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

Sam Heard

6/02/2023 3:14:06 PM

What happens when an area loses its GPs? Dr Sam Heard is witnessing the fallout, and has set out a treatment plan to combat the issue before it is too late.

Dr Sam Heard
The RACGP NT Chair Dr Sam Heard (above) has noticed a decline in primary care over the past decade.

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.
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Dr Diana Lorraine Hart, OAM   7/02/2023 12:09:12 PM

Sam it is happening in the city as well. For years I have sat on the area committee for shared antenatal care. This meant new mothers could also have a regular GP once the baby was born instead of flitting between various medical centres. Now we are forced to write a ‘named’ referral so the hospital specialists can access Medicare at specialist rates and we are no longer allowed to continue GP shared care. This is deskilling all the GPS in our area and consequently last year I resigned from the committee as there was no point in continuing. It won’t be long before the patients only go to the chemist or the specialist! The pharmacies are now allowed to give out JE vax and Zostavax. It is only a short step to include Yellow Fever and away will go all our Travel Medicine. So why would a young doctor want to do General Practice when we are being squeezed out in every direction. All our extra skills are no longer being recognised or valued despite us being more cost effective.

Prof Mark Raymond Nelson   7/02/2023 3:48:48 PM

Well said (written) Sam.

Dr Danielle Stewart   8/02/2023 11:19:52 AM

Excellent opinion piece. Sam knows what he is talking about and it’s good to hear some concrete solutions. I particularly like the idea of using tax concessions as incentives. As we all know, it’s a disaster everywhere. And very sad knowing that people foresaw this decades ago and warned against letting primary care suffer as it has. I still suspect we are heading in one of two directions- a system staffed entirely by salaried GPs like the UK NHS, or the USA version where GPs cease to exist and everyone uses specialists for everything. Neither one appeals to me at all but I’m not sure we can bring back general practice from this cliff edge when new graduates don’t have any interest in it. It’s just too hard for them to have to know everything about everything when they can earn more for knowing and doing less as a sub-sub-specialist!

Dr Susan Margaret McDonald   9/02/2023 9:53:09 PM

The Medicare system is not fit for the management of complex and chronic disease.
To work as a future GP you will not need to know everything about everything but you will need the trust of your patient, will need good supportive consistent teams, a good relationship with the specialists in your area, to feel valued by the community and your colleagues and be well remunerated on par with your hospital colleagues.
The increasing trend to subspecialisation needs to be reigned in as while it may be good for a small number of individuals it is not good value for money. The same with expensive new drugs for a few oncology patients. Spending the money on newer diabetic drugs with weight loss potential for large numbers of GP patients all across Australia will reap huge dividends.
Doctors will come back to GP land when they again feel in control of their profession,
are well paid and respected and their views are heard for primary care is still a fascinating specialty.

Dr Murray John Schofield   14/02/2023 11:07:58 AM

Sam, such great reflection and review. I wonder how often you may be engaged at the negotiation tables with the depts of health to consider the big picture options. I have often had discussions with my mentor and senior GP about the needs of remote Australians particularly ATSI people with a similar vein of thought to yourself.
However, we can talk about financial rewards which are no doubt significant and an enticement. But i think there needs to be a focus on what is offered by the local community/councils/NT government for partner employment, social connections, safety. Most of us come as package in some form either as a family, couple or a single with a pet. Simple needs but important for us all to be able to function at the high level needed as a GP in such situations.
We rarely see any discussion of the emotional/psychological need of GP's and what's available.
Much appreciated and inspired.
thx & kind Regards Murray

Dr Fiona Maclean Pringle   17/02/2023 1:28:37 AM

“Powerful incentives” and holiday cover are not the whole answer..

The more remote, the worse the GP crisis- not so!

In Central NT, Public and Primary Health Care is fully staffed with experienced GPs, who practise in some of the most remote areas of the NT.

Kim Mahood, in her book about Central Australia ‘Wandering with Intent’, described toxic management that can prevail, when “a petty power broker can reign unchecked for some years”.

It can’t be a secret that a good manager is critical to recruiting and retaining GPs.
At PPHC, the Medical Director knows and practises what works; it is “the best of times”.

What matters is his respect and genuine support of doctors, understanding the environment in which we work. There is a deep commitment to flexible work, a strong focus on opportunities for ongoing education, appropriate remuneration, open communication and encouragement of innovation and collegiate interaction.

As Eva Cox wrote “We know what works, so why don’t we do it.”