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Senate Select Committee on Health
Health policy, administration and expenditure

COVENTRY, Dr Tash, President, Rural Doctors Association of Queensland

MOSS, Ms Marg, Executive Officer, Rural Doctors Association of Queensland

SEN GUPTA, Professor Tarun, Immediate Past President, Rural Doctors Association of Queensland

Evidence was taken via teleconference—

CHAIR: Welcome. Thank you very much for joining us today, and we look forward to receiving an opening statement. Who would like to make a statement?

Dr Coventry : First of all, thank you for this opportunity and for putting up with the technical hitches. We get quite used to that in the world of telehealth and teleconferences, but it is still frustrating, and we appreciate your time. I guess I would just like to set the scene a little bit, because certainly the federal and state funding is an issue for rural medicine and rural communities. In rural areas the current separation of state and federal funding streams actually works against comprehensive general practice and patient-centred care. For example, in towns where there is sufficient workload for six funded medical positions to cover both primary or chronic as well as secondary or acute care, we are increasingly seeing two separate workforces. One workforce is funded federally and tasked with primary health care. In that situation these three doctors might work a standard working week consulting, nine to five, Monday to Friday. They are not expected to provide—and in some circumstances are actually prevented from providing—acute and/or hospital based care. They are not in a position to care for their own patients when having an acute complication for their chronic disease. The patient is not able to have continuity of care in their treating doctor. Meanwhile, the remaining three hospital based doctors are left carrying the full weight of emergency and inpatient care 24/7. The roster is, at best, a one-in-three on-call. There is no possibility of providing local extended specialist services, such as obstetrics or birthing. Recruitment is challenging for this second group, and retention virtually impossible.

This divided model of care also creates disharmony between the two groups and contributes to poor information sharing. There is duplication of services as well as service gaps, and it is not conducive to a patient-centred model. There is an increasing number of examples of this across the state, including Goondiwindi and Oakey and across Cape York. What a comprehensive and traditional GP model would deliver in the same sized town is quite different. All doctors would be involved in the delivery of primary and secondary health care, and all doctors should be providing general practice services as well as contributing to the hospital by means of emergency and after-hours care. This would also increase the potential for specialist services, such as obstetrics, anaesthetics and paediatrics, to be delivered locally. Rostering would still allow dedicated and protected primary health and general practice clinics. Information sharing would be automatic. Patients would be at the centre of care. Current examples of this are seen in Longreach and Cloncurry.

As mentioned, this holistic concept is the traditional rural GP model and has been a career pathway now accessible to newly graduated doctors in Queensland through the Rural Generalist Pathway, with much success. Over 200 are undergoing training concurrently, and 59 have already graduated from the four-year pathway. The majority of trainees and fellows are working in regional and rural areas. So, there is a future workforce for our rural communities. In 2016 the intake for Rural Generalist Pathways will be 80. So, there is ongoing hope for a future medical workforce and to be able to plan services in rural communities. This also allows better recruitment and retention of skilled staff to rural areas who are GPs with additional skills. They can be best utilised only when the jobs in rural towns continue to provide the diversity of care that these doctors want to deliver. The potential to increase capacity in rural hospitals is great, but it will require the pooling of federal and state funds into the future in collaborative service models.

So, in the review of federal funding we ask that it not be reduced but, rather, that efficiencies be found in collaborative care models in response to community needs, rather than funding sourcing driving the model of care being delivered. We understand that in some sites this could well require a current service needs assessment and even service delivery assessment, and we would support this in the hope of better meeting the health needs of our regional, rural and remote communities. Thank you.

CHAIR: Thank you very much, Dr Coventry. You have described innovation attempts in a pretty constrained environment.

Senator McLUCAS: Thanks very much all of you for presenting to us today. Dr Coventry, you said that some of the primary healthcare federally funded doctors are prevented from working in the acute setting. In the olden days—and I am probably showing my age now—we used to have doctors who would have private practice in a rural town but also work in the hospital as a visiting medical officer. When you say that they are prevented from working in the acute setting, what is preventing that from happening? Or have I missed something?

Dr Coventry : No, it is a very good question. In fact, that remains the model in many rural towns that have traditionally had those private GPs who would provide after-hours services to their private patients. Many of those will also take up positions at the hospital to provide public cover, and that is in addition to hospital based doctors, who have started providing primary health care and are certainly very keen to expand that. So, in successful towns we are seeing a very blended model of private and public health service delivery. The real standout appears to be through chronic disease and broadly Aboriginal medical services, where the workforce and the terms and conditions of employment are set up quite differently. Perhaps Marg or Tarun would like to answer that as well.

