Far from the facilities and comforts of the city, a small but highly dedicated group of health care professionals and volunteers work to ensure the people of the bush have access to quality medical services. With ingenuity and commitment, these outback.
By Pamela Robson and Kirsty McKenzie
When Bryan Connor was studying at the University of Glasgow’s prestigious medical school, he envisaged the years ahead as a suburban general practitioner (GP), treating coughs and colds, dispensing antibiotics and hormone replacement therapies, and referring patients with more complex problems to a battalion of specialists. He considered the prospect of coming home in the dark, winter evenings to sit comfortably by the fire, do the odd crossword, read a John Grisham novel or watch The Bill on television before going to bed to prepare for another routine day. But he didn’t like what he saw, so he did something about it.
In need of a challenge, Bryan applied for registration in Australia as an International Medical Graduate (IMG), which meant he had to work in a rural or remote area of need. That is how he ended up as the sole doctor in the small north-west Queensland town of Richmond, serving about 2000 people scattered over an area of 30,000 square kilometres. For the record, that’s half the size of Scotland, bigger than Wales and twice the size of Northern Ireland.
Over the past seven years, Bryan has delivered scores of babies, plastered broken limbs, cut out skin cancers and stitched up lacerated muscles as part of his daily rounds. He is regularly called out to emergencies, which are often life-threatening injuries resulting from car crashes or station mustering accidents. He finds himself sewing up wounds caused by dog bites or, more often, feral pigs. He is a psychiatrist, dermatologist, cardiologist and surgeon to his patients, and they love him for it. It’s about as far from the life of the average suburban GP that Bryan can get.
When his time was up as an IMG and he had the luxury of opting for life in the city or by the beach, Bryan decided to stay on, and then moved even further west – by about 287 kilometres – to the slightly larger town of Cloncurry (population 3500). The reason? There are three GPs and they can share the burden of the 24-hour on-call roster. Quite simply, Bryan is hooked on country living. He is the closest possible thing to the traditional family doctor as immortalised in A Country Practice or Dr Finlay’s Casebook – the type of medico who has all but disappeared from the city and suburbs, but who most people would love to have.
Offer Bryan a suburban practice where he can work part-time and sip a latte or go shopping and there’s just no contest. His stamping ground is among the cattle stations of northern Australia, which can be as isolated as any Antarctic field base. Here, he has to rely on personal initiative. He is the supreme generalist in an age of specialisation – and he wouldn’t have it any other way. He is passionate about making a difference to the lives of the small fragmented community he serves. He spills over with praise for the people of the bush who, he argues, deserve the same standard of health care as the people of the city. They put up with so much more; they are uncomplaining, loyal and decent. The doctor-patient relationship is very close in a small community, where the family doctor can make a big difference to people’s lives. That’s the key to what keeps most rural doctors in the bush.
Rural GPs are a feisty lot. They have to think on their feet, accept being on-call all the time and, importantly, have the self-confidence to deal with almost anything that comes along. They are the doers of this world, the types who naturally rise to challenges; none of them are bystanders in life. Talk to a few of them and sooner or later they’ll say something like ‘you only get out of life what you put into it’ or ‘you have to like having medicine intrude into your life’ or ‘country GPs are immeasurably happier than their urban counterparts’.
Bryan Connor has just been named the Royal Australian College of General Practitioners’ (RACGP) GP of the Year, partly because of his efforts to attract new GPs to the bush and then supporting them when they get there. The problem is that, while Bryan and many other rural GPs can’t think of a better or more satisfying way of life, the bush has difficulties attracting and retaining young health professionals. “In the past, there have been too many young people who were daunted by the prospect of hard work, no let-up and isolation,” Bryan says. “We’re showing them that being a GP in a rural or remote area can be infinitely more satisfying than life in the city where much of the time you never really get to know your patients.”
Bryan says education is the key. “We bring undergraduates here and let them see that it’s not just all hard work – they won’t be left on their own,” he says. “I think in the past a lot of rural doctors felt overwhelmed and undervalued. But there are changes taking place, and they’re all for the good. There is more emphasis being placed on training and supporting rural doctors. I’m optimistic that we can bring more people out here who are better trained and will stay. I can see the rebirth of the country doctor.”
There’s plenty of evidence to show that those living in non-metropolitan areas are likely to be in worse health than those living in the city or suburbs. For indigenous people, the situation is even more dismal with health standards far below the rest of Australia.
