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Community Affairs References Committee
05/06/2012
Health services and medical professionals in rural areas

CORDWELL, Dr Lauren, Manager, National Rural Faculty, Royal Australian College of General Practitioners

KIRKPATRICK, Dr Kathryn Anne, Chair, National Rural Faculty, Royal Australian College of General Practitioners

[13:50]

CHAIR: I understand information on parliamentary privilege, and the protection of witnesses and evidence have been provided to you?

Dr Kirkpatrick : Yes.

CHAIR: We have your submission, No. 41. I invite you to make an opening statement and then we will ask some questions.

Dr Kirkpatrick : I am a GP in Dalby, Queensland, on the Darling Downs. I have been a GP for quite a number of years—I do not want to reveal how many. I have been a member of the Royal Australian College of General Practitioners since the early 90s. The RACGP is one of two colleges recognised by the AMC as specialty colleges in general practice. We are responsible for education and standards for the profession of general practice.

The RACGP has over 20,000 members of whom 19,000 are GPs practising in Australia. The National Rural Faculty has over 7½ thousand members spread throughout Australia. You have copies of maps of distributions in our submission but we will leave with you today some new figures as of yesterday so that you can see graphically where our membership lies.

Senator MOORE: There are no maps in our copies.

Dr Kirkpatrick : I will leave them with you. We have a very vibrant faculty. Over 4½ thousand of our 7½ thousand members work in RA 2 to 5 locations. The National Rural Faculty aims to support our members through education and training so that they can provide the very best possible health care to their communities.

The Fellowship of the Royal Australian College of General Practitioners certifies competence to practise as a GP anywhere in Australia—urban, rural and remote. The Fellowship in Advanced Rural General Practice is awarded by the National Rural Faculty on behalf of the college as a post-vocational training fellowship. It recognises the advanced skills that some GPs undertake in order to increase their confidence to practise in a rural community. So you do not have to have a FARGP to practise, but we recognise that some GPs have undertaken extra study skills procedural training, and we recognise that with the fellowship. We have some 429 graduates of our FARGP. The FARGP was originally a graduate diploma and it was first awarded in 1996.

Senator NASH: Can I ask what FARGP stands for?

Dr Kirkpatrick : Fellowship and Advanced Rural General Practice. Currently we have 424 enrolments in the fellowship.

CHAIR: How many graduates did you say you had?

Dr Kirkpatrick : We have 429.

CHAIR: That is what I thought. And there are 424 enrolments?

Dr Kirkpatrick : Yes. And those enrolments can be practising GPs as well as doctors enrolled in general practice education and training through GPET. The RACGP has the largest rural membership of any specialist medical college in Australia. That is across all the specialties and yes, we are all special.

You have read our submission and I do not intend to reiterate that, but I would like to talk about the complexity of recruitment and retention of rural doctors in Australia, and the sorts of things that we need to consider. There needs to be consideration of: the individual doctor, their personal attributes and needs as well as their professional needs; and their family and what their family needs to be there in order to support the doctor in the town—and sometimes that is an extended family. We also need to look at the community and to think about local government as well as the state and federal governments. We need multiple tiers of consideration in order to think about how best to serve rural communities with the best health care, the health care that they should expect and the health care they deserve.

The other thing to share with you is that in April 2012 in Canberra the National Rural Faculty celebrated 20 years of the faculty. As part of that we had a breakfast forum, which was attended by medical students from ANU and some of the other universities, registrars, GPs old and new, members of DOHA and people from GPET. The question that was posed at the forum was: if government had an unlimited amount of money, identify the strategies to secure and retain the current and next generation of GPs in rural and remote Australia. It was a great discussion.

Senator MOORE: We should have been there. It would have been such a great forum.

Dr Kirkpatrick : It was. What struck me the most was the generosity of the participants in what they shared with us. There were lots of personal stories, not just pie in the sky; it was coming from personal experience.

Senator NASH: Is there an audio recording of that morning that we could have? Did anybody record it?

