In this two part article, I am reviewing the basis for the serious problem we have in providing adequate health care for Australians who live in rural, and particularly, remote areas. Good intentions are, as ever, intertwined with political machinations which make policies for solutions harder to implement. Currently, yet another government review is soon to be released. Here is the background needed for judging the results.
Thirty percent of Australians live in rural and remote areas of our huge country. They supply 60% of our wealth but experience significantly worse health outcomes compared to their metropolitan cousins. Infant mortality, depression, suicide, various cancers, heart disease and diabetes are all more common. Even without the disgraceful status of indigenous health, rural Australians can expect four fewer years of life than people living on Sydney’s north shore. Several factors fuel this formula but none is as important as the lack of access to timely, competent medical care. If Rural Australians accessed Medicare funded services at the rate city folk do the Medicare bill would increase by two billion dollars a year!
Physician care that is available is underpinned by a policy of sending overseas trained doctors (OTDs) who wish to live in Australia to rural areas for several years before they are free to move to a metropolis. While there is some regional variation, 44-57% of General Practitioners working in rural Australia are OTDs. While acknowledging that, as of today, they are invaluable for the areas they work in would not be serviced by doctors if they were not there, the scheme has many problems. For many of us a major disquiet is an ethical one. While we need these doctors, our need is as nothing compared to the needs in their countries of origin. Partly for this reason the government wants to phase out the scheme. However, there are major practice issues that leave many patients dissatisfied. Medical knowledge must be melded with cultural awareness and good communication skills. While some OTDs meet these requirements for many this is a challenge they cannot meet. Rural Australians need and deserve to be cared for by doctors who understand rural/Australian culture, the epidemiology of disease in their community, can communicate well and actually want to be practicing in the bush.
For the last twenty years, various tactics have been used in an attempt to have more Australian trained doctors available in regional and remote Australia. The centre piece of the Howard years efforts involved a misplaced confidence in the power of the medical market place. Let’s train so many doctors that many will have to move to the country to earn a living. So, over a decade or so we doubled the number of medical students in Australian universities. We moved from graduating 1500 new doctors a year to more than three thousand a year. This approach has failed but provides medical educators with a difficult problem as we try and find “hands on” training programs of excellence for so many. It turns out that in a Medicare “fee for service” system the additional doctors can practice where they wish and generate patients and income.
At least four major enquiries into this shortage over the last few year came to one fundamental conclusion. The vast majority of medical students are attracted to city living. They simply don’t want to work in the bush. This is why cash incentive programs to move from a metropolitan practice to work in a rural community and offers to pay for student’s medical education if they would work in the country have failed. Worse, those students who lived in rural communities and, on entry to medical school were thinking of a rural career changed their mind after 4-6 years studying in the city. The attrition rate is about 82%! Plenty of time to fall in love, make a new group of friends and be dazzled by the big lights as well as the excitement of major medical centres.
Which brings us to the crucial issue or “Rurality”. The Department of Health in Canberra introduced a requirement that 25% of all students enrolled in Medical schools must be “Rural students”. Additional fund would be made available for such students and penalties might apply if a school did not meet the expected quota. The latter stick has never been applied. The problem was, and is, the definition schools can use to judge rurality. At first the definition simply said that to be considered a rural student, applicants must have lived for 5 years in a rural postcode. More recently when there was little evidence that the original definition was resulting in more graduates working in rural areas, the time requirement was lifted to ten years. In other words, you may have been born in Broken Hill moved to Melbourne when you were ten years old, not seen a cow since and yet you could claim advantages associated with being a “Rural student”. Missing in all this was any review of the designated rural student’s plans for a rural career.
Metropolitan based universities, with Commonwealth help, introduce other initiatives to try and address the fundamental problem; how to produce adequate numbers of graduates who want to work in rural Australia. All medical students are required to spend at least four weeks in a rural setting during their course. A number of “Rural Clinical Schools “have been established in major rural towns, usually ones with a “Base” hospital. They are well equipped with their major asset being well trained, wildly enthusiastic clinicians, who love rural medicine. Some students spend longer than four weeks, some may stay a year or more, flexibility is available. I was involved in setting up two of these schools and if love of rural life and medicine was an infectious disease the staff of these schools would have had great success. It is no fault of theirs that they have not reaped the desired harvest from their efforts. Currently fewer than 10% of Australian Medical students work outside of the big cities and a disproportionate number of those live on the coast not inland.
There are evidence based solutions to the problem which I will discuss in Part 2 of this article. These solutions however are struggling as they are mired in university, vested interests and, of course, politics.
John Dwyer is Emeritus Professor of Medicine at UNSW