Although 30 percent of the Australian population lives in rural or remote areas, only 22pc of male GPs and 17pc of female GPs practise there. A recent survey conducted by Access Economics for the Australian Medical Association (AMA) highlighted critical deficits in psychiatry, obstetrics and anaesthesia. Also in short supply are nurses, midwives, dentists, physiotherapists and other members of the allied health professions. The health woes of the bush are also due to the gradual but relentless shrinkage of health care facilities like country hospitals and maternity units that has shadowed the depopulation of country towns since the 1970s.
The shortage of health workers isn’t confined to the bush nor is it an exclusively Australian phenomenon. Around the developed world, people are living longer, technology is advancing and demand for health services is ever on the increase. At the same time, there is an undersupply of medical personnel, and they are also getting older. The average age of a nurse or GP is well into the 40s and creeping closer to retirement age with each year. Countries such as the UK and US have already started cranking up their tertiary training programs.
Every state in Australia is struggling to meet demand for doctors, nurses and allied health professionals. Many people trace the shortages back to a Federal Government decision to slash medical places at universities a few years ago. According to the government, even with the new places created in the previous budget, it will not be until 2016 that shortfalls will be addressed because it takes many years to train a doctor or nurse.
But once doctors and nurses are trained there comes another hurdle – state governments will have to be able to afford to employ them. Right now, when medical workers in the UK graduate, the national health system can’t find the funds to pay them. London’s Daily Telegraph recently reported that the extra money pumped into training health professionals had provided skilled graduates who were now working in McDonald’s, bars and supermarkets, or moving overseas. And the country that most were moving to? Australia. Indeed, more than half of the doctors working in the bush are from overseas. In Queensland, where the state government is still dealing with the fallout of the Jayant Patel case – the Indian-trained US surgeon linked to the deaths of 17 patients at the Bundaberg Base Hospital – and where the shortage of rural doctors has been particularly serious, Premier Peter Beattie has travelled to the UK for a couple of intensive recruitment campaigns.
When a town is facing tough economic times, there tends to be an exodus of business owners and professionals who opt for the financial security of urban areas where there are better prospects. This includes GPs and other health workers. Governments have typically responded to fiscal restrictions by cutting back services in the less populated, outer areas to concentrate funding on centralised facilities in larger centres where they are most efficient. It makes sense; a larger central hospital can deliver more sophisticated but costly services more easily, whereas a series of small hospitals can each offer only a limited, more modest range. However, it also means rural people have to spend more money and time on travelling to those services. As one GP puts it, governments are simply moving the costs of health care on to the patient. Pregnant women are being forced to travel hundreds of kilometres to give birth because the maternity ward in their town has been closed, while cancer patients have to travel long distances for ongoing treatment.
According to the Rural Doctors Association of Australia (RDAA), if a patient in the bush is diagnosed with cancer, they are up to 300pc more likely to die over the ensuing five years than if they lived in a well-off city suburb. Former RDAA president Dr Ross Maxwell, a GP who has been serving the south-east Queensland town of Dalby (population 12,000) for the past 17 years, says many rural patients can’t have a cancer diagnosis and treatment close to home and therefore in a timely manner. It is this lack of access that creates poor cancer outcomes in the bush. “Obstetrics and emergency facilities are among the biggest worry, and there’s a serious shortage of specialists like psychiatrists and dermatologists,” he says. “Up to 30pc of all our calls are about mental health problems and up to 70pc of those patients have a diagnosed mental health disorder.”
The RDAA also wants to see the Federal and state governments communicate with each other and coordinate rural health care delivery. According to the association, the Federal Government has been introducing very useful support measures to maintain the procedural work force in rural areas, but state governments have been closing hospitals in which these proceduralists work. This is illustrated by the fact that 130 small rural maternity units across Australia have been closed in the past 10 years. It wants substantially more government funding for patient and carer transport and accommodation if diagnosis or treatment requires people to travel to larger hospitals in the cities. It is also lobbying for financial incentives that will keep doctors in the bush, such as additional locum support and bigger loadings paid for after hours and on-call work.
But, like Bryan Connor, Ross Maxwell believes the satisfaction he gets from the job outweighs the problems. “I really enjoy the people,” he says. “It’s a wonderful privilege to be able to live and work with a community; to get an insight on how people deal with the problems in their lives, how they cope in adversity. It’s like a three-dimensional jigsaw. I feel very fortunate being able to make a difference in some small way. I guess that medical practitioners in the cities have a sense of satisfaction, but I believe it’s more powerful, more intense, in a small, isolated community.”
Ross says training is critical to keeping doctors in the bush as it equips them to deal with the rigours of remote practice and then they are more likely to stay.