Dr Kirkpatrick : No. We have a letter that went to the health minister with the information, but I am sorry; we do not have the audio.

Senator MOORE: Can we have the letter?

Dr Kirkpatrick : We can do up a letter. That will be fine. We had a panel where three of our board members of the National Rural Faculty presented their stories and their visions for general practice. They were very different; we had a doctor from the Riverland in South Australia, an international medical doctor from Wagga Wagga and a medical student who sits on our board. So we had three very different perspectives on general practice and what general practice can look like. Then there was a small group discussion. The top-rating discussions were taken to the floor, and that is where our list came from. I thought I would share that list with you, if that is all right.

It was separated into support for rural GPs and their families and their communities. The top thing was keeping rural hospitals open. Having a hospital in town is one of the joys of being a general practitioner in rural and remote Australia. It means you can look after your patients from the practice into hospital; they do not have to leave the community, except in extremes. If you are confident with what you are doing or you have someone on the end of the phone that you can call then you can keep them in the hospital. Secondary care is something that all of general practice has lost and is something that the RACGP would like to reclaim. It should not be the province just of doctors working in rural general practice; it should be open to all GPs, because that is what GPs used to do. For many reasons, we have lost that ability to admit to hospitals in regional centres.

Senator NASH: Could I interrupt one more time and ask you whether you can provide on notice for the committee the reasons that we have lost that ability to be in hospitals?

Dr Kirkpatrick : Sure. The Provost of the faculty has a wonderful history. At our dinner at the faculty celebrations he gave a speech which will give you that information.

Support for families of rural GPs: a number of speakers today have spoken about employment for spouses and education to children. I would like to add child care to that. When I went bush I was a single parent with an 11-year-old child who I used to have to take out of town to get overnight care when I was on call. That was a one-in-two on call. She hates the bush with a passion, now, because of her experience of having to be away from mum. It was also a problem if I had an unexpected delivery and was called out—but you are never off call in a rural community, anyway, because you are working a one-in-two on call. I will share with you a story. My daughter appeared outside the labour ward one day, with her hairbrush in her hand, saying, 'Mum, will you do my hair?' She knew very well how to do her hair, but it was: 'Mum, you are my mother; you are not just the GP for the town.' That is my personal story but I have heard similar stories from my colleagues about children in that situation. Child care is important so that women—and men—can work knowing that their children are being well cared for.

Senator McKENZIE: You are not talking about a typical six-to-six childcare centre; you are talking about a flexible—

Dr Kirkpatrick : It needs to be very flexible, because general practitioners in rural Australia do not lead six-to-six lives. We have stories from our members who are GP-obstetricians with children about getting a call: 'We've got Mrs So-and-so in labour. Can you please come?' The doctor turns up but there is nowhere to leave the children, so they take the children with them. The hospital then complains because the children have appeared at the hospital while mum or dad is doing the delivery. In one case the doctor said, 'I am going to stop obstetrics,' and the hospital said, 'Whoa! We hadn't figured on that one. How might we work at that?' The hospital actually set up an area that the children could be occupied in, so there would be videos and games and books so that the children were occupied and safe while mum or dad could do the delivery. The other extreme was when the doctor said, 'I'm giving up obstetrics,' and the hospital said, 'Good, we'll close the maternity unit.'

CHAIR: I have heard of that before.

Dr Kirkpatrick : So there are different takes on it. But good child care is really important so that we can do what we are trained to do but also have children and have a family life.

Senator MOORE: Doctor, I think this has almost degenerated into a discussion. We are all saying 'I'm sorry' while we interrupt.

Dr Kirkpatrick : I am happy to have a discussion.

Senator MOORE: If you could keep going through the points, that would be great.