Prof. Sen Gupta : In many of the smaller towns we deal with there are people in the private system and people in the public system, and there is often the sensible blending of arrangements. What we think is really important is the skills available and the services provided to the town, not necessarily the model of remuneration. And you can see both things happen. You can see creative local models where people said, 'Let's pool our services, pool our on-call, deal with both chronic disease and acute disease and so on,' and that is a really sensible, good outcome. Silos can wind up with competing services—towns with several doctors on call or local arrangements that may, for example, mean that someone is not credentialed. They may have the skills but for some reason they are not locally credentialed to offer that service. That is what we mean by competing public and private services getting in the way of each other.

Senator McLUCAS: When the resource is not generous—to be kind, I suppose—we have got to make sure that we can provide the best care that is possibly available, particularly in a constrained environment. I was trying to truly understand Dr Coventry's comment about prevented, and I think you are going to scope of practice, Dr Coventry, rather than some legislative barrier.

Dr Coventry : I do not know that it is a legislative barrier but an employment barrier in some of the different streams that we have seen initiated.

Prof. Sen Gupta : If I could add to that: the way a lot of small Queensland towns work is that the hospitals do a really great job with the acute stuff. They will have staffing, they will have doctors on call or available, they will have nurses and so on, to deal with all the acute stuff. However, a lot of the primary care, a lot of the health promotion and the chronic disease management is done much more efficiently downtown in the private practice, where the funding, the models, the staffing and the way it is arranged is just different. That is more efficient than hospitals trying to duplicate that. The best models we see—St George was a recent model that I visited in south-west Queensland, where all of the doctors at the hospital do some work in private practice. So there has been a sensible local arrangement to enable that, so the skills are shared around and the patients' needs are best met by different doctors in the best place in that town—if that makes sense.

Senator McLUCAS: So you are in effect saying that primary health should be done by GPs and that acute health services should happen in hospitals. I do not think anyone would disagree with that. Is that what you are saying, and we just have to facilitate that to occur?

Prof. Sen Gupta : And I think finding local solutions to that, or enabling local solutions, but not barriers. So, yes, exactly.

Senator McLUCAS: Who puts up the barriers to that sort of local solution? I do not mean individuals by name, I mean structures. What stops those local solutions being found?

Ms Moss : I am happy to provide a couple of de-identified examples, if that is okay. One of the sorts of examples of barriers that we could offer is where in very remote locations there is actually not a private general practice presence. Generally the general practice services that are normally found in a private doctors surgery would be offered by a combination of a community care type of clinic or possibly combined with an AMS service. An example of a barrier seems to be where there is an interpretation that funding sources limit the service provider's abilities to transcend that primary health care/acute care divide. That would be a specific example that is very relevant to our most remote communities and some of our very rural, highly isolated communities.

The other example that we would give for more densely populated areas is in fact an example of duplication, where there is private practice in place, general practice in place, as well as general practice occurring in community settings. Someone may present with an acute presentation at the public hospital and then at times is in some ways overserviced by the public health system with allied health and follow-up care, for what are actually duplicated services that they have been receiving in general practice through advance primary care plans and the like. As an example of this type of duplication would be a diabetic who presents for some reason with an acute complication to an emergency department and then gets referred onto the public health system through numerous referrals. These are possibly the two examples—one is an example of duplication and overservicing; the other example is a consequence of some of our most isolated, most disadvantaged and sickest Queenslanders who receive in adequate services or have gaps and a lack of continuity in their service provision because of the perceived or real requirements of their funding sources.

Senator McLUCAS: Thank you, I understand that. Perhaps I should explain that I grew up in a little town called Ravenshoe and I was born in Atherton because we did not have a hospital in Ravenshoe, but that did not stop my brother being born in the hallway. I do understand what you are talking about, but in an isolated community there is simply not going to be a private GP in Pormpuraaw—ever, in my assessment. Am I missing something? I am sorry to push this but I am trying to work out what you are saying.

Dr Coventry : That size of community really needs the rural generalist model—GPs who are also capable of managing an emergency. It is unsafe for doctors to go to somewhere so remote if they do not have those skills because the communities will perceive them as a doctor with potentially lifesaving skills. Certainly, knowing the complexity of disease that occurs, it is a continuum where you cannot separate acute from chronic disease management. Yet the threat is that through funding it makes an artificial and competitive arrangement on the ground.

Senator McALLISTER: The idea of 'competitive' is interesting. Do you mean that it is competitive in the sense that different organisations are competing for financial resources? Or that different organisations are competing for talent in an environment where talent must choose between different organisations?

Dr Coventry : It is really the former. It is certainly competing for funding, whether through direct funding to provide the services or through access to Medicare billing.

