Bega Valley GPs are warning of an impending disaster that could see the shire bereft of general practice doctors for residents and for the support of aged care homes.
Local doctors warn that general practices are being hit by two main issues: many local GPs are approaching or have reached retirement age; and taking on a general practice is more onerous and not as financially rewarding as other medical careers available to doctors.
Practices are struggling to attract new GPs and even if they could, there's the housing issue. It leaves some practices closing their books to new patients.
The majority of medical practices from Bega to the border of Victoria are run and owned by specialist GPs who are coming to the end of their careers due to age, overwhelming fatigue and in several cases, serious life threatening health issues.- Dr Michael Pentin
Michael Pentin is the owner and principal GP of Curalo Clinic, Eden and said he was concerned about the future of GP services in the shire.
"The majority of medical practices from Bega to the border of Victoria are run and owned by specialist GPs who are coming to the end of their careers due to age, overwhelming fatigue and in several cases, serious life threatening health issues. The vast majority of the principal practitioners are in the age group 60 to 70 years old," Dr Pentin said.
He said most clinics have little in the way of succession plans due to a variety of reasons but mainly over the past 10 years very few doctors have moved into the area who are willing to take on this role.
The irony was that practices were dependent on these senior doctors to supervise registrar GPs (trainees) and IMGs (International Medical Graduates).
And while these might seem like a possible source of next generation doctors for the Bega Valley, the reality was very few stay either because they are at the time of life where they have a partner and/or children somewhere else, or in the case of IMGs they prefer to return to their communities in the cities.
"Of those who have stayed in the Bega Valley many have opted to work at South East Regional Hospital where they are able to do shift work for excellent remuneration (which GP practices would find hard to match)," Dr Pentin said.
We need to train people locally but unfortunately it's harder to attract people. There are less GPs and specialists - it's a bit of a basket case all round.- Chloe Campbell, RN, trainee doctor
"We also compete against the local Aboriginal Health Services which are very heavily subsidised by the government. This work does not have the responsibility of running a practice in addition to seeing patients," he said.
Chloe Campbell is a Registered Nurse (RN) who has completed the first year of her five-year Doctor of Medicine course at Charles Sturt University. She comes from Bombala and wants to practise as a rural generalist when qualified.
She said the community had already seen it play out in Bombala with a shortage of GPs.
"The main problem is staffing, it's huge and because there's such a shortage, doctors can name their price." Ms Campbell said.
"We need to train people locally but unfortunately it's harder to attract people. There are less GPs and specialists - it's a bit of a basket case all round," Ms Campbell said of the rural medical system.
"People are finding it hard to pay but doctors can't afford to bulk bill. The question is how do we support our communities to access medical help and get GPs to stay open?"
"When you look at the wages of a GP registrar versus a registrar in a hospital, financially it doesn't make sense," Ms Campbell said.
Dr Pentin said there was little incentive to take on a practice because of high overheads from staff, equipment, insurance and IT requirements.
"General practice is very poorly paid when you evaluate the responsibility, extended hours worked and the need to run a business with complex requirements such as numerous staff, complying with accreditation, maintenance of education and computerisation," Dr Pentin said.
He said that most full time, newly qualified Australian trained doctors opt for specialist training in other fields due to the complications of running a general practice.
"Additionally, the several fold increased remuneration paid to specialists in comparison to GPs, for less hours worked by many and a better work life balance, is incomparable. Most local practices have been advertising for permanent GPs for many years with little success."
Dr Pentin isn't alone in his concerns.
At Merimbula Medical Centre, Frank Simonson said recruitment was extremely difficult, made worse by the policies of the Southern New South Wales Local Health District paying locum doctors to work at the hospital.
"We have been fortunate in having qualified and experienced younger doctors move into the region. Some of these doctors have worked in local medical practices, but they have been enticed by the high payments made for hospital medical workforce (and to some extent nursing workforce), leaving local general practices without help," Dr Simonson said.
"The hospital is paying these doctors over $200 per hour plus superannuation. This is the benchmark for remuneration of medical staff, but this is completely unrealistic in the current general practice environment with Medicare funding."