Dr Kirkpatrick : International medical graduates are a large proportion of our general practitioners in rural and remote Australia. The RACGP has had two programs that were pilots funded by the Commonwealth to provide mentoring to IMGs and assistance to achieve fellowship of the RACGP. The evaluation of each program found that neither should exist without the other, that there is a need for mentoring so that IMGs can integrate into the Australian healthcare system and understand their community, but they also need assistance to achieve the professional qualification. There is a need for general practice mentors. There needs to be appropriate support and training for those mentors so that they can understand there is a difference between mentoring and supervising and enable them to provide that rock.

Leading on to supervisors, the National Rural Faculty would like to see a program whereby semi-retired and retired GPs can be supervisors for the next generation of doctors who are coming through. At the moment there are difficulties with the current registration system around continuing professional development recency of practice. Retired doctors are unable to provide that supervision for clinical training. We suggest that GPs who are looking to wind back their clinical practice can wind up their supervision and support for students and GP registrars. We are developing a paper around that.

There are a number of members of our board and at the forum who were passionate about restoring hands-on learning of procedural skills to undergraduate training. When I went through I had to get 20 deliveries as a sixth year medical student. Now a medical student can come through the system without having performed a delivery, or they might only use a simulator. So it is about enabling medical students to undertake procedures during their learning and not just out in the community. If they have a skill that they can take with them when they are in a rural community then the engagement is much better.

CHAIR: I was just imagining how someone would simulate childbirth.

Dr Kirkpatrick : There are models. We would like to see the number of rural places and the length of rural placements increase, but it cannot be without support for supervisors. We are already stretching our teachers, but there are only some 1,500 general practices in Australia that teach. One of the things that we need to do is to make teaching valuable to the teacher, but not to the detriment of providing health care within the community.

Senator MOORE: Now the doctor is waiting to be interrupted!

Senator McKENZIE: There is a difference between a vocation and a profession. There desire to give back and develop the next generation is more from people entering a job as a vocation rather than a profession. Is the development of the vocation of their role as a GP or as a doctor still happening within their training?

Dr Kirkpatrick : Sorry, I am not quite sure of your question. Do you mean the role-modelling and the apprenticeship—

Senator McKENZIE: No.

CHAIR: There is a special skill to teaching. Do you mean—

Senator McKENZIE: I think even using the word 'skill' is glossing over it. That thing—

CHAIR: Love or commitment or—

Senator McKENZIE: that makes good teachers or good doctors is more than just an acquisition of skills and application of those skills.

Dr Kirkpatrick : I am sure there a born teachers and born doctors.

Senator McKENZIE: And there are doctors who are technicians and doctors who are doctors in the sense that I am talking about, in the sense of its being a vocation. I will flesh it out hopefully in a question on notice and it will be a bit clearer for you.

Dr Kirkpatrick : Can I say that in Britain they are mandating education and teaching models for all of their medical students and registrars so that everybody has some degree of understanding of educational method and how to teach. In Australia there is an understanding that everybody will teach but often times there is no 'teach the teacher'. It is becoming recognised as a need but it has not been a mandated activity.

Senator MOORE: Doctor, when the students stream out on their medical placements—you have the different levels of medical placement: the undergrads and then the clinical schools, where it is much more focused—to have their country practice, my understanding is that the GPs who take them on all volunteer. They say that they are going to do it but it is an individual choice. There is no requirement to have any particular experience, length of time or anything before you say, 'Hey, I'll take one, or two.' I know sometimes they go in pairs now, for safety. That is right, isn't it?

Dr Kirkpatrick : Absolutely. All of those points are correct. But we also hear from our students that they prefer to have a critical mass of health professional students, whether it is doctors, physios or OTs, because they learn from each other and they are supportive of each other—rather than having a single placement in a small community without reliable—

CHAIR: They may never have been in the bush before, or in a small community.

Dr Kirkpatrick : Absolutely.

Senator MOORE: So a place like Dalby would be okay, because of the size and the hospital and the other services that are there.

Dr Kirkpatrick : Yes.

Senator MOORE: That would provide the experience. But Charleville or somewhere like that may not.

Dr Kirkpatrick : I think Charleville is a great place.

