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Dr Kerryn Phelps, AMA President, to the NSW Summit on the Rural Doctor Shortage, Tamworth, New South Wales

Good afternoon.

We are here today because there are not enough doctors in country Australia.

In fact, there are not enough doctors in Australia overall, but the situation is, by far, the worst in the rural areas.

Country people know it, doctors know it, and the AMA knows it. Our politicians know that health is the number one issue in rural areas but do not yet recognise that current policies will not deliver the doctors where they are needed.

Why is there a doctor shortage?

There has long been a problem getting doctors to country towns and communities and keeping them there - the Federal Government tried to find solutions but the problem persisted.

Indeed, it has more than persisted. Today there are new pressures:

    • huge medical insurance bills for doctors - obstetricians, neurosurgeons and other specialists being forced to stop practising in some areas because of the costs and the high risk of litigation, forcing young mothers-to-be to travel long distances to have their babies and placing more pressure on those doctor who remain.
    • the country GP who performed some procedures such as delivering babies, doing anaesthetics and minor operations can no longer afford the insurance costs, and is being forced to give up some of this more professionally rewarding work at great detriment to the local community and reducing the attractiveness of rural practice.
    • the heavy-handed threat of prosecution under the Trade Practices Act stopping doctors cooperating to provide round-the-clock services to patients as they have always done - bureaucratic meddling of the highest order

As recently as this week, the ACCC announced it is prosecuting three Rockhampton obstetricians over a roster that helped them provide 24/seven cover and informed financial consent for their patients. With that roster collapsing chances are that Rockhampton will be left with no private obstetric services. This, on a background where virtually all GP obstetric services in Queensland, west of the Divide has disappeared. Now, the ACCC is threatening specialist services in major regional areas. It fails the public benefit test and it fails the commonsense test.

We await with anticipation the findings of the Wilkinson Inquiry into the effect of the Trade Practices Act on rural medical practice, as a chance of restoring commonsense and public benefit.

    • we have a changing nature of the GP workforce with more doctors seeking part-time work or more family-friendly work environments and conditions
    • there is an unsustainable over-reliance on overseas-trained doctors given a worldwide shortages of doctors
    • and Government failure to address the unique nature of country practice and providing the necessary social and financial incentives to get doctors to move to rural and regional Australia and stay there.

These pressures are contributing to country doctor shortages which are bad now and threaten to be devastating further down the track.

For country people, this is an all too-familiar story played over an over again.

The banks close down and the jobs disappear and the people disappear.

The Telstra depot closes down with the loss of jobs and vital services. There are no local technicians to fix the phone in many places, when once they were a common part of the landscape. Telstra's answer - get the doctors to provide a list of people with life-threatening illnesses who can expect to get their phone fixed in a reasonable time frame. Too bad for everyone else. And too bad if you didn't know you had a life-threatening disease.

Government offices are relocated to bigger centres.

The corner stores and the small businesses close down because they can no longer compete.

And now the local family doctor - often the cornerstone of the community - is an endangered species too.

Health outcomes for country people are poorer because the reality is there is no equity of access to quality health care and services in Australia.

Communities in rural and remote areas experience higher rates of injury mortality, specifically road transport accidents, homicide and suicide, as well as higher morbidity and mortality from diabetes, asthma and coronary heart disease.

Also of concern are the higher rates of alcohol consumption and smoking the further you move from the cities and major regional centres.

The AMA believes that all Australians should have reasonable and appropriate access to uniform, high quality primary health care.

The AMA is concerned that the health care infrastructure and level of professional support in rural and remote areas are insufficient to provide quality care and retain and recruit general practitioners relative to community needs.

A viable medical workforce in rural/remote areas will only be achieved by vastly improved planning and commitment at all levels of Government in collaboration with the medical profession and other stakeholders.

We are well past the band-aid stage.

We advocate a coordinated approach involving improved education and training, greater local community support, increased incentives and better work conditions.

Workforce

Federal Government policy on rural general practice is informed by an understanding of the adequacy of GP supply. The various AMWAC studies of the GP workforce have been very influential with government. AMWAC report 1996.1 estimated that in 1994, the urban GP oversupply was 4,400 and the rural undersupply 500 for a net oversupply of 3,900, or about 2,500 in full-time equivalent terms.

AMWAC report 2000.2 estimated that in 1998, the urban oversupply was 2,300 and the rural undersupply 1,240. A clear indication that the rural undersupply was getting worse despite the many programs seeking a fix.

The essence of those AMWAC analyses is that we have too many GPs overall, but that they are in the wrong places.

It just didn't make sense - doctors all over Australia from Bondi to Broken Hill were saying that they were having trouble finding locums, practices couldn't get assistants, few doctors were saying that they were able to work any harder, so the AMA commissioned Access Economics to conduct the largest ever survey of the GP workforce in Australia. Evidence-based politics.

On the basis of this information, we think there is a convergence of views now occurring in this area, and we expect the next AMWAC report on the GP workforce will have rather different conclusions to the two earlier reports.

The AMA/Access Economics workforce report, titled An Analysis of the Widening Gap between Community Need and the Availability of GP Services, shows there is a national under-supply of general practitioners — with an estimated shortfall of between 1000 and 2000 doctors — right now - and that the imbalance is not just between city and country, but also between inner and outer urban areas.