Dr Simonson said that hospital cover by local doctors used to be based on fees for service, which he said were returned into the general practices to support business expenses.
"The income derived from the hospital in those days is dwarfed by current salaries."
In the cities there can be bulk billing centres which rely on rapid throughput. There is no time to think about patients or plan treatment because the bulk billing rate simply does not pay for this time.- Dr Frank Simonson
Dr Simonson said that in addition to higher salaries, doctors can finish their shift and go home without the need to worry about the cost of running a business.
Both doctors said bulk billing was hard to do in rural areas because the model was different from the cities.
"In the cities there can be bulk billing centres which rely on rapid throughput. There is no time to think about patients or plan treatment because the bulk billing rate simply does not pay for this time. The most expedient approach taken by bulk billing centres is referral to public hospitals or private specialists," Dr Simonson said.
"The patient can then either wait indefinitely in a public hospital outpatient service or see a private specialist, usually at significant cost. Therefore, most medical graduates are choosing specialties rather than general practice," he said.
"In rural medicine we simply cannot do that. There is no significant public outpatient service and there is limited specialist support. So, we must think about what we are doing and plan treatment for patients individually."
Dr Pentin agreed and condemned the move to encourage corporate owned bulk billing practices in cities practising "fast food style medicine" funded by Medicare.
"This form of medicine is not acceptable in the country areas, and shouldn't be in the cities, as you cannot refer everyone with the slightest thing wrong to the specialist around the corner that day. Unfortunately from time to time a bulk billing doctor will move into the area, skimming off easy work with rapid throughput 'free' medicine which just compounds the fragility of the financial viability of the other general practices," Dr Pentin said.
Dr Simonson said that while patients and politicians would like bulk billing to take place it was simply not financially viable.
The options currently discussed by most of the local practice owners is to either simply close the doors or to continue practicing until they are carried out in a wooden box.- Dr Michael Pentin
"For a 15-minute consultation the bulk billing rate is $39.10. If you see four patients an hour, then you will have earned $156.40. My wages bill alone ranges from $95-$135 an hour depending upon the day. Out of what is left, I must pay for the running costs of the business, which includes insurance, rent, supplies and so forth. After all this is paid there is not much left to pay the doctor," Dr Simonson said.
Last year some local doctors met with Eden-Monaro MP Kristy McBain, and the shadow federal health minister Mark Butler.
"They acknowledged, discussed and sympathised with our issues, but there has been no progress or contact since," Dr Pentin said.
"The government's current inquiries into rural health are plans for increased rural training which do not address the short to medium term and will be all too late even if they can be achieved. Labor's proposal for acute care clinics is not likely to help the rural health drought because they will struggle to staff them and only make other practices unviable," he added.
The two doctors believe the closure of local practices was inevitable, leaving the community struggling to access primary health care.
I am aware of other GPs contemplating selling their buildings for uses outside healthcare to recoup their investment when they retire. Immediate action is needed for this issue by whoever forms the next government. The Bega Valley may become a primary care desert in the very near future.- Dr Michael Pentin
"The local residential aged care facilities, which currently struggle to get GPs to see their residents, will not be able to find GPs and will eventually be forced to close and relocate their residents to the cities, therefore needing to retrench their numerous staff and isolate the elderly from their communities and families," Dr Pentin said.
"I ask the people in both sides of politics, both state and federal, to listen and to urgently address the matter and urge them not to use political upmanship as the situation is too serious."
Dr Simonson said neither party had made any attempt to improve access to medical care in rural areas.
"I understand that the Labor party is proposing the establishment of bulk billing services to support the role of emergency departments. Whatever the merits of this proposal are, it will have no impact on rural medicine," he said.
Dr Simonson believed there should be a new business model which allowed for part-time work, something that had become increasingly popular.
"The greatest advantage of local medical practices looking after local communities is continuity of care. Patients can come and go, visit specialists, see other health services knowing there is oversight of their health. This is all going to disappear," Dr Simonson warned.
"We have tried to warn politicians about this impending crisis, but nothing has happened. Most of the principles managing local general practices have reached and are past retirement age, but they continue due to loyalty to their patients. Eventually we will just simply be unable to keep doing this," he said.
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