Senator MOORE: So do I.

Dr Kirkpatrick : One-doctor towns can be a really valuable place to learn, except if the GP is burnt out and professionally isolated and is not going to give a good perception—

Senator MOORE: A good experience.

Dr Kirkpatrick : of what general practice is about. So, there needs to be support for the supervisors.

Senator MOORE: But at this stage that person could put their hand up and get a placement. There could be too much negative feedback later, but they could have already done the damage.

Dr Kirkpatrick : Yes. The National Rural Faculty, in association with the Australian College of Rural and Remote Medicine, has the contract to deliver the Rural Procedural Grants Program. Are you aware of the Rural Procedural Grants Program? Yes. I do not need to talk about that. The National Rural Faculty would like to see the funding for that extended. We would also like to see it extended to other areas of advanced skill. At the moment it is restricted to surgery, obstetrics, anaesthetics and emergency medicine. There are other areas of medicine that are practised at an advanced level by general practitioners in rural Australia that would benefit from recognition and support to maintain CPD.

Senator McKENZIE: Such as?

Dr Kirkpatrick : Such as mental health, Aboriginal health, paediatrics and internal medicine, to name a few.

CHAIR: And the rest.

Dr Kirkpatrick : Those are the big ones—mental health, Aboriginal health and internal medicine—because there are very few general physicians anymore, so the role of the rural general practitioner is to take on the role of the general physician. Being able to maintain a continuing professional development in that area would benefit the community. I am nearly at the end. The next few points come to identifying community need. It is no good placing doctors in a community where the need does not exist. We need current information about what would benefit the community and increase their health. It might be that we need someone with Aboriginal health skills or we need someone with mental health, or there is an hospital but we need an obstetrician and an anaesthetist in order to be able to provide the mix of skills that complement each other to deliver the health to the community. That was really confused and I am terribly sorry.

CHAIR: It is all right. We got it.

Dr Kirkpatrick : Good. We need that local health information and, while Medicare Locals seem to have a huge job on their hands, once they are established we would hope that that would be one of their roles.

Senator McKENZIE: Have you been able to communicate that to somebody that defines the role of Medicare Locals? Has there been a process that you have been able to be involved in?

CHAIR: I thought that was inherent in what they were supposed to be doing.

Senator NASH: We are really struggling with trying to get a sense of how they are going to work.

Dr Kirkpatrick : It is written into their contract.

Senator McKENZIE: So it is part of their role. We are not hoping that it will be part of their role.

CHAIR: I thought one of the key ideas of having Medicare Locals was to do just that.

Senator McKENZIE: Data collection.

Dr Kirkpatrick : Except we are feeling quite anxious about—

CHAIR: Whether they are actually going to do it.

Dr Kirkpatrick : How they are going to manage to do everything that—

Senator NASH: With the Medicare Locals, who is going to audit the set-up process of each of the individual Medicare Locals? It just seems to me that it may not be right in the set-up phase, and nobody seems to be able to give us a clear indication; there is no real template and it is all quite grey and there seems to be a lot of independent authority to set Medicare Locals up as they see fit to deal with local issues. But who is actually going to audit and oversight the initial set up process, to your knowledge? How does that work?

Dr Kirkpatrick : I do not know. Sorry.

Senator MOORE: It is the department. Get the department back and ask them. It is certainly the department.

Senator NASH: Yes, thank you. I am just interested to know if anyone out there has any sense of it, but obviously you do not either.

Dr Kirkpatrick : I attended a think tank that was run by the National Rural Health Alliance and the Australian Healthcare and Hospitals Association. The thing I took away from that was that there is a sense of the unknown and no sense of certainty.

Senator NASH: Thank you.

