Closure of Katherine’s only general practice hits home for rural GPs

Anastasia Tsirtsakis

26/11/2020 3:41:27 PM

Practice owner Dr Peter Spafford’s experience highlights Australia’s rural workforce challenges and their impact on local communities.

Katherine road sign
To cater to the 10,000-strong population of Katherine, it is recommended the town have nine GPs – but the only general practice in town was operating with just two.

Katherine’s only general practice closed its doors just last month, leaving the 8000 patients on its books with no other option but to travel three hours to Darwin for a GP consultation.
The decision to close was not an easy one for GP and practice owner Dr Peter Spafford – who has been a resident of the Northern Territory town for 19 years and owner of Gorge Health for 10 – but he felt he had no other option.
A 2018 workforce assessment conducted by the Northern Territory Primary Health Network (PHN) recommended the town, with a population of almost 10,000, needed nine GPs to provide a service equal to elsewhere in Australia.
The reality on the ground, however, has been just two GPs, four at best.
‘But even with that number, there have been waitlists. So there’s always been a difficulty in providing full general practice services to the community,’ Dr Spafford told newsGP.
The decision to close was not a sudden one.
Dr Spafford had been struggling to recruit GPs for some time and the practice had financially ‘limped along’ with people expecting to be bulk billed – a model he says is unsustainable.
‘Unfortunately, what’s happened is that over time there’s been more and more pressure being applied to general practice, per se, and it’s no longer fun,’ Dr Spafford said.
‘Running a small business, every year there are more regulations, there are more problems with employment. The Government doesn’t make it easy.
‘We get no benefits at all for being out here. We get nothing.’
Katherine holds a special place in the heart of RACGP Rural Chair Dr Michael Clements, who completed two-and-a-half years of his training in the town.
‘It’s very disheartening and disappointing. The impact on this community can’t be underestimated,’ he told newsGP.
‘We know that if it’s hard to get access to primary healthcare chronic disease burden will increase, acute health emergencies will increase, and mental health will go untreated because the GPs provide the bulk of mental health care in any community.
‘So we really must see the relevant agencies such as the PHN, the GP training organisation and the Territory Government look to see what novel solutions there are.’
Dr Spafford told NT Independent he approached the local PHN for a solution in May, and was told he would not be involved in that process.
The NT PHN has secured another local GP to operate an interim service one day a week out of an aged care facility with the aim to increase hours as more GPs are secured.
While a positive step forward, the community remains under-serviced.
Dr Spafford says the expansion of the telehealth item numbers in response to the COVID pandemic were welcomed, but he was discouraged by the amended requirement for a patient to have visited the practice face-to-face in the previous 12 months.
‘For the people who really need telehealth, like people out on the [cattle] stations … basically by bringing a rule like that you take that opportunity away from them,’ he said. ‘Just to try and stop some people from rorting the system.
‘It wasn’t rorting the system, it was providing alternative healthcare.’
While the amendment represents a significant relaxation on the 2019 telehealth requirement to have seen a patient three times in the previous 12 months, Dr Clements recognises the barrier.
‘In the efforts to restrain overspend on telehealth, it looks like we’ve left our rural and remote communities behind,’ he said.
‘The rule of needing to see patients face-to-face in the last 12 months to access telehealth is a barrier and it should be looked at as part of the revision of telehealth, which is early next year.’
RACGP Rural Chair Dr Michael Clements calls the closure of the Katherine practice ‘very disheartening and disappointing’.