More places have been added to the key medical schools around the country. A new medical school has been established at Queensland’s James Cook University – Australia’s only new medical school in 25 years and the only full medical school in Queensland’s far north. A survey of the first cohort of James Cook medical students showed 64pc would be seeking internship positions in non-metropolitan areas after graduating.
Both the Australian College of Rural and Remote Medicine (ACRRM) and the RACGP run fellowship courses that dovetail with mainstream medical studies. ACRRM was formed 10 years ago out of a conviction that rural GPs needed their own organisation. About 600 GPs broke away from the RACGP, which they believed was too urban-focused. ACRRM now has more than 2000 members and an active executive.
In June 2006 the Council of Australian Governments (the body responsible for coordinating national policy across state and territory governments) recognised rural medicine as a generalist-specialist discipline under Medicare. This was an important milestone for the rural doctors who had been lobbying for the right to have the GP generalist recognised as a classification and for GPs to have accredited training
in subjects such as obstetrics, anaesthetics, surgery and emergency medicine – normally the preserve of the specialist colleges.
The states are now recognising the need for high-level generalists, with Queensland Health introducing the Rural Generalist Program, otherwise known as ‘Country Gold’. This is the result of a good deal of hard lobbying by people including Associate Professor Dennis Pashen, vice-president of the ACRRM and director of the Mount Isa Centre for Rural and Remote Health. Dennis, a former GP from Ingham in far north Queensland, has been stirring for a better deal for remote doctors – and, ultimately, their patients – for many years. The Mount Isa centre is part of James Cook University and one of a series of centres in places including Broken Hill, NSW, Alice Springs, NT, Geraldton, WA, and Whyalla, SA, which were started in the mid-1990s by the government’s Department of Health and Ageing. It acts as a support centre and provides accommodation for more than 200 medical, nursing and allied health students training across 700,000sq km of remote Australia. It has a skills laboratory to help train students in procedural and emergency medicine, a library and a research unit.
ACRRM recently won an Australian Primary Health Care Research Institute grant of $1.8 million to study the role of generalists and what it will take to successfully develop a future generalist workforce. Dennis says that, without proper training and recognition, rural communities have little hope in attracting and keeping health professionals. But he also says that changes to the way health services are delivered are crucial.
It’s a sentiment shared by Dr Chris Mitchell, the vice-president of the RACGP and chair of the National Rural Faculty. “We keep hearing that we need more doctors,” Chris says. “It’s all about ‘workforce, workforce, workforce’. But the situation is far more complex than that. Yes, we have an acute shortage of doctors, nurses and other medical personnel; we have an ageing population and an ageing medical workforce. But, realistically, we’re not going to be able to find the numbers we need. We need a bigger workforce just to keep pace with where we are at today, yet future demand will be greater still. We can’t stand still. If we just keep doing what we are doing now, the wheels are going to fall off.”
According to Chris, who is part of a multi-doctor practice near Lismore in northern New South Wales, not only are more people needed, but resources must be used carefully too. “We also need to expect that nurses and other practice staff will do some of the jobs that doctors do today,” he says. “Some allied medical professionals will also need to be able to do a wider range of things. Our practice nurses are already taking some of the roles currently provided by podiatrists and dieticians.”
Many general practices are becoming one-stop shops providing services from acute fracture care to cardiac rehabilitation, while an increasing range of chronic disease management is expected to take place at practices in the next few years. “Increased specialisation does not necessarily mean we’ll get better results,” Chris says. “In fact, there is extensive literature to show the more we invest in general practice care the better the results for patients.”
The RACGP runs the four-year Fellowship in Advanced Rural General Practice course. It has been shown over the years that 70pc of those GPs who participate in the course will stay in the bush. It includes a 12-month stint of advanced rural skills training in subjects such as anaesthetics, obstetrics, emergency medicine, mental health and Aboriginal and Torres Strait Islander health. Participating registrars chose a mix of training to meet the special needs of their community.
In his role with the college, Chris sees that each state is looking at different solutions. For example, New South Wales has funded procedural training programs and has also identified mental health and emergency medicine as priorities. “New South Wales has funded supernumerary positions for hospital registrars so that country hospitals, which are often under extreme financial pressure, get a free, fully-funded registrar,” Chris says. “South Australia has developed a really good package and is supporting rural doctors through incentives such as providing locums while the doctor is away from his or her practice because of training. In Victoria, they have a ‘hospital in the home’ program. This is about keeping the patient at home with good monitoring and support care. This has special benefits for country people. The Federal Government funds a really wonderful program, which gives financial support to cover costs of locums, flights, etc. to enable rural procedural GPs to leave their practices and travel to do 10 days’ training a year.” With new techniques constantly developing, this support helps keep sk