Monday, February 22, 2010

Tamworth GPs close their books

The Tamworth Statistical District - this includes the main urban area and its immediate surrounds - had a population of 42,499 at the 2006 census, so we are not talking about a small centre.

The Northern Daily Leader now reports that existing Tamworth GPs have effectively closed their books, unable to accept new patients. The story takes place at the same time as debate about the future of Bellingen Hospital reaches a new peak (here and here). As an aside, the Save Bellingen Hospital Facebook page has now reached 2,440 fans!

The NDL story includes some very thoughtful comments from Graeme Kershaw, CEO of the North West Slopes Division of General Practice.

I thought that I might take Graeme's comments as an entry point for some comments of my own, focusing on the different elements of the complicated mess we have created for ourselves. These draw from my own experience as CEO of a specialist medical college, as well as later work force analysis.

Graeme refers to the monumentally stupid decision of the Federal Government to cut back on the number of places for doctors in training back in the 1990s. Then Minister for Health Michael  Michael Wooldridge concluded that there were too many GPs and that this was leading to over-servicing, increasing Medicare costs. Training places were cut as a result.

While this was a silly decision, Graeme is correct to suggest that it is only part of the problem. He says first:

“Many trainee doctors are going into the specialities like surgery and internal medicine – not surprising really; while they are training in hospitals they are taught by these same specialties that encourage them to follow in their footsteps”

“Even in doctors who are raised and trained in rural areas, up to 50 per cent choose not to become GPs.”

Let's disentangle this one a little.

In general, not always, specialists get more money than GPS and attract higher prestige, so it's understandable that doctors, and especially those with an academic bent, should be interested in specialisation.

The attempt to create a speciality of general practice has not, to my mind, worked very well. This "specialisation" has in fact added to the hoops that those interested in general practice have to jump through, without affecting the relativities between general practice and the more traditional specialities. To this extent, it may have actually reduced the incentive to become a GP.

I can't judge the validity of the comment on rural training without knowing the equivalent figures for metro trainees.

The extension of medical training at non-metro universities is actually quite recent. My feeling is that things such as the new rural medicine course run by the Universities of Newcastle and New England in combination will have a positive impact.

A central problem, one that applies even more to longer specialist training, is the interaction between partner and family formation and the location and length of training.

People acquire partners from those they are in contact with. As time passes, it is more likely that partner relationships will become long term, including marriage and kids. Increasingly, locational decisions have to take partner considerations into account.

It seems clear that metro born kids are less willing to move to regional areas than country kids. The longer the training in metro centres with their heavy preponderance of metro students, the more partnerships form, the less likely subsequent movement.

This actually affects less prestigious areas in the metro centres as well, with surpluses of doctors and other health professionals in some areas, major deficits in others.

Graeme continues:    

Doctors from the “baby boomer” generation received their medical education for free.

“Generations X and Y come out of their training with large HECS debts to repay and they won’t feel the same obligation to the give back to the community that ‘boomers’ once did,” Mr Kershaw said.

This one is hard to measure, although I suspect that Graeme is right. People are influenced by a sense of altruism and community obligation. If you have paid for yourself, the obligation is reduced.

Graeme then looks at service cut backs in local hospitals:

A lot of hospitals in small communities no longer provide obstetric services locally, so they won’t attract the type of rural doctor they once would; someone who wants to deliver babies as well as look after the diabetes and the heart problems.

This is part of the Bellingen Hospital case. Take obstetrics away, and you reduce the practice range of local doctors. However, there is a broader issue as well.

The "specialisation' of medicine in combination with changing approaches to medical indemnity has reduced the willingness and probably capacity of GPs to provide certain services. My tonsils were removed by a GP. Today my parents would have taken me to a specialist. That's fine, but doesn't help much if a specialist is not available.

Graeme finishes:    

“GPs are treating much more complex problems, often associated with long-term diseases, than they were 10-20 years ago,” Mr Kershaw said.

“They are doing this at a time when hospitals are developing therapies that mean that people are not in hospital as long as they used to be, and they are discharged back into the care of their GP.

“As a result, GPs cannot see as many people per day as they may have been able to 20 years ago and so, with less people seen and less doctors available, waiting times are increasing.

“GPs realise that they have an ongoing obligation to their existing patients and because of this, have to stop taking new patients.”

Again, I suspect that Graeme is right and the that the problem is going to get worse with an aging population. This adds to the complications, especially in inland areas with limited doctors and an aging population. 

3 comments:

Martina said...

We have been doing some very intensive research into medical workforce issues in rural Victoria and I would agree with the comments. The specialisation of the medical workforce means that there are no pathways to 'general' medicine which is what rural communities need most.

Hospitals need salaried medical staff but where do they get them from especially if they cannot provide enough supervision to employ PGY1+2 doctors straight out of university? If they are not in a District of Workforce Shortage (and many smaller rural centres are not classified in this way) they cannot even employ overseas trained doctors who are working towards full registration.

If they employ doctors who have not got a Medicare Provider Number, they cannot access Medicare funding and have to finance the doctor's salary themselves - and thats not going to be an attractive salary.

And if they do employ salaried medical officers, what is their career pathway? They can't really get full registration unless they are vocationally registered - or working towards vocational registration. So there is no other pathway than a specialist pathway (even for GPs).

The decision to require GPs to jump through the numerous hoops required by other "specialities" means that nobody can become an independent medical practitioner in less than 12-14 years - if my calculations are correct. That means that the GP has lost the key attraction it once held - that it was an easier and quicker pathway to becoming an independent practitioner. Without that edge, why wouldn't you become an opthalmologist, anaesthetist or cardiologist and get some real money and a lot more prestige?

With increasing feminisation of the workforce, the decision to require doctors to 'specialise' in General Practice (an obvious oxymoron) is a great way to ensure that we have less GPs.... Many women want to have families and don't want to spend 14 years getting their professional qualitfication....

Why can't we have some kind of Diploma in Family Medicine which can be done in two years and with less associated costs?

Jim Belshaw said...

Thanks for this, Martina. You capture things very well. I will bring your comment up as a main post.

Jim Belshaw said...

Martina, I have now included your comments in a broader post triggered by your remarks - http://belshaw.blogspot.com/2010/02/systemic-failures-in-health-and-other.html