How to save primary care in remote Australia: RACGP NT Chair

There is a health workforce crisis in Central Australia and much of remote Northern Territory.
 
The current social disruption and negative experiences of residents in Alice Springs mirrors the turmoil sometimes faced by remote health staff. But this is our country and remote Australians require healthcare to a level that many in the city do not.
 
Patients are having dialysis locally, there are emergencies that frequently require patients to be evacuated, along with housing, educational and environmental issues that desperately need advocacy.
 
It was not always like this.
 
During more than 30 years as a GP and educator in the Northern Territory, I have attempted to strengthen primary care and have been ably supported by motivated colleagues along the way: young doctors, nurses and Aboriginal health practitioners in training, and by older doctors who have moved to the area to contribute to the health of remote Australians.
 
Over the past decade, however, I have witnessed a worrying decline in primary care services and an unwillingness to tackle the issue until it is too late.
 
How did we get here?
The first casualties have been independent primary care services through general practices in Tennant Creek, then Nhulunbuy and finally Katherine.
 
Doctors in these independent practices used to make good incomes by combining primary care, occupational health and hospital procedural practice. Then hospital services, here as elsewhere in Australia, became increasingly reluctant to use GPs, and have employed their own staff – a move helped by allowing hospitals access to Medicare.
 
Many more doctors now work in these remote hospitals, offering a free and responsive emergency service to the town and enjoying a relatively infrequent on-call roster.
 
This change, and the reduction in GPs, has led to more ‘outreach’ primary care, with doctors in the hospital who have some primary care experience, or are training to provide primary care, visiting remote communities or even offering general practice services in the hospital.
 
The reduced medical provision in remote communities places pressure on remote nursing staff, who have responded by working predominantly as locums with an increased focus on financial reward.
 
When a workforce consists mostly of locums, costs will inevitably escalate as virtually everyone will be influenced by the financial offerings.
 
More recently, as the funding of general practice and Aboriginal Community Controlled Health Services (ACCHSs) has stagnated and salaries become less competitive, staffing issues have had an impact.
 
At first this appeared to be related to COVID-19 and confined to remote regions, but the situation has deteriorated dramatically over the past six months. GPs in training have taken up places in remote areas of the NT at the lowest rate since 1990, and applications for graduate nursing positions in Central Australia have evaporated.
 
The negative impact of staff shortages on current staff is serious and there is no solution in sight. I believe we are at a tipping point that may see primary care provision revert to early colonial times with the entire health service being provided by government.
 
The new ‘single employer’ model for primary care training demonstrates how unattractive it is to work outside of government in rural and remote areas, and how unwilling government is to enable support for transfer of entitlements.
 
Why preserve primary care and equity?
In 1992, Professor Barbara Starfield, a paediatrician and researcher, proposed four pillars of primary care: first-contact care, continuity of care, comprehensive care, and coordination of care.
 
The promptness of access, the comprehensiveness of the care and how well it is coordinated are well recognised as key features of quality.
 
Not only did Professor Starfield recognise the key aspects of healthcare required for better outcomes, she also drew attention to the dangers of over-supply of specialists. In 2010 Australia was ranked about eighth in the world for strength of primary care and around fifth in health outcome indicators.
 
However, the number of specialists is growing rapidly and interest in working in primary care reducing dramatically.
 
The health issues in remote Australia are at rates that are among the worst in the world for some key diseases; diabetes, kidney disease and rheumatic heart disease.
 
Serious life-threatening infections and other presentations remain common. While everyone understands the social determinants of these conditions, healthcare can mitigate the effects significantly.
 
Unlike some city-based advocates, I do not see effective comprehensive healthcare or care coordination occurring without GPs and well-trained nurses. For those who see nurses as the solution, recent locum nurses without any primary care qualifications were offered incomes that amount to over $500,000 per year. 
 
Powerful incentives needed
I propose a comprehensive solution to support GPs, rural generalists, nurses and Aboriginal health practitioners who work more than six sessions per week to help ensure an engaged workforce that delivers the continuity of care that people desperately need.  
 
I will begin with the locum provision, the most pressing issue given the current shortages. GPs in private general practice in the NT find it very difficult and costly to get away, which adds to burnout pressures. Locum costs are also very high for ACCHSs, particularly now locums are needed in towns such as Katherine and Alice Springs where accommodation is costly and difficult to organise.


The viability of independent practices in remote parts of Northern Territory has been a casualty in recent years. 
 
To help address this, I propose doctors, nurses and Aboriginal Health Practitioners whose main employer has been a general practice or an ACCHS in the past 12 months, and who provide and co-ordinate care in MMM areas 6 and 7, receive locum cover for six weeks each year. This would be fully paid by the Primary Health Network (PHN), with locums given accommodation and a car – keeping it competitive as all health professionals giving locum cover in NT hospitals receive the same.
 
Then there is the question of income. GPs in ACCHSs and private practice now earn less than their city-based colleagues, and while nurses and Aboriginal Health Practitioners do earn more money working in NT primary care, it is not sufficient to recruit staff. There needs to be a considerable differential in income to address the health practitioner shortages in these areas.
 
Tax relief could be a powerful incentive to help do this, and I propose all health practitioners employed by a general practice or ACCHs do not pay any income tax if they live in MM7 areas, while those living and working in MMM 6 would have a top rate of 20%. The eligibility criteria would be similar to the locum relief, but the health professional would only need to have been continuously employed for the previous three months for the incentive to start.
 
Training pathways
Working in remote primary care is difficult and requires considerable orientation and often learning a number of new skills. Feeling confident that you, along with the help of the local team and remote specialist support, can deal with the problems that present themselves is important.
 
This is most likely if there are adequate training pathways such as the RACGP and ACRRM training, Advanced Training in Remote Indigenous Health Care, Graduate Nurse Training in Primary Health Care and Indigenous Health and Graduate Aboriginal Health Practitioner Training.
 
Then there is the work of the Anangu Health Service, with the Central Australian Aboriginal Congress collaborating with Australian National University to develop a centre of excellence for remote healthcare.
 
There is, however, a major shortage of GPs in training in both college pathways for 2023, which needs to be addressed. Neither could present solutions due to the massive undertaking they had to transfer training from Regional Training Organisations (RTOs). With virtually no trainees from either college in remote private practice or the ACCHSs, a significant training opportunity is going missing.
 
Remote supervision is also increasingly important during workforce shortages. Placing two nurses or GPs in training where one experienced staff member would normally operate, and ensuring quality remote supervision, is a possible framework to help halt and reverse the trend.
 
Time to act
A full quota of staff who are trained and supported is essential to meet the needs of remote Australians. The numbers and costs are small when compared to national healthcare budgets.
 
It is time to act in a decisive and meaningful way.
 
Dr Sam Heard is the RACGP’s inaugural NT Chair.
 
Log in below to join the conversation.

NT Rural general practice