Access all areas: Time for a new solution to primary care access for rural Australians

by Stephen Duckett

Published by Croakey (the Crikey health blog), Monday 30 September 2013

Access to primary care for those Australians living in rural areas has been a continuing issue for a number of years. Previous attempts to resolve this have concentrated on methods of increasing numbers of GPs in rural areas. The Grattan Institute are proposing a new solution that is potentially cheaper and more timely. Many thanks to Peter Breadon for this overview.

A new Grattan Institute report, Access all areas, proposes solutions for the parts of Australia with the worst GP shortages.

How hard it is to see a GP – and how much it will cost you – depends on where you live. In the places with the fewest GP services per person, patients are more than twice as likely to pay out-of-pocket costs. That is one reason why people in very remote areas are much more likely not to see a doctor about their health problem.

This isn’t just unfair; it’s irrational. People in rural areas with low access to GPs are more likely to have serious health risks. If they can’t get care it will cost them, and the taxpayer, much more in the long-run.

These problems are long-standing and successive governments have tried to fix them. But they haven’t achieved nearly enough. Where the need is greatest, progress has been glacial. Based on progress over the last five years, it would take 65 years for very remote areas to reach the service levels enjoyed in major cities.

We propose two new solutions to bring the seven lowest-access parts of rural Australia up to a basic minimum standard. Our approach is to give GPs support from a broader team, letting GPs focus on the complex work that only they can do.

At present we are not making the best use of doctors’ time. Nationally, around one in five GP visits only involve one problem, one or two medications and no pathology, imaging, referrals, procedures (other than immunisation), or treatment (other than advice). For 2.7 million of these visits each year, the problem treated is a cold. In 53,000 cases, it is excess ear wax. Almost half of GPs (44 per cent) report that they often do things that less qualified people could do.

The first solution is to let community pharmacists do more. They are trained and trusted professionals. They are also located throughout Australia, including in most of the areas with low access to GPs. Pharmacists can ease the load on GPs by providing vaccinations, the sole reason for 1.1 per cent of all GP visits. With the agreement of GPs and their patients, pharmacists should also be able to provide repeat prescriptions for up to 18 months, and give patients advice on medications for chronic conditions.

Second, Australia should introduce physician assistants, a new workforce group that Croakey has profiled in the past. Physician assistants work under the direct supervision of a doctor. They have two to three years of training, much of which overlaps with medical training. Two Australian trials of physician assistants have been very successful, and physician assistants have a good track record of providing health care in rural parts of America. Where they have been introduced, they have provided high quality care and have been popular among patients and other health care workers, including doctors.

These changes should happen in the seven rural Medicare Local areas with the worst shortages. They are:

  • Kimberley – Pilbara, which covers most of the WA’s north east, including Broome, Kununurra, Karratha, and Roebuck
  • the Northern Territory
  • Central and North West Queensland, which includes Mt Isa, Carpentaria and the Northern Highlands
  • Goldfields – Midwest, a huge region of WA, including Kalgoorlie, Exmouth, Carnarvon, and Esperance
  • New England in northern New South Wales, which includes Armidale, Tamworth, Inverell and Scone
  • Southern New South Wales, the south east of NSW, including Queanbeyan, Goulburn, Bega and Cooma
  • South West Western Australia – includes the southern population centres of Albany and Denmark.

These are new solutions, but are very achievable. Reaching the goal we’ve set would only cost $30 million dollars a year. It would only shift 0.6 per cent of Australia’s GP visits to pharmacists or physician assistants. It would only require 101 physician assistants. They’ve been trained in Australian universities before, so this isn’t a barrier.

Our suggestions are affordable, small-scale and supported by good evidence. There’s no excuse not to act, especially when the benefits of improving access to primary care are considered. Bringing access in these seven areas up to our goal could reduce hospital costs by $30 million a year – the entire cost of our proposal – by catching health problems sooner. And lower hospital costs are just one of the many benefits of primary care.

So why hasn’t this been done already? Perhaps the previous Government was waiting for the massive expansion in medical training to cause a trickle-down effect – for enough doctors to eventually move to where they’re needed most. But even ‘trickle’ is a generous term for the result so far, and the evidence suggests that GPs are rarely lured to rural areas by financial incentives. The previous Government might also have hoped that overseas-trained doctors would do the trick, but this has also done too little in areas with the worst shortages, and is unlikely to do much more.

Another explanation might be fear of change among policy makers or health care workers. However, the rural health experts and providers we spoke to agree that new responses are needed, and most of them supported our suggestions. These ideas aren’t the only good ones. We need a rich variety of health workers and health care settings in rural Australia, and some other promising options are discussed in our report. Yet pharmacists and physician assistants can be a big part of the answer.

More than a million Australians live in the seven areas discussed in our report. Surely we wouldn’t accept this problem if it affected any other group this big, not when $30 million would go a long way to fixing it. We shouldn’t in this case either.