Should rural general practices be embedded in hospitals?

Jolyon Attwooll

23/03/2022 4:20:43 PM

The issue is under the spotlight after a senator asked if rural areas could ‘just get rid of private practice’ during a Senate Committee hearing investigating workforce struggles.

Sign pointing to a hospital and health campus.
Basing general practices on regional hospital campuses has been floated as one solution to helping ease the rural workforce crisis.

‘In rural health, we should never ever talk about single solutions or an always-or-never solution with how things should change.’
That is the view of RACGP Rural Chair Dr Michael Clements, who has a particularly comprehensive grasp of the challenges facing general practice in remote parts of Australia.
He made the comment in response to the main talking point emerging from the latest Senate Committee hearing on providing health services to outer-metropolitan, rural and regional Australians: whether rural general practices should be based in state-funded local hospitals.
The question was put by Hollie Hughes, the Federal Senator for NSW, who has become noted for an adversarial approach towards a profession that has been at the forefront of the COVID-19 pandemic response.
Following a similar pattern, Senator Hughes made her inquiry in loaded terms shortly after a $45,000 incentive payment for rural hospital doctors was discussed.
‘Listening to what was being said, as to the attractiveness of the hospital situation, I thought: why don’t we just get rid of private practice – just fund more GPs into hospitals some way or another and just get rid of private practice?’ she said.
‘And if you want to go into private practice, that’s your choice, but we could look at solutions in rural areas – I’m not talking about everywhere – and having more GPs based out of a hospital who’d go under that system.
‘Do it that way, because, if you’re not having problems recruiting there but you can’t keep them in private practice, and if we’re going to start looking outside the box at different ways to do things, what’s the point of private practice?’
Looking beyond the language, Dr Clements said there is merit to the idea in some circumstances – and that it is already in place in certain communities.
‘A good example of where this is already occurring is Barcaldine and Longreach [in rural Queensland],’ Dr Clements told newsGP.
‘[They are] a very clear example of where they’re doing this, where there is a well-functioning general practice that’s offsite to the hospital.’
However, he states that in those instances clear boundaries need to be established to ensure the same approach as general practices elsewhere.
‘Whether it’s operated by a hospital or by a community-controlled organisation, or by a private business shouldn’t really matter – as long as they are treating it like a traditional general practice, where you can make appointments, have a GP that knows you,’ he said.
Dr Clements is also equally clear that ‘every solution needs to be tailored to the community’.
‘Certainly, we shouldn’t have a hospital take over general practice where there could be a viable general practice with the right supports, or if the proposed model wouldn’t follow the traditional general practice models of care an accredited facility requires,’ he said.
Dr Cathryn Hester, a practice owner and GP in Karana Downs in Queensland, is another to urge caution for ideas that offer easy fixes to complex problems.
‘You have to be really careful because it sounds like such a simple solution, but it has the effect of really distorting the marketplace for GP services,’ Dr Hester told newsGP.
‘While it can be a solution to a market failure of general practice, it could also cause the failure of private practices in regional and rural areas, which is really not helpful for communities.’
Dr Hester also believes state governments do not have a reassuring track record of running effective primary care.
‘It’s just not their usual remit. They don’t understand the continuity of care and longitudinal care in the way that GPs do,’ she said.

RACGP Rural Chair Dr Michael Clements believes any general practice workforce solution needs to be tailored to the community it is trying to serve.
Another witness at the hearing, Dr Eleanor Chew, pointed out the ‘distinct difference’ in the role of a GP in a rural community compared to a hospital doctor.
‘We have a large amount of evidence that supports the fact that care provided by a GP, in terms of the continuity of care provided to a patient, is much more beneficial to the patient and far more cost effective,’ Dr Chew said.
‘With hospital practice, one gets episodic care, acute care – reactive care. With the GP, one gets holistic, comprehensive and continuing care.
‘The outcome for the patient is far, far better with a regular GP than it would be with hospital care.’
A further witness, Professor Richard Murray, Dean of the College of Medicine and Dentistry at James Cook University who has qualifications in rural general practice and public health, pointed to the changing nature of general practice, and the impact that a robust primary care system could have on hospital care.
‘With an ageing population with increasing comorbidity and increasing complexity, relationship-based healthcare, GPs and primary care teams ... are the ways that we will help to hold back the costs of acute public hospitals,’ he told the committee.
‘By allowing general practice to degrade and fail, all we’re doing is tripling the costs and, indeed, losing opportunities to improve the life, dignity and health of the community – by allowing a primary care system to fail.’
The committee is looking at potential remedies, including rural general practices moving into state-based hospital care, although witnesses did not always find it easy to air their views.
At one stage, Senator Hughes was reprimanded by committee Chair Senator Janet Rice to stop ‘disrespectful’ interruptions, having urged another witness to ‘move beyond the “woe is me” mentality’.
According to Dr Hester, GPs in regional and rural areas are not engaging in self-pity, but rather are finding it ‘tougher and tougher’ to serve their communities for ‘a multitude of reasons’.
‘Having to try to run a general practice when you can’t actually recruit general practitioners because nobody wants to be a general practitioner – that’s tough,’ she said.
‘Also, the escalating costs of providing care, which haven’t been matched by Medicare [is exacerbating the situation] – it’s not just GPs being fragile snowflakes.’
Dr Hester also describes a claim made by Senator Hughes that other small businesses in rural and regional towns do not get the same sort of federal support as general practice as ‘incorrect’.
‘One that springs to mind is that pharmacies get an enormous amount of federal funding to be operating in regional and rural areas,’ she said.
‘They are small businesses, and of course, they’re vital for communities just as general practices are, so I don’t think GPs really need to be called out specifically.’
She is hoping for a change in tone.
‘It’d be much nicer if we could see Senator Hughes spending a day in general practice to see what it is that we actually do,’ Dr Hester said.
‘She might be able to form a more informed and balanced decision as to whether she should disparage GPs to this extent.’
The full transcript from the recent Senate Committee hearing is available on the Parliament of Australia website.
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Dr Horst Paul Herb   24/03/2022 11:03:42 AM

With all due respect, perhaps it would be more helpful if the "witnesses" or commenters on the matter would be GPs actually working in those areas where the proposed model could be implemented. A practice in a suburb within 40 minutes driving distance from the Brisbane CBD is hardly representative of rural and remote practices with long standing viability problems for private practice.
In the Kimberley, the Gulf of Carpentaria, and Cape York (my main work places) hospital integrated General Practice has long been established, and successfully at that.
The plus side is having a life besides work, being able to enjoy a family life, and to take time off when required for ongoing education and training - all things that were impossible when I still had my own rural practice. Income is also much better, thanks to a disproportionate funding of hospital services vs chronic underfunding of primary care.