While he does not claim to have the answers, Dr Spafford believes more needs to be done to secure an adequate workforce and questions aspects of the Rural Generalist Program.
‘One of my big bones of contention with the Rural Generalist Program is that they come here to work at the hospital and solve their problems, but it hasn’t solved general practice,’ he said.
The sentiment comes as no surprise to Dr Clements, who says Dr Spafford’s comments ‘certainly echo what we’ve heard in other rural communities’.
‘The experience in Katherine that Dr Spafford describes, where there are rural generalists engaged in the hospital but not working in community practice, does not actually meet the Collingrove definition that has been agreed to by ACRRM [Australian College of Rural and Remote Medicine] and the RACGP,’ he said.
‘It’s never been the end goal to have rural generalists just filling rural hospital positions.’
To address the shortfall of GPs working in community practice, Dr Clements says state, territory and federal government authorities must work together and ensure positions are distributed between general practices and hospitals.
He says the current challenges are largely a reflection of the current processes and funding regimes in place.
In a submission to the National Medical Workforce Strategy, the RACGP called for rural GPs to be ‘remunerated appropriately for the increased risk they carry, the on-call hours, and their additional skills’.
‘It is often a situation where hospitals are offering more stable salary packages, which can be very attractive,’ Dr Clements said. ‘This is similar in community controlled Aboriginal health services, where multiple sources of funding can help offer the GP a package that recruits them and attracts them to that particular environment.
‘Unfortunately, with a reliance on Medicare and fee-for-service modelling in the past, it can be very difficult for private practices like Dr Spafford’s to compete with those state governments and Indigenous services.
‘There are certainly some rural incentive payments and rural bulk-billing incentives. But these are by far nowhere near the magnitude required to attract and retain staff.’
The solution, according to Dr Clements, is multifaceted and requires a whole-of-system approach that considers everything from housing security and spousal employment to children’s education and the training environment.
In its submission, the RACGP put forward the single-employer model, so as to allow for the portability of employee benefits for GPs in training from placement to placement, as well as support for GPs and their families to move to rural locations. 
‘We’ll continue to train and advocate for community-based general practice,’ Dr Clements assured.
‘We’re proud that the majority of our training pathway takes place in community general practice as a means to support that model of care.
‘We think it’s important that the state-based jurisdictions work hard to ensure that anybody training in the rural generalist pathway are encouraged to take on the dual roles as per the Collingrove Agreement.’
NT PHN was approached for comment.
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Dr Ian Mark Light   27/11/2020 8:53:22 AM

Workers on oil rigs off shore deservedly are remunerated very generously and though it is a different pressure remote General Practice deserves the same considerations as do the vital support workers such as psychologists and acute and chronic care nurses .
A supportive team plus solid remuneration and good security backing is an obligation .
A huge Research solar farm with Battery Construction and other projects like heat resistant native crops in the area ought be recommended.

Dr Graham James Lovell   27/11/2020 9:09:16 AM

No Australian Government has had the wisdom and insight to see the incredible value that Australia has had in their General Practices.
Value proven in outcome data showing improved health outcomes for the community versus no improved community health outcomes from increased Specialist numbers,
who now outnumber GPs , and cost markedly more to both Medicare and the patient
(one of my local greedy surgeons wanted $4,000 MORE than his colleague for the same operation).
With the difference since Medicare started in increases between GP rebates and CPI now around 50% this model of funding for what is a privately run business is not sustainable in its intended and original format.
The bureaucrats without this insight have inevitably encouraged the nightmare of 5 minute medicine, and it’s negative impact on the standard of care.

Dr Nell De Graaf   27/11/2020 8:16:57 PM

Going to be alot more expensive than funding general practice properly when the whole town attends the hospital for everything!
Also may make it not so pleasant to work in the hospital when its workload increases massively....

Dr Christopher Edward Clohesy   29/11/2020 9:53:49 PM

ALL doctors should undertake a compulsory rural/remote rotation. The taxes of rural/remote people helped finance the undergraduate and postgraduate training of all these doctors.

Also, having a rural background as a selection criteria to do medicine has clearly failed. Universities need to re-examine their selection policies.

Regional training providers need to prioritize rural/remote placements first before urban placements are chosen.

Dr Hung The Nguyen   8/12/2020 3:41:13 PM

It is always sad and concerning when a GP clinic closes in rural and remote Australia. However, it is not true that Dr Spafford's clinic is the only GP clinic in Katherine. We need to remember the value of the ACCHS, in Katherine's case it is Wurli Wurlinjang HS, for the rural community and for the large Aboriginal population. Most ACCHS do see a significant number of non-indigenous patients. Most ACCHS are accredited to the RACGP Standards for General Practice 5th Edition and provide a valuable, evidence based, comprehensive, whole of life care to families and communities.
Make no mistake, although the Katherine community is suffering without its private GP clinic, it cannot live without its ACCHS.