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Monday, 24 May 1999
Page: 5227


Senator EGGLESTON (9:59 PM) —The shortage of doctors in rural and remote regions of Australia is a complex problem that the Howard government has been tackling on many fronts with some success. In 1998 there was an increase of 4.1 per cent in the numbers of doctors in rural areas. However, the problem is far from being solved. Only 16 per cent of doctors work in rural areas while 30 per cent of the population lives in these areas. The problem has an added urgency when one discovers that an estimated 22 per cent of those doctors working in rural areas will retire in the next 10 years and on average doctors working in rural practice only stay for two years.

It is interesting to compare the experience of the more rural and remote provinces of Canada with what we are trying to do in Australia. Canada has similar problems to Australia, with the bulk of the population concentrated in their southern cities and with similar small rural farming communities as well as isolated centres in their remote northern areas. However, Canada has been much more successful in providing doctors to rural communities than has Australia. As of 1997, the Canadians had one doctor for every 797 people in rural areas whereas in Australia there is only one doctor for every 2,761 people. So Canada has almost four times as many doctors per head of population in rural areas as Australia. Why is it difficult these days to recruit doctors to rural communities in Australia, what has the Howard government done to redress the decline of rural doctors and can the Canadian experience be of any use to Australia?

Rural practice is unattractive to contemporary medical graduates for reasons which can be grouped under four headings. Firstly, working conditions: rural doctors very often are on call 24 hours a day, seven days a week. They suffer professional isolation, lack locum support and local back-up, and the level of technology available in small rural hospitals is usually not what they are used to. Secondly, there are social factors, largely to do with their partner's lack of employment, lack of educational opportunities for their children, distance from extended families, and the tendency of doctors to marry city people who find it hard to adjust to life in small country towns. Thirdly, these days young doctors lack the skills that doctors had 40 years ago: they cannot do anaesthetics, obstetrics or surgery. Finally there is the question of income. The population in rural and remote areas is small and, as with other professions, doctors find that practising in small towns is just not financially viable.

Given that these are the problems, what solutions can be considered? Firstly, it has been found that medical students from country areas are 40 per cent more likely than their city counterparts to be happy to work in the country after graduation. Medical schools are now being encouraged to reserve places for country students and in the recent budget the Howard government provided $4 million over four years to provide scholarships to meet the accommodation and other support costs of country students studying medicine.

Secondly, programs are now in place to specifically train doctors for rural practice so they have the procedural skills required. In WA, the Western Australian Centre for Remote and Rural Medicine, which is largely federally funded, has been very successful in providing general support, locum services and postgraduate education to rural doctors in WA. The federal government is funding the establishment of eight university departments of rural medicine, which will do much to identify the training needs of rural doctors.

Thirdly, addressing the issue of income, the federal government has set up the Practice Incentive Program, which rewards rural doctors and other GPs for providing quality care. In this year's budget the federal government has allocated $43 million to a rural retention grants scheme under which doctors who continue to practise in small rural towns for more than two years will receive cash grants to supplement their incomes.

Ideas promoted by the National Farmers Federation, such as geographic registration under which doctors are only allowed to practise in limited postcode areas in the country, just do not work. Coercing doctors into country practice when they do not want to be there is a recipe for an unhappy outcome all round. An example is the experience in South Africa when, to overcome the shortage of doctors in the country, army doctors were sent to country towns. These doctors resented being sent to the bush. They played a lot of golf and went fishing but were just not interested in remaining in country practice and as soon as they could they returned to the cities.

What has been achieved in dealing with this problem since the Howard government took office? The number of doctors in rural Australia has gone up by 7.2 per cent in the last two years and in remote areas it has gone up by 21.5 per cent. But in spite of this success the fact remains that Canada has four times as many doctors per head of population working in rural areas as we do. What is it that the Canadians do that we do not in Australia? One solution which has been very successful in some Canadian provinces is to put salaried doctors into health centres in small rural towns. In this model, community health centres in these small towns provide a wide spectrum of medical and paramedical services such as physiotherapy, occupational therapy, podiatry, social work and so on. Instead of having just one doctor, the centres have two or three salaried doctors, who thus have a reasonable working roster with adequate time off for recreation and study and who give each other professional support.

The concept of having salaried medical officers in rural areas overcomes many of the problems associated with the present model of traditional private practice in small towns. We do have a similar system to this in some parts of Australia such as in the north of WA where, in the Kimberley small towns like Halls Creek, Fitzroy Crossing and Wyndham as well as larger towns like Derby and Broome, the medical services are provided by salaried doctors working from the local hospitals, which have been turned into community health centres of a kind.

As part of the coalition's 1998 election commitment, the new Regional Health Service Centre Program is an initiative to further improve the provision of health and community care services in rural communities. Regional health service centres will be established in 30 communities which will involve the Commonwealth for the first time in providing funding for primary care medicine at these centres.

What about getting doctors to work in these centres? I believe that in the future, with the restrictions the federal government has placed on the availability of provider code numbers for private practice, it is going to become increasingly difficult to get private practitioners to work in small rural towns. This is because the doctors who obtain provider code numbers, and so can set up in private practice, will inevitably go to the larger towns and cities where they can make more money. So for those doctors who do not have a provider code number the option of working as a salaried medical officer in a regional health service centre will become increasingly attractive.

The question arises as to how such medical officers will be paid. In the Northern Territory, a trial of cashing out Medicare benefits is being conducted. Under this trial all the medical benefits which would have been paid for health services in an area are used to provide medical services, including buildings, equipment and the salaries of health professionals including doctors and paramedical staff. It is an interesting precedent, and I for one will be interested in the outcome of the trial, but there are problems in implementing the scheme.

In the Kimberley region of Western Australia, the state government funds medical services and it is possible that a combination of cashing out medical benefits and a mix of government funding and shire support could be the answer to providing medical services based on this model. The Canadian experience has been that salaried medical officers have been the answer to the provision of medical services in small rural areas and, as such, the Canadian solution could well be the answer to our problems.