The other side of the fence: Health care in rural NSW

By HAYLEY PENROSE:

“Access to good quality primary health care and emergency care, I think, is a reasonable right for most Australians.”

A simple statement, yet one that is continuing to spark a dynamic debate in the lucky country with rural towns of western New South Wales working hard over the years to build and maintain a health care workforce.

The access that NSW Rural Doctors Association president Doctor David Richmond is talking about is not available to everyone.

“It’s a long term problem. So defining the fact that there is a problem is the first thing,” he said.

Rural towns have struggled for decades to establish themselves as a prominent force within the health care system, the defining moment being the NSW Rural Doctors Dispute of 1987.

Across NSW doctors banded together to fight for their rights following the Federal Government’s announcement of spending cuts. The dispute resulted in the formation of the Rural Doctors Association which continues to lobby on a range of medical, political and industrial issues on behalf of rural doctors.

Today, many of the issues that plagued rural health care almost 30 years ago, such as billing and workforce numbers are still prevalent. Support networks for rural doctors including the Rural Doctors Association (RDA) and Rural Doctors Network (RDN) are working in conjunction with the government to try and combat the inequality, namely what is stopping health professionals practicing in rural areas.

One of the biggest issues that Doctor Richmond, a generalist doctor based in Cowra, has encountered is a lack of exposure.

“A lot of the medical schools for a long time were… based around major training hospitals in the metropolitan system and exposure that medical students had to a rural environment was extraordinarily limited. There wasn’t a lot of exposure for people to get out to the rural areas and actually see, and feel, and get an idea of what goes on out there,” he said.

To entice people to take their expertise rural, there are a number of incentive schemes in place that provide financial assistance to make these towns more accessible.

Medical student, Simon Walters completed a placement within Moree Plains Shire through the RDN. Mr Walters is originally from the Hunter Valley but relocated to Sydney to study medicine at Sydney University. He enjoyed hisplacement so much he described it as a holiday.

“I knew that I was going to like it because I’m interested in practicing rurally when I finish… and then probably being a GP[General Practitioner] that does anaesthetics and obstetrics, like delivering babies, and being sort of like a jack of all trades, which lots of the GPs up there are. It was a really cool town to be in.”

Being based in Sydney, Mr Walters would not have been able to experience Moree Plains’ health system without assistance from the Rural Doctors Network.

He applied for a bush bursary which involved, writing an essay and going for an interview where he believes his passion came across to the panel.

“I was really grateful for being able to experience that and receive the scholarship. I guess, for me, because of my age [29 years old] I can’t get Centrelink anymore and I don’t have any support from family so I have to work every weekend. If I don’t get a scholarship then I can’t take work off because I just won’t be able to afford rent or pay off credit cards, stuff like that. So it was amazing to be able to take a couple of weeks off work and go and do it.”

There are a number of similar options for medical students provided by organisations including the RDN, The Land newspaper and local governments.

The Australian government also provides financial incentives to people who practice rurally based on the Australian Standard Geographical Classification – Remoteness Areas, or the ASGC-RA.

The ASGC-RA categorises areas of rural NSW to determine the level of financial incentives sectioning the state into five areas based on remoteness in relation to the nearest urban centre. Doctors practicing in RA4 locations for example, can receive $18 000 in retention grants if they stay for 3 – 4 years, while doctors moving from metropolitan areas to an RA4 location may be eligible for a $60 000 relocation grant.

IMAGE: Rural Health Australia website

IMAGE: Rural Health Australia website

The RDA is challenging this system, hoping to implement a fairer scheme that takes more into account than just location.

“It separates places into city, then large rural and so on, roughly based on as the crow flies type numbers. And there’s so many anomalies in it. So on an obvious scale you’ve got Gundagai with 1500 people which has got the same rural classification as Hobart and Townsville which are obviously cities,” Dr Richmond explained.

Over the last decade there has been an increase in the number of full-time workload equivalent doctors in rural areas according to information released by the Department of Health.  

From 2000 to 2013 the number of Full-time Workload Equivalent (FWE) doctors has increased from 5771 to 7593 working in rural NSW.

FWE measures services provided, taking into account doctors varying workloads giving a good overall indication of the workforce as it adjusts numbers based on partial contribution or part time workers.