Senator McALLISTER: What should be done about the way organisations or health care is funded to address that? Whilst people might use different language to describe that problem, the idea from a patient centred perspective is looking for a clear articulation between what is happening in primary health care and what is happening in acute care and on the way back into primary again. That is plainly a goal for everybody—even a bipartisan goal. What you think ought to be done to make that better?

Dr Coventry : There is certainly room to review the patient journey on the ground as it currently stands—with a great deal of funding being implemented and yet not necessarily resulting in service or outcomes that are positive. To really map what is going on—where the gaps are and where the duplications are—to get a sense of what the needs are for a healthy delivery of health care. Then we would have an idea of what the picture looks like and then we need to look at how we meet that with existing funding. Who pays for what? How do we share the funds so that the patient actually gets what is required? It is very piecemeal in a number of sites. There are services running in complete isolation without even understanding where they fit in the patient journey. With a lack of coordination comes an inefficient distribution of funds.

Senator McALLISTER: In thinking about the patient journey, another interface that we often hear about is that between GPs and other providers of health care in the Primary Health Network. Obviously in remote areas there is a particular model that seeks to address that, and that is through the Aboriginal community controlled organisations. They have a particular way of resolving that challenge. Does your organisation have a view about what a good interface between a GP and other health care providers in rural communities looks like?

Dr Coventry : That is an excellent question. The difficulty is that in each community that would look quite different—only in that the complexities over geographical isolation, the resources at hand, the potential for improvement in service delivery and even looking at being able to have birthing return to communities. There does need to be an overall sense of service planning that incorporates private, public and AMS streams as well, and there is not a great deal of evidence that that has been truly appreciated on the ground. Certainly there is a sense that it would need to be driven from a federal perspective. On the ground it is very difficult to change frameworks that have been imposed from a bureaucratic level at a more local, even state, level when it is so complex and the funding streams are quite difficult and to see if there is any flexibility in the way that moneys can be delivered. So there is a lack of flexibility, really, for how funding can be delivered on the ground. Even if local commissions came up with an idea of how it might be achieved, it is very difficult to really appreciate whether there will be a political response to that in favour of implementation.

Senator McALLISTER: So the Primary Health Networks, and prior to those the Medicare Locals, were one step in the direction of having a coordinated response to primary health care and, indeed, all health care in a geographic region. Has your organisation got a view about how that is going—particularly, I suppose, for the parts of Australia that your members work in?

Prof. Sen Gupta : Maybe I could say a couple of things about that. We certainly welcome the dialogue of the PHNs. I think it was Tash who said that the focus is really on the communities and the patients and how their needs are being met—not so much on programs providing individual services. To explain that: for example, we have had a lot of dialogue recently about Cape York, and there are really good services in Cape York—Apunipima, who you heard from today; the RFDS, who you also heard from; and the HHS. They are all doing good things. What was really appreciated is the dialogue to say to all of them, 'Can we all work together to make sure that we do not have three different sets of services flying to the same place on the same day and stretching things too thinly.' Can we not take what Puggy Hunter used to call a body parts approach to health, but a holistic approach to health? I think one of the things here is about that global coordination. So if you are going to Cooktown, where Tash is med super, she or her team would be the ones you talk to. In Pormpuraaw, it might be someone quite different; it might be the local health workers and so on. So you do need that local coordination, that local buy-in and that local view as to: 'What are the services that are needed and how are they best delivered in a coordinated way?' I think part of that then is also the evaluation and the reporting mechanism—even just how many services you provide and count activity. It is actually counting outcomes and counting the way those things have been coordinated and how things have been engaged, so the patients do have a much better experience and a much better journey through the system.

Senator McLUCAS: That is a real theme that has come through today from Dr Newland, from Dr Whitehead and from Apunipima—that desire for a more coordinated outcome for Cape York communities was expressed by all of them, even though they are all playing a part in the delivery of services. There seems to be a real appetite to move down that track, which is, I think, a good thing. I now better understand where you are recommending we should go.

Dr Coventry, can I go to your comments about the Queensland Rural Generalist Pathway and how successful that has been. Have we measured that success somehow? Is it still only Queensland that is progressing the Rural Generalist Pathway, and what should we be recommending about that in our report?

Dr Coventry : That is an excellent question. Yes, there has been an independent review of the pathway. It was released last year. I do not have it with me but I will certainly be very happy to forward that to you. In answer to your next question regarding implementation in other states, there has, through RACGP and ACRRM, been a dissemination of the success of that pathway. There is increasing interest and even buy-in from other states to adopt a similar model. But it has yet to be supported fully at a national level.

Senator McLUCAS: What are the barriers to that, Dr Coventry—or anyone?

