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Thursday, 25 August 1994
Page: 388


Senator SANDY MACDONALD (3.40 p.m.) —The dire shortage of general practitioners in rural and regional Australia is an issue that must be addressed substantially in a bipartisan fashion. All governments and health professionals must work to help solve this ongoing crisis. Today, over 40 per cent of medical students seek to be specialists. The dissatisfaction with general practice is widespread and entrenched. This dissatisfaction is most clearly demonstrated in rural Australia, where little more than 10 per cent of Australia's GPs service 30 per cent of Australia's population. The expert view is not that we do not have enough doctors; it is just that they are not where they are needed.

  There are 54 medical practices in rural New South Wales desperately seeking to fill vacancies, including one in my home town of Quirindi. In northern New South Wales, the town of Barraba needs 1 1/2 doctors, Quirindi one, and Gunnedah is losing two from a group of five. Armidale is losing one and at Inverell last year the surgeon, the anaesthetist and a general practitioner all left.

  There are currently 250 practices throughout rural Australia advertising vacancies, with approximately 500 rural positions available. However, if we look at the need for medicos in country areas on a per capita basis, there is a real need for about 1,000 doctors.

  What are the causes of this decline? There are three main reasons. The first is social isolation, especially for those brought up in metropolitan areas. The second is professional isolation, and the third is the level of remuneration obtained by rural GPs. All three factors intertwine.

  On social isolation, there is the difficulty of finding suitable employment for spouses, the difficulty of making new friends, and the isolation of families when they are used to greater opportunities elsewhere. Doctors, like policemen and even politicians, are never off duty. A visit to a pub or a club always means free professional advice to their fellow drinkers. There is the lack of appeal that rural Australia might initially have for young women doctors, who now make up about 50 per cent of medical students. There is the problem that there are virtually no holidays because of the difficulties of acquiring a locum. There is often a limited choice of education for a doctor's children and the substantial extra cost of boarding, which may be the only option available to them. Generally, there are the distances involved—the impact of the tyranny of distance so understood by all of us who live outside the metropolitan areas in this country.

  Professional isolation is felt by rural GPs. It is very difficult for a medical education to prepare GPs for the professional isolation and emergencies they often face alone. The level of income for country GPs may not be commensurate, often for working 24 hours a day. This occurs for a couple of reasons. GPs get proportionally a lower percentage of the medical dollar compared with specialists and country GPs are doing less procedural work. In other words, they are not delivering babies or fixing broken legs as often as they used to, because of the move towards specialisation in medicine. This increased amount of consultation in general practice provides for a lower income. Overall, for them to provide to their families the sort of standard of living they would be able to provide elsewhere means that there is a requirement for a substantial financial incentive in addition to everything else.

  There are a number of possible solutions. The rural incentive program, which subsidies a doctor's move to a country area, should be made more attractive. Medical schools could allocate a percentage of their annual intakes to students from rural backgrounds, but this has obvious problems. Now, with the introduction of pre-medical degrees beginning at Sydney and Flinders universities, there may be a way to address this imbalance. Doctors can be encouraged into the bush through specific rural training. A good example is the Tamworth rural doctors training unit, which is doing just this in its four-year vocational training program for rural general practice. It is a first for New South Wales and the second such unit in Australia, for which the people involved deserve rich praise. There are 13 young doctors training at Tamworth at this time, out of a total of 20 in the state.

  There is now a national association of 10 to 12 rural training units, with units also at Wagga and Dubbo in New South Wales, and 85 young doctors Australia wide. This is being expanded. I am not saying that all these doctors will stay in country areas. However, overseas experience has shown that more of them will stay in general rural practice after experiencing country life during their training period. It becomes very attractive to some.

  The University of Newcastle should be congratulated for its excellent initiative which sends undergraduates out to country hospitals for internships under its country term program. The university's medical facility also has special entrance criteria for Aboriginal students, which encourages successful students to return to remote communities and tackle the major health problems confronting Aboriginal Australians.

  On another front, there should be increased funding for locum schemes to allow overworked rural GPs to take a break for extra training or just a holiday. Unfortunately, there is a belief that market forces will push GPs out to country areas. This has not happened. We have to ensure that people making decisions in relation to rural health policy know what they are about. The problem must be approached systematically. I will quote from the final report of the Rural Undergraduate Steering Committee for the Department of Human Services and Health. The report states:

The shortage of rural medical practitioners has not been solved by increasing the number of medical graduates and waiting for a `trickle down' effect from the cities to rural areas . . . Innovative strategies and those successfully used elsewhere need to be evaluated, developed and implemented in Australian medical schools.

Intertwined with this issue of rural health is the need for uniform state and federal legislation to address the ballooning medical indemnity costs. High insurance costs force rural general practitioners out of obstetrics and other high risk medical activities, leaving many women in country areas to travel long distances to rural centres for the delivery of their babies.

  Insurance costs for specialist obstetricians have risen from between $4,000 and $5,000 at the beginning of the decade to nearly $30,000 a year now. If GPs stop performing such services as obstetrics in these towns there will be a dramatic effect on the quality of life in smaller country centres and further burdens placed on regional hospitals. I quote from Senator Crowley's additional response to a question on medical indemnity insurance asked by me yesterday in the Senate and incorporated in the Senate Hansard today. She stated:

. . . there has been a continuation of the long term reduction in the number of GPs providing birthing services. In the period from 1988 to 1992, during which time there was a dramatic rise in the cost of indemnity, there was a decline of 732 in the number of practitioners delivering babies in the private sector—687 of these were GPs. This trend is of particular concern for rural areas where access to specialist obstetricians is limited.

We need all governments and health professionals to join forces and produce a workable system that will be equitable to all concerned and give value for money. If we do not do something about rural GPs, country people will continue to suffer. The system is not equitable, and the only saviour might be to have the flying doctor servicing a large part of the inland, not only our outback, as part of our folklore.