Dr Kirkpatrick : The last point that I would like to raise is about rural general practitioner self-care. It is about us supporting our membership so that they are not professionally isolated, that we are not placing students with burnt-out GPs and that there are safe working hours. That is about looking at models of general practice. It is about job sharing. It is about complementary skills in communities. There needs to be a range of skills that GPs have in a community and there needs to be general practitioners in rural Australia who work in an office based situation to keep the practice turning over while the colleagues are at the hospital delivering emergency services, anaesthetics or surgery. There needs to be a network of GPs in the town to provide the broad spectrum of care that is needed and to keep things ticking over. Thank you.

Senator McKENZIE: In your submission you are very supportive of clinical placements during doctor training. We have heard a variety of views on it from other submitters. I am interested in your reasons as to why it is an important part of doctor training.

Dr Kirkpatrick : It is about seeing patients, getting medical experience hands-on. It is about experiencing the culture. And it is even about self-esteem because the students are allowed to take a history, make a diagnosis—under supervision—

Senator McKENZIE: Could you—

Dr Kirkpatrick : Did I misunderstand the question?

Senator McKENZIE: No, you didn't. I was not specific enough. I am talking about the mandatory nature of a rural placement. The argument has been, 'People who want to do rural, go and do rural; other people, don't waste our energy'—the low-hanging fruit argument. Could you make a comment on why it is important for all graduates to do a rural placement?

Dr Kirkpatrick : If you do not go, you do not know.

Senator McKENZIE: Work for the NT.

Dr Kirkpatrick : You do not know what you do not know.

Senator McKENZIE: I am looking for evidence that it has these other things to it.

Dr Kirkpatrick : Not off hand, I do not have it. I suppose we all have anecdotal evidence that it works. I am one of those. I grew up in Toowoomba. I started out in aged care and rehabilitation. I set up the first aged-care assessment team for Queensland. It was in south-west Queensland and we covered 400,000 square kilometres. I saw what rural GPs did. I did not have a very rural experience when I was a student. I had a midlife crisis, I suppose, and retrained, went back to the hospital for 12 months and went bush to Miles, a one-doctor town. I was the second doctor and became a procedural rural GP.

Senator NASH: Is it worth giving consideration, in a policy sense, to the tracking of the rural medical students going out on placement? It seems to me it would not be too hard to gauge from them whether they intend to practise in regional communities. Some will say yes and some will say no. Then you could track, down the road, among those who said no, having gone out and done rural placement, who then changed their mind. Wouldn't it be sensible to actually track that data?

Dr Kirkpatrick : I will have to check, but I am sure there is a paper that came out of the clinical school in Toowoomba recently along those lines.

Senator NASH: Yes, that would be useful. But it is not just a responsibility of the individual jurisdictions. Maybe this is a national data collection type of idea, so that we can then specifically track to see if going to a rural placement actually changes somebody's mind when they were not going to go to the bush in the first place. I will go to my other question. There are differing views around the Queensland health rural generalist program. I know you say in your submission that the state based medical workforce initiatives are working as deterrents to the recruitment and retention of rural general practitioners. Perhaps you could expand on that for us.

Dr Kirkpatrick : The feedback we have from some of our members in Queensland is that private general practice cannot compete with the amounts of money through the industrial award that Queensland health offers to attract private GPs. So if as a fourth- or a fifth-year you can get $300,000 working for Queensland health in a Queensland health facility, private general practice cannot compete with that. And given that the end points of training for a Queensland health program are both general practice end points, there needs to be a community experience. There needs to be experience in community general practice, or else you are not getting the true training to general practice. So the registrars who are within the hospitals or the rural generalist trainees who are within the hospitals do not particularly want to go out into community general practice, because there is no comparable income for them. We have heard that from a number of our members who are rural GPs in Queensland, where there is a Queensland health hospital, as well as the private GPs.

Senator NASH: I am just trying to get my head around this. Obviously the Queensland rural generalist program came into being because the private system was not providing the workforce necessary. So I understand the argument that they cannot compete.

Dr Kirkpatrick : No. Queensland health employs doctors to run hospitals in Queensland. So in small towns there might be a doctor who is the medical superintendent at the hospital and who also might work in general practice. So Queensland health employs the doctors.

