural Health Commissioner is a significant step forward toward achieving a more equitable healthcare service nationally.
A new champion for rural patients, the role offers a new opportunity to ensure our collective voice is heard bringing to focus the important work we do. Through this key role, rural patients finally get the focus they deserve and we know that lasting change will require a broad policy lens encompassing all disciplines.
Those working in rural Australia know that it takes a dedicated team and an enduring local commitment to tackling the many challenges in delivering regional, rural and remote healthcare.
A focus on the full multidisciplinary team is key to providing more integrated and improved patient-care strategies. Strategies which work to address access constraints in the context of diminished rural resources require supportive policy to enable integration. It is in developing these service solutions, through policy advancement, to support viable rural models of care that we can work together to address disparities.
One of the first tasks for the new Commissioner will be to work with stakeholders to develop a National Rural Generalist Pathway. In maximising workforce outcomes, the ‘generalist’ role has long been the basis of rural medical practice enabling strong patient reach across settings to address access constraints.
It is clear that rural GPs in utilising their broad scope to provide services across the continuum of care in a range of settings have always offered, and remain, a key solution to addressing rural patient need. But we are not working alone and this same level of focus is warranted across all disciplines to work to the level of service integration required.
It’s reassuring that a much broader remit is envisaged by Dr Gillespie for the new Commissioner role. We all understand that addressing workforce and services issues to provide more effective, comprehensive healthcare is much broader than medicine.
A focus encompassing nursing, dental health, Indigenous health, mental health, midwifery and allied health alongside medicine is required. The patient must also be given a strong voice and reaching out to the health consumer through collaborative community-led engagement will be important.
To realise strong reform, a needs-based approach which can allow for flexibility is required. But it’s a hard sell. A community-led model or approach doesn’t always fit current funding models and our system does not always allow for the required integration.
It is by working through the service mix required, both private and public, which are specific to local need and achievable against available resources, that communities can find the solutions they need. Removing barriers to enable multidisciplinary healthcare teams to deliver comprehensive patient care across rural settings is key to making this work.
How to address increasing local demand for palliative care services, for example, needs a significant local commitment and many disciplines to make this happen. Working through to address poor service integration such as fragmentation which can sometimes occur due to policy barriers which limit the participation of allied health in aged and community care is another key example.
We know what’s needed and what works well in rural. We’ve had years of review and it’s time to implement. Lasting change can only be realised through enabling more community-initiated solutions, adding flexibility to enable service integration.
Finding local solutions in addressing need takes local leadership and time for critical planning which often needs to occur outside of practice hours. Support for this type of action can and will lead to improved skill utilisation and solutions which can work.
It really takes a whole community - involvement by all sectors of the health community – to drive this level of change.
In my own town of Wagga Wagga we certainly strive toward this level of engagement but in implementing new solutions our collective voice is not always loud enough. There is renewed hope that the new National Rural Health Commissioner can help us raise the volume enough for our community-led action to lead to change.
A big part of securing the next generation of rural GPs is around ensuring there remains a positive focus on general practice.
Rural practice is challenging which in turn makes it very rewarding, enabling you to develop a breadth of skills to build resilience in addressing need. Providing that insight for future doctors in a supportive way during those early learning years is so vitally important.
Sitting with a registrar recently, I was surprised to learn that he considered himself a rural generalist, and not a rural GP. This is despite the fact that he was training to a curriculum which is general practice: the endpoint in training for a rural generalist is of course a general practice Fellowship.
Let’s be very clear: rural generalists are rural GPs.
General practitioners are generalists by definition. The term ‘rural generalist’ describes a rural general practitioner working to the full scope of their practice with skill sets that are informed by the needs of the community they serve. These skill sets may encompass both advanced procedural and non-procedural skills working across primary and secondary care contexts with an emphasis on emergency medicine.
It’s about ensuring the right skill mix against demand.
The Federal Assistant Minister for Health, Dr David Gillespie MP, certainly knows this requirement well and his own definition is fitting: “A rural generalist is a doctor who’s trained as a general practitioner but has extra skills so that they can operate in a hospital setting as well as a community setting. That involves not just being a jack of all trades, but being a well-qualified doctor who can cope with the extra problems, clinical, public health, and hospital skills that you need to look after a regional town.”
It is the context that matters most and is key to getting health rural workforce policy right. The general (core) and advanced (specific) skills required in addressing patient need depend on the health needs and context of the community.
That is why it is important we align training investment to service need. In developing a rural generalist pathway nationally, this, therefore, must also be broad. We need a national pathway that equips general practitioners with a full range of competencies enabling them to deliver patient care closer to home in the primary and secondary care contexts.
We know that developing skills around the ongoing care considerations are the areas that best serve the community. We also know that dedicated and clear pathways for rural GPs to acquire advanced skills and utilise them in a way that is valued and recognised are important workforce factors.
Supportive strategies like these are vital in attracting and retaining a skilled rural workforce that is responsive to need. Most of all it’s about valuing the contribution to the healthcare system of quality general practice and its essential and enduring role in supporting rural communities.
 Gillespie transcript. 29 March 2017. RDAA Poli Breakfast. Dr David Gillespie MP Federal Assistant Minister for Health. Canberra.