1. From Associate Professor Balaji Bikshandi, Intensivist:-
My views would concentrate on the intensive care services in regional/rural NSW. At present the resource discrepancy between metropolitan and regional/rural intensive care systems are enormous. Metropolitan centres exploit this deficiency and utilise various classification systems to paralyse the operations of very many regional/rural hospitals by depriving them of the ability to care for the critically ill. The retrieval service being a major beneficiary of this arrangement, quite happily approves of this and aids in perpetuating this schema. Essentially this makes the local health district (lhd) model a big joke! Every lhd is subservient to the metropolitan ICU masters and is never ‘local’!
Add to it the invented classification of intensive care units by the agency for clinical innovation which was designed with a view of stifling regional/rural specialists doing basic life saving work while their metropolitan counterparts could spend resources on over utilising valueless therapies such as adult Extracorporeal Membrane Oxygenation, unnecessary tracheostomies and trans oesophageal echo cardiographys.
Metropolitan ICUs will not let a self sufficient intensive care service to develop by duly qualified specialists holding the fellowship of the college of intensive care medicine in rural and regional centres.
This leads to persons without specialist qualifications assuming positions of Intensive care directors and becoming subservient slaves to their metropolitan masters. This bring individuals without any Australian experience from abroad under the pretext of specialist unavailability but in effect it is a lie.
A specialist who is duly qualified and trained in Australia to provide their services in regional/rural Australia requires at least ten times of skill and proficiency. But they stand to be unfairly treated and criticised by the arm chair politicians in the “referral” centres in the city ICUs. Somehow such critical individuals are beyond reproach despite their much lower experience in comparison to the specialists who provide their services to regional/rural ICUs.
The current COVID crisis very well exposes this disparity as politically motivated and self centred. Not a single regional centre received an onsite PCR machine and if they did, it was held at ransom by a city centre far away (which will be within the lockdown zone!).
A strong plan needs to be in place to boost visiting medical specialists in intensive care to provide services to regional/rural Australia. The requirement for 24 hr services will mean a few staff specialists is a ridiculous idea. It only serves to save pennies at the cost of lives. Such specialists be protected from the metropolitan inexperienced Intensivists in every way, specifically from politically motivated unfair criticisms and setups.
2. From Associate Professor Stephen Flecknoe-Brown, Haematologist, Port Macquarie:-
The value of medical specialists living and working in rural and remote NSW is not given much attention here. They are needed to service the needs of rural and regional hospitals; around the clock.
Although the proportions of General Practitioners per 10,000 population in Outer Regional NSW is about half that in Inner Metropolitan areas, the proportion of medical specialists is one tenth, and falling.
A report from the Royal Australasian College of Physicians in January 2020 showed that trainee numbers in rural & remote Australia were less than the number of practising physicians by a significant proportion, while numbers of trainees based in metropolitan areas continued to grow, outstripping the supply of vacancies for fully-qualified physicians. Yet still the imbalance continues.
3. From Dr Nicholas Stephenson, Radiologist in Wagga Wagga:-
The draft submission Luke sent does not include nearly enough emphasis on the medical workforce shortages that regional, rural and remote Australia face. It is critical this be emphasized and discussed more, if health outcomes are to be improved. This includes shortages of GPs, GP Proceduralists, Rural Generalists and [non-GP] Medical Specialists. To that could be added shortages of Nurses and Allied Health practitioners.
The fact that in my region of NSW more than 70% of the GP workforce is overseas trained is an inditement of the ‘system’. It is recognised that the states are responsible for their respective jurisdiction’s medical and health workforce. The Commonwealth has funded a massive increase in medical graduates numbers, has invested in rural clinical schools, new rural medical schools, new training pathways, rural entry criteria, etc. Unfortunately the states and territories have not updated their postgraduate training pathways, such that far too many specialists are trained in metro for metro and far too many GPs are not trained to be ‘bush doctors’ (although in that regard the Commonwealth stands guilty of appointing Synergy to manage GP training, rather than the two relevant Colleges). I also accept that the medical profession and many of the Colleges have not updated their training systems so as to provide appropriately trained doctors for all Australians.
With regard to ‘bush doctors’, it must be recognised that doctors in rural and remote communities need a very different knowledge and skill set to suburban GPs – to be able to provide emergency care in Emergency Depts, etc. Medical Specialists are essential to train GPs with these skills and knowledge as well as back them up in the regional hubs of the rural and remote communities.
Evidence from all over the world shows that the best way to get newly trained doctors to choose to live and work rurally is to train them rurally. This matches the Commonwealth’s approach.