These are important findings. It will be immediately obvious that it is much harder to solve imbalances in the distribution of doctors if there is an overall shortage instead of an overall surplus.

For country areas, there is both threat and promise in this situation.

The threat is the difficulty of competing for doctors against outer urban areas — areas where there are also not enough doctors but where there are practice advantages over rural areas such as relatively ready access to major acute hospitals and specialist services, and education and recreation opportunities for doctors' families.

The promise is that hundreds of thousands of outer urban residents are now experiencing what country people have experienced for decades. The combined electoral clout of the rural and outer urban areas may be just what is needed to awaken our politicians around Australia and our bureaucrats from their torpor.

The Access Economics report notes the increasing difficulty we will face in recruiting overseas-trained doctors. Many countries are now seeking to shirk the cost of training doctors and are recruiting from other countries. Right now, the British and Canadian agencies are trying to recruit Australian doctors, and the NSW Government is spending $2 million trying to recruit British doctors.

The report points to the need for an increase in the number of training places for general practitioners, and the need for an increase in patient rebates for medical services. It is pointless to train more GPs if they leave the workforce in disgust or disillusionment within a few years because of poor remuneration and poor conditions.

Unless these workforce issues are addressed in the near future, there will be a severe nationwide shortage of general practitioners in the coming years, estimated by Access Economics to be in the order of 10,000 by the year 2020.

Medicare

The declining value of patient rebates under Medicare means that most GPs are experiencing difficulty meeting practice costs and keeping patient gap payments at a reasonable level. I agree with Craig Knowles that the Relative Value Study was a missed opportunity for the Federal Government. But it is not lost. It could be revisited.

Indemnity

The AMA has consulted closely with the Federal and NSW Governments to address the issues arising from the medical indemnity crisis to ensure that the equity of access to affordable health services be maintained for all Australians regardless of their circumstances or where they live.

We hope this consultation process will reap dividends at next week's Medical Indemnity Summit in Canberra.

There must be an urgent national approach to this crisis with harmonisation of State-based reform.

The Federal Government must continue down the road of structured settlements and devise a national scheme for care for the care and rehabilitation of severely injured patients.

Action to get doctors to country areas

The AMA for years has been putting forward suggestions to Government to get doctors to the country and keep them there. They are not 'quick fix' solutions; they involve planning and generational change.

Let me list just a few:

    • The development of better locum schemes
    • Retention payments for doctors working in rural or remote areas
    • Mentor support from experienced doctors
    • Provision of equipment and other facilities for service delivery, including IT support
    • Support for female rural doctors to practice in ways that reflect their multiple roles, including the acceptance of flexible working hours and flexible training courses
    • Rural origin scholarship schemes
    • Rural clinical schools to improve opportunities for rural students to obtain a degree in medicine
    • Early and continued exposure for medical students to rural practice
    • Access to ongoing and appropriate continuing medical education with appropriate levels of professional support
    • And education for prospective rural medical practitioners about the community in which they will practice.

Some of these possible solutions are national, some State-based. As we heard from Keith Hollebone, some very practical solutions are local.

Governments must recognise rural and remote health as a high priority issue.

They must move with urgency to re-establish the infrastructure necessary to sustain viable communities so that the systems to maintain comprehensive health care delivery are not further jeopardised or, as we are seeing, disappear altogether.

Commonwealth and State Government policies on deregulation have resulted in rationalisation and centralisation of community services, exacerbating problems of access to non-metropolitan health care.

Technological and support facilities have been reduced and many small country hospitals have run down, greatly decreasing practice opportunities for both specialists and general practitioners.

Consequently, appropriate treatment choices for patients are even more limited.

It is time to stop the rot. It is time to reverse the trend and put more and better medical services into our country communities.

Encouraging the doctors to stay would be a good start.

Getting more doctors to come and settle for the long term would be even better.

To do that we need good policies and a bit of vision.

Australian Health care Agreements

There have been reviews back as far as 1975 recommending change in relationships between State and Commonwealth health programs, levels of responsibility, financing strategies and so on but little in the way of positive change. We are at the beginning of the process to renegotiate the Australia Health Care Agreements to 2003 - 2008.

Most of the negotiations will have to be done this year if the outcome of any agreement is to be reflected in the 2003 - 2004 Federal Budget. The current political environment provides a unique window of opportunity for the State and Federal Governments to transcend party-politics and work with the medical profession and communities to address the very issues we're talking about today.

Sooner or later we have to make a decision about increasing the percentage of GDP spent on health.

We need a national standard of performance for our health system, city and country, which enables us to monitor with confidence how the system is performing, and which ensures the right of all Australians to affordable and accessible health care wherever they live.

We can ensure that the Australian Health care Agreements are about more than the Commonwealth and the States getting together every five years for a fight over money. The agreement signed two weeks ago by all of the Health Ministers to work together towards this vision could well be the revolutionary step we have been asking for.

Country Australia is the real Australia. We can't let it disappear.

Let's preserve communities and improve them so we can attract more professionals, not just doctors, back to rural and regional Australia.

Let's embellish the lifestyle riches that are already here.

We've heard a lot of great ideas today. Great ideas deserve to be shared so they do not operate in isolation.

And facilities in rural areas must be resuscitated, maintained and strengthened.

As they say in the movies: "If you build it, they will come."

Thank you.

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