Outer regional, remote and very remote areas of the state also saw an increase in FWE of 45 per cent.

FWE

Death rates for rural and remote NSW showing an overall decline within the same time frame according to data released by the Australian Bureau of Statistics.

 death rates

Even with these positive statistics, Dr Richmond can still see room for improvement.

“What seems to have been shown out of the current incentive schemes is they help maintain doctors to keep practising in rural areas but they’re not a big enough carrot to attract people to work in rural areas,” he says.

From a student’s perspective, Mr Walters says it all comes down to finances.

“The only thing that could be improved is if they have more funding, because I think a lot of people are sort of in that boat, like they want to go rural but they can’t really afford it so that’s the scholarship thing. It’s not like you get the scholarship and ‘woo-hoo I’ve won money,’ it’s like you need it to facilitate it.”

Rural health care in Australia took another hit when Treasurer Joe Hockey released the 2014/2015 budget on Tuesday May 13. The document outlined the introduction of a $7 co-payment when visiting a doctor.

The fee has received an enormous amount of backlash with fears it will lead to a two-tiered health system with the more wealthy receiving more care, but the National Rural Health Alliance (NRHA) says it will hit rural patients the hardest.

In a media release, the NRHA said “people in rural and remote areas have about $2.1 billion less access to primary care every year than people in the major cities… People in more remote areas are already paying the same rates of taxation for much less access to publicly-funded health care. Regardless of the financial situation, rural people should never have to pay more for less.”

One way to ease the pressure in rural areas has been the recruitment of overseas trained doctors.

They are required to complete a 10 year moratorium before they receive an unrestricted Medicare provider number. The moratorium involves practising in areas deemed by the government as a district of workforce shortage which are usually outside Australia’s main cities.

Recruiting overseas trained doctors this way has propped up the system but Dr Richmond points out that has not resulted in a long term solution.

“[The RDA] suggest that [the moratorium] should be scrapped or phased out [because] they really should be working with more support. If anything they should be working in Mosman you know just down from North Shore Hospital than out at Peak Hill by themselves and isolated… If it wasn’t for the fact that they had to work out here they wouldn’t be here. They’d all work where their communities are in mainly metropolitan areas really.”

Overseas studies, like Factors influencing family physicians to enter rural practice by the College of Family Physicians of Canada, have found that people with rural backgrounds are more likely to want to stay and work in rural areas.

By targeting these people and perhaps creating a developmental relationship between student and town Dr Richmond believes more people would be willing to stay or return to rural NSW, despite the hesitancy that many feel because of the isolation that can comewith relocating as well as the heavy workload and less support.

“Work[ing] in the country, it’s a more difficult job than working in the city and I’m happy to stand up and have that silly argument with anyone, without making it look like we’re big heroes or anything but it’s more difficult for so many reasons,” Dr Richmond said.

The NSW town of Cowra where Dr Richmond works. IMAGE: Ian Sutton

The NSW town of Cowra where Dr Richmond works. IMAGE: Ian Sutton

While on placement in Moree, Mr Walters was able to experience so much more than he would have in a metropolitan area because of the wide range of services the two general practitioners there provide.

Over the course of his time in Moree Plains he got experience in gynaecology, oncology, Aboriginal health, an ambulance call out, and assisted in surgery, something he says wouldn’t happen until at least his third or fourth year in the city.

Mr Walters has his heart set on a rural career after experiencing first-hand the difficulties that families face.

“The biggest thing I got from my childhood [was] me and my family having to go to Sydney to see a specialist. I knew that from an early age it’s difficult for people in the country to get that access, especially, I mean I came from a middle class family but for people that aren’t that well off they can’t afford to like leave work and take their kids down to hospital.”

Not every town can justify having the facilities for a heart and lung transplant or be the home to a neurosurgeon it’s just not realistic but Dr Richmond says the depletion of medical service in rural areas does not reflect our wealthy society.

“I think Australia’s very lucky and I think the idea that we can have such a discrepancy in the medical work force in rural areas versus metropolitan areas is pretty horrifying,” he said.

“There’s always problems around the place… and I have an interest in not letting the system fall to pieces.”

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