One example of how the states could do better is the trial occurring in the Riverina, where the Murrumbidgee Local Health District is this year appointing GP Trainees on a 4 year salaried training program (incl approval from the Commonwealth to use Medicare funds when the Trainees are working in GP practices) so as to give them a structured path to ‘bush doctor’ (aka GP Proceduralist, Rural Generalist), rather than the trainees having to negotiate moving between hospitals and GP practices themselves during their training period. Critical to the success of that is the availability of locally resident medical specialists who will provide alot of the specialists skill training these doctors will need.
I would also like to emphasize the importance of locally resident doctors (and other health practitioners), not visiting practitioners. When discussing ‘workforce’, we should concentrate on the locally resident workforce, because they are the ones who are available 24/7, who are invested in upskilling their peers and fellow practitioners, working as a valuable team member with the other local/regional staff and investing generally in the community in everything they do. Please see my discussion paper for more justification of this. In this regard, I wonder if the table on Palliative Care practitioners relates to locally resident practitioners, visiting practitioners or a combination of both. It seems dodgy. I know the shortage of Oncologists is a major barrier to cancer care, in addition to shortages of support services.
The above problems are not partisan and all NSW govts and the NSW bureaucracy have failed to adequately plan and manage their medical workforce.
4. From Dr John Flynn, Physician in Armidale:-
I have been a rural Physician for 40 years, and have never known the rural situation to be worse than it is at the moment. The two main culprits as far as my practice is concerned are the New England Local Health District and the RACP.
5. From Dr Fiona McCrae, Dermatologist in Orange:-
I am the chair of the Regional and Rural Committee for the College of Dermatologists and we have made a submission on behalf of the College.
However I would like to support and add to Nick’s comments, especially:
When discussing ‘workforce’, we should concentrate on the locally resident workforce, because they are the ones who are available 24/7, who are invested in upskilling their peers and fellow practitioners, working as a valuable team member with the other local/regional staff and investing generally in the community in everything they do.
There is a critical shortage of Dermatologists outside of metropolitan Sydney. Unfortunately I am now the only full time Dermatologist (and only female) west of the Blue Mountains (Orange). The closest are Canberra (5), Griffith (1), Wagga (1) and Tamworth (1) – with the 3 of these regional Dermatologists close to retirement. I cover an area of over 350 000. We have a small group of FIFO to Dubbo and Orange however with COVID Dubbo completely stopped. Those that FIFO don’t triage – so they don’t end up dealing with any urgent or serious/complicated cases, which places even more strain on my services. I have a 9 month waiting list and work full time. I have an interest in genital dermatology. The female Dermatologist in Wagga retired last year and now a good number of her patients have been referred to me in Orange for long-term followup.
As Nicholas stated, there is overwhelming evidence that the those who train rurally are more likely to be retained rurally. The numbers are greatest for JMOs (31-35%) followed by medical students. Increased attention needs to be placed on training and supporting those who wish to train in regional areas. Despite an increase in JMO positions in regional NSW areas, demand outstrips supply and we are losing access to potential doctors. I was fortunate to have great mentors and be well supported during my JMO training.
I am pleased to see the trial in Murrumbidgee. It is not just about developing the contacts to work as a valued team member of the medical and greater community, but it ensures we attract those with the personality, integrity and commitment to work in these geographical areas. It has been shown multiple times that regional doctors work longer hours than their metro counterparts. It would definitely be easier to work in the city, not worry about fee structures or different socioeconomic concerns, referring complicated patients to the tertiary referral hospital, and living in a different suburb to where I practice. There is also the need to support those who are early career doctors – it is very difficult to set up a solo practice without a bit of experience and hence confidence. Unfortunately by the time most develop this they are well established in the city environment – both medically and socially, and have developed a certain mentality about rural practice.
Unfortunately, I would love in be involved more in my LDH, but until recently due to prompting from other colleagues, there has been little interest in the 7 years I’ve been back in Orange. I am unable to find any Dermatology KPIs for NSW Health and have flagged this with our college. Most rural dermatology training positions are STP/ITP funded, which are heavily private practice based. This places an added burden on any regional supervisors who decide to apply to supervise/run a position. Having completed a full year of regional training as well as FIFO training, and previously supervised rural registrars fulltime for 3 years, I have come to the realisation that it is too hard to train registrars rurally without the input of local health services and the medical community support that it provides. Not only does it exclude dermatology registrars from learning opportunities and development of those important medical and social contacts, it excludes them from registrar accommodation assistance (it is very hard to find affordable rentals in our area).
In addition there has been a major push with telehealth implementation. Unfortunately a lot of decisions regarding telehealth have been made by those who don’t experience it on a daily basis. Many areas have very poor infrastructure despite NBN. Many don’t have the up to date equipment to utilise access. Even larger regional cites such as Bathurst and Orange have had large sprawls of housing and the nodes/infrastructure have not been maintained or increased to deal with the increase in population. As a result the bandwidth is strained and on multiple occasions telehealth consults were abandoned for telephone discussions.