Senator NASH: I understand that, but what I am getting at is that that has obviously sprung up for a reason through lack of workforce, so something was not working properly in the first place.

Dr Kirkpatrick : Yes, but is was not the private GPs; it was doctors not wanting to work in Queensland health hospitals, or single-doctor towns where there is a hospital and they are the only doctor in town. So it was about attracting doctors to work for Queensland health.

Senator NASH: So where is the competition that makes the private sector say they cannot compete? What would they otherwise be doing? If you took away the rural generalist program—and that is probably the best idea—what would be happening, that is not happening now, that they cannot compete for?

Dr Kirkpatrick : Private GPs work in town. I will give you an example: Dalby. At Dalby we have a 20-bed hospital. There are four doctors employed by Queensland health at the hospital. They work purely in the hospital. We have three medical practices in town. I work in one of the major ones there. We have eight full-time-equivalent GPs. We work as VMOs to the hospital, but we are not employed by Queensland health. If the doctors are not at the hospital then the private GPs would be picking up the patients. The patients would get a Medicare rebate and then pay us, whereas the doctors at the hospital are paid by Queensland Health to see the patients that present at the hospital. I am not explaining this very well.

Senator NASH: No, you are explaining it very well actually. Before those doctors went there were any or all of the eight GPs fulfilling that role that is now being usurped by the other doctors coming in?

Dr Kirkpatrick : Queensland's system is different from New South Wales and Victoria—

Senator NASH: I am conscious of the time, so could you take that on notice and provide to the committee how it works. Use Dalby as the case, if you like, to give us an explanation so we can get our heads around it.

Dr Kirkpatrick : Sure.

Senator NASH: That would be great.

Senator MOORE: Dr Kirkpatrick, I know you were in the room when the College of Rural and Remote Medicine were here.

Dr Kirkpatrick : Yes.

Senator MOORE: You have your own rural practice program within the College of GPs. How does that work with the College of Rural and Remote Medicine? Do they crossover? Are doctors members of both? Tell me how they work together.

Dr Kirkpatrick : They work in parallel. Many of the members of the Australian College of Rural and Remote Medicine have a fellowship of the Royal Australian College of General Practitioners. They also have a fellowship of the ACCRM. The RACGP program offers training to GPs which is context specific. They all have core skills but they pick up skills to meet the context in which they wish to practise. That may be an Aboriginal medical service. It might be a procedural practice in rural Australia. It might be an urban practice. So our core fellowship enables a doctor to practise anywhere. Then our FARGP, as I explained earlier, recognises any advanced skills that they might pick up to increase their confidence to practise. We have both colleges for general practice and accredited for general practice. Some of the doctors who are training—so the registrars with the RTPs—are training to both end points. Some of the training is recognised by both colleges. Some of the training is specific to one or the other.

Senator MOORE: So you can get recognised prior learning? If you have gone through the work that you do under the College of GPs in the special rural area that could be assessed in your application against advanced status at the College of Rural and Remote Medicine?

Dr Kirkpatrick : I believe it is a possibility. I have not been a member of the ACCRM for quite some time.

Senator MOORE: From just reading it from the outside it would seem as though they are doing very similar things, that the core practice is GP and to get your FRACP, which is one of the first number of letters after someone's name when they become doctor. But the actual specialists in rural medicine seem to be doing very similar things. Do you work together as organisations, particularly on things like lobbying on policy and advocacy? Do you the two colleges work together?

Dr Kirkpatrick : There is an organisation called United General Practice Australia, which is made up of the RACGP; the ACRRM; the RDAA, the Rural Doctors Association of Australia; and GPRA, General Practice Registrars Australia. It was the division's organisation. UGPA has certainly lobbied together around certain situations that have been specific for general practice. There is that united approach.

CHAIR: Thank you. There were some questions on notice. We will send out a note to clarify what those questions are. Thank you very much for your time, and your submission is much appreciated.

Pr oceedings suspended from 14:35 to 14:52