THE EXPANDING THE EXPANDING ROLE OF ROLE OF

GENERALISTS IN GENERALISTS IN RURAL & REMOTE RURAL & REMOTE

HEALTH HEALTH

Pashen, Dennis., Murray, Richard., Pashen, Dennis., Murray, Richard., Chater, Bruce., Chater, Bruce., White, Col., White, Col., Sheedy, Sheedy,

Vicki., Vicki., De la Rue, Stephanie. , Du Reitz, De la Rue, Stephanie. , Du Reitz, Marnie.Marnie.

2525thth Feb 2009 Feb 2009

BackgroundBackground

2007 - Australian Primary Health Care 2007 - Australian Primary Health Care Research Institute (APHCRI) funded Research Institute (APHCRI) funded 12 Stream 6 Grants on “Generalism”.12 Stream 6 Grants on “Generalism”.

Systematic reviewSystematic review: To map the : To map the historical demise of a rural historical demise of a rural procedural skills base and potential procedural skills base and potential for repopulating a skills base in rural for repopulating a skills base in rural medicinemedicine

Australian College of Rural and Remote Medicine

FindingsFindings• Decline in ‘generalist’ specialists Decline in ‘generalist’ specialists over the over the

past 50 years – extreme in rural areaspast 50 years – extreme in rural areas

• Decline in GP proceduralistsDecline in GP proceduralists– Differential rebates- a disincentive to rural Differential rebates- a disincentive to rural

procedural practiceprocedural practice– Rural hospital and maternity services closures Rural hospital and maternity services closures – Loss of a ‘critical mass’ necessary to provide Loss of a ‘critical mass’ necessary to provide

procedural servicesprocedural services– Loss of access to procedural training for Loss of access to procedural training for

GPs/Rural DoctorsGPs/Rural Doctors– Indemnity crisisIndemnity crisis

Evidence supporting RGsEvidence supporting RGs

• Rural hospitals are as safe as major Rural hospitals are as safe as major secondary and tertiary hospitalssecondary and tertiary hospitals

• Investment in primary health care Investment in primary health care and ‘generalist’ medical services and ‘generalist’ medical services may be more cost effective, efficient may be more cost effective, efficient and equitable for rural communities and equitable for rural communities compared with specialist and sub-compared with specialist and sub-specialist medical service providersspecialist medical service providers

Evidence supporting RGsEvidence supporting RGs

• Specific training and career Specific training and career pathways for ‘rural generalists’ has pathways for ‘rural generalists’ has been implemented in Queensland. been implemented in Queensland.

• Mid-level practitioners like physician Mid-level practitioners like physician assistants, practice nurses and assistants, practice nurses and nurse practitioners can extend the nurse practitioners can extend the reach of medical generalists and reach of medical generalists and specialist servicesspecialist services..

2007 New College 2007 New College FellowsFellows

Australian College of Rural and Remote Medicine

• 72 Cardiothoracic Surgeons• 47 Cardiology Physicians [MTRP 12th Report. Feb 09]

Policy ImplicationsPolicy Implications• Expand the clinical teaching capacity of Expand the clinical teaching capacity of

the health system in regional areasthe health system in regional areas

• Establish regionally based mechanisms for Establish regionally based mechanisms for vertically integrated training including vertically integrated training including generalist pathways. generalist pathways.

• Create opportunities and infrastructure for Create opportunities and infrastructure for articulated ‘generalist’ pathways with articulated ‘generalist’ pathways with clear training and career structure within clear training and career structure within hospital and community sectorshospital and community sectors

Policy ImplicationsPolicy Implications

• Fund education and training Fund education and training initiatives required for safe initiatives required for safe delegated practice arrangementsdelegated practice arrangements

• Promote the role of generalists by Promote the role of generalists by developing policy of inclusion within developing policy of inclusion within hospital role delineation and hospital role delineation and privileging & credentialing privileging & credentialing processesprocesses

Policy ImplicationsPolicy Implications

Funds pooling mechanisms at the Funds pooling mechanisms at the regional or district level : -regional or district level : - would support flexible and would support flexible and

sustainable health care models (in sustainable health care models (in rural and remote communities) that rural and remote communities) that bridge the primary care and hospital bridge the primary care and hospital care continuum. care continuum.

This could support more generalist This could support more generalist training for rural practice.training for rural practice.

Policy ImplicationsPolicy Implications Fund trials of mid-level Fund trials of mid-level

practitioners practitioners In autonomous practiceIn autonomous practice In delegated practice In delegated practice

Enhance the viability and Enhance the viability and sustainability of rural and remote sustainability of rural and remote medical generalist workforcemedical generalist workforce Training and ongoing supportTraining and ongoing support Remuneration and professional recognitionRemuneration and professional recognition

Policy ImplicationsPolicy Implications Address indemnity costs: -Address indemnity costs: -

Act as a barrier to rural models of care.Act as a barrier to rural models of care. Reduce the effect of metropolitan Reduce the effect of metropolitan

specialist colleges in creating a “road-specialist colleges in creating a “road-block” in rural procedural practice.block” in rural procedural practice.

Facilitate integration of other Facilitate integration of other disciplines into generalist primary disciplines into generalist primary health care, including nursing, health care, including nursing, medicine, Indigenous Health Workers, medicine, Indigenous Health Workers, Allied Health Allied Health

Australian College of Rural and Remote Medicine

Future Future ConsiderationsConsiderations

Expansion and geographical spreadExpansion and geographical spread Hospitalists in NSWHospitalists in NSW RGs in WARGs in WA

Expansion of scopeExpansion of scope Rural Generalist Stream – Emergency Rural Generalist Stream – Emergency

MedicineMedicine Expansion of trainingExpansion of training

Identified RG training facilitiesIdentified RG training facilities Identified RGs within system to act as Identified RGs within system to act as

preceptorspreceptors

Australian College of Rural and Remote Medicine

Questions?Questions?

APHCRI PUBLICATIONAPHCRI PUBLICATION

2007–2008: APHCRI Stream 10 2007–2008: APHCRI Stream 10

The Expanding Role of Generalists in Rural The Expanding Role of Generalists in Rural & Remote Health: A Systematic Review & Remote Health: A Systematic Review

www.anu.edu.au/aphcri/Domain/Workforce/www.anu.edu.au/aphcri/Domain/Workforce/Pashen_1_final.pdfPashen_1_final.pdf

Australian College of Rural and Remote Medicine