Prof. Sen Gupta : I could say a little bit more about that. I think the success of the Rural Generalist Pathway is that it has been tailored to the Queensland situation. That means that it is not just a training pathway. There are four pillars, and they relate to recognition and reward of the profession and attractive career pathways. In other words, at the medical school level we now see our best students applying for the Rural Generalist Pathway and queuing up in numbers. There are 77 across the state for the 80 places next year. So it has been tailored to Queensland and the obstacles have been removed, making it attractive and easy for people to train. There is a bunch of data that we will happily send through on the email about the evaluation and also about the data. The critical things are as follows. Firstly, there is the tailoring to the local jurisdiction and the remuneration needs. Secondly, people are well trained in their first few hospital years and then they go bush. While they are completing training, they are providing a high quality service. The 220 current trainees in Queensland and the 59 graduates are providing a high quality service to rural Queensland in the last two years of their training. That is important.

The external evaluation also demonstrated return on investment. The money that that state has put into this has actually been returned—this is an Ernst & Young figure—by about 1.3 or 1.4 to one. That is in terms of savings on aeromedical retrievals and the provision of services locally, with people not having to be transferred and dealt with elsewhere in expensive major hospitals. Those are the kind of key factors. Also, I want to mention one more thing. There is a criticism that this is kind of the state health system, and that it is aimed at public hospitals. In fact, the communities are benefiting because there are skilled doctors in increased numbers available in those communities. Many of them are spending time in private practice. The data we can show you suggest that 30 per cent of trainees are spending some amount of their time in private practice. That number is increasing. The amount of time people are spending in private practice is increasing. So the community is benefiting both publicly and privately.

Dr Coventry : I just want to add to that. We are seeing an evolution now. Certainly initially it was about trying to keep sites that were birthing open. So the big push was to have good GPs with their vocational registration with either ACRRM or RACGP, but with an additional procedural skill. It has truly evolved now to be far more about meeting the needs of the community and for there to be a lot of office based additional specialist skills, such as paediatrics and mental health. We are seeing the super GP now being very much supported and trained through the entire system, and predominately within the health system. They need to be able to handle emergencies and have basic anaesthetic skills as well. But, certainly, they need to have the capacity to be further trained in the private sector and to, ultimately, work in private general practice.

Senator McLUCAS: And not necessarily in a rural setting. The skills are quite transferable into an urban setting as well.

Dr Coventry : Absolutely. That is right.

Senator McLUCAS: Do we know how many of those rural generalists are still in country areas?

Dr Coventry : Yes. At the moment, the 59 fellows, I believe, are all in either regional or rural areas. It is very difficult to have proceduralists go to remote areas simply because the facilities are not there to utilise their anaesthetic skills or their obstetric skills. As we develop more rural generalists with mental health as their special skill and Indigenous health as their special skill, we are really wanting to have that cohort move out to the smaller communities that do not necessarily have a secondary hospital within the town itself.

Senator McLUCAS: How long has this been going on for? Just remind me. I know that we have heard this before. How many years of training of rural generalists have we had?

Prof. Sen Gupta : The first intake was 2007 and the number has grown since then. I have some very simple graphs that I will email through to the email address we have been corresponding with. I will do that now so you will see in a snapshot what has happened over the past few years. Essentially, the intake was 20, 30, or 40 for a few years. Former Minister Springborg announced two years ago that the intake would double the 2016 intake to 80. We have 77 enrolled, so we are very close to that. As to the question about how many continue to serve in rural areas, the vast majority do. There are small numbers that are lost to some of the specialties—anaesthetics, for example. However, they tend to still attach their practice regionally—in the regional centres or outer metropolitan. So they are certainly still meeting the needs of underserved populations.

Dr Coventry : They are GPs. That is the bulk of their work. The special skills augment the job that they do. This cohort is so keen to deliver services that provide that inpatient, outpatient emergency and general practice care that it would be remiss to then have a system that did not allow them to practice to their full scope. I guess the hope is that there is this rationalisation within our rural and remote communities, now that we have a workforce suitable to working in those locations, so that the positions themselves are receptive and reflect using those doctors to their full capacity.

ACTING CHAIR ( Senator McLucas ): Unfortunately, we have run up to time. It was really important to get that evidence on the rural generalist pathway. We have had conversations around that for a long time in this committee and it has been really good to get that on the record. On behalf of the committee, I thank you all for presenting to us today and, in particular, for agreeing to provide us further information, as you identified, Professor, to that email address.

Prof. Sen Gupta : I have just sent those details through to Michael. Thank you very much.

ACTING CHAIR: Thank you. We have not had any documents tabled. I thank all the witnesses who have appeared before the committee for giving their time today. Thank you also to Hansard, Broadcasting and the secretariat. Thank you for coming to my city of Cairns.

Committee adjourned at 15 : 53