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Easy Entry, Gracious Exit Model for Provision of Medical Services in Small Rural and Remote Towns - 2014

02 Sep 2014

1. Background

The AMA believes that the best solution to a shortage of rural medical professionals lies in attracting and retaining, through good pay and conditions, permanent resident doctors in rural and remote areas.[1] However, it acknowledges that the Easy Entry, Gracious Exit model could be a useful solution in circumstances where there is a chronic shortage (or in absence) of local medical professionals.

Easy Entry, Gracious Exit refers to a walk-in-walk-out approach, which aims to make general practice in difficult rural areas more attractive by enabling GPs to work as clinicians without having to become small business owners and managers[2],[3].

The model seeks to support both the desire of GPs to focus their work on clinical care (rather than practice management) and to reduce the need for any significant up front financial investment on their part. The reduced financial commitments allow more freedom to come and go as a doctor’s circumstances dictate. Domestic and surgery accommodation, and full infrastructure for the general practice is provided by a third party, as well as the option for VMO rights and contracts to be negotiated on behalf of the doctor.

Previous recruitment models have concentrated on the continuity of the doctor, rather than the continuity of the practice or practice management structure. This model was initiated with the hope that by removing many of the previous barriers to recruitment it would be much easier to attract doctors and that once doctors arrived in these towns they would find that, while free to leave at any time, the support, financial arrangements and the interesting medicine would be so attractive that they would readily remain for a reasonable period.[4]

This position statement outlines AMA key principles in support of the Easy Entry, Gracious Exit model to improve access to quality health care in small rural and remote towns that are experiencing chronic shortage of medical professionals.

2. Variations/alternative models

2.1     RDN’s Rural and Remote Medical Services Ltd (RaRMS)

The Rural and Remote Medical Services Ltd (RaRMS) is an entity established by the NSW Rural Doctors Network (RDN) to implement the Easy Entry, Gracious Exit model (in Walgett and Lightning Ridge initially). RDN established RaRMS as a not-for-profit company to overcome a multitude of barriers in small rural towns that were experiencing a chronic shortage of GPs and which had reached crisis point.

Since 2001, RaRMS has succeeded in attracting and retaining doctors in rural/remote areas of NSW, and in facilitating a greatly expanded range of medical, nursing and allied health services available from its surgeries. RaRMS currently runs five practices in vulnerable towns. The program includes locum relief and has enabled continuity of patient medical records. It has encouraged doctors to stay longer (the average retention rate is 5 years). There is also evidence that the improved medical services in RaRMS’ towns have reduced hospital outpatient presentations.[5]

2.2     Wentworth Shire Council

The council has, for several years, owned and operated the local medical practice in Wentworth and a subsidiary practice in the next community of Dareton. Practice equipment and furniture were purchased from the existing GP who was leaving Wentworth. The building and medical records were not purchased. The medical records of these new practices are now the property of the shire/practice and will stay with the practice when the doctor leaves. The council had new practice premises purpose built, which they lease, rather than own. The council employs the practice staff (doctor, practice manager/registered nurse, and a receptionist). All are employed under normal council employment conditions - salary, super, recreation and sick leave etc.[6]

2.3     Ochre Health

Ochre Health (formerly known as Australian Outback Medical Services) was formed in 2002 in response to a doctor crisis in Bourke and Brewarrina. Existing and new doctors were engaged by Ochre Health on attractive incentive remuneration arrangements, and are supported with increased education and time off. Ochre Health recruits permanent and locum doctors through its agency, Ochre Recruitment. Ochre Health offers practice management services to relieve doctors of administration duties to enable them to concentrate on patient care. Ochre Health developed complex clinical data sharing and other IT communication between various practice sites. Ochre Health increased practice turnover and increased the range of services available and improved health outcomes through use of CDM, public health projects, allied health partnerships and enhanced nursing services. Ochre Health also worked with the local Shire Councils, the local hospitals, public health and similar programs, residential care facility, the Bourke Aboriginal Medical Health Service and other organisations as required to develop long-term arrangements which guarantee a supply of doctors to these communities. Links with specialists were maintained and cultivated.[7]

2.4     The Remote Area Health Corps

The Remote Area Health Corps (RAHC) has been successful in meeting the needs of remote Indigenous communities. The RAHC is Australian Government funded and designed to attract urban health professionals to work for a short period (3 to 12 weeks) in remote Indigenous communities in the Northern Territory where there is a need for a clinical service but there is no local health professional available.

RAHC provides support and training and covers transport costs to the location. The receiving health service provides accommodation and employs the health professional on a casual basis at the usual pay rate for the position. This means there are none of the additional costs associated with agency staff. In addition, RAHC endeavours to assist health professionals to transition into permanent roles within the health services. RAHC has placed over 600 health professionals in almost 2,000 placements since its first placement in December 2008.[8]

3.             Effectiveness/benefits

Experience from the above initiatives has shown that the Easy Entry, Gracious Exit model has been very successful in expanding and improving the stability of the general practice workforce in the towns involved. The successes of this model can be seen as:[9]

  • A dramatic increase in the number of doctors in participating towns.
  • Retention of several doctors beyond originally stated departure dates (e.g. an average GP retention rate of 5 years across all RaRMS centres).
  • A significant expansion in Medicare services including greater uptake of Enhanced Primary Care (EPC) items, outreach services to outlying communities and more clinician time to participate in disease prevention and health promotion activities, including formal public health activities.
  • The creation of a platform that can be used to provide a wider range of Primary Health Care services.
  • A successful partnership of health policy makers, health service organisations, health practitioners, communities and academics. This has formed the basis for raising ad hoc partnerships to formal contractual partnerships.
  • Stability in the professional and clinical working environment, resulting in more productive, less stressed clinicians.
  • Continuity of practice infrastructure and practice management skills independent of continuity of the medical practitioner.
  • Enhanced opportunities to address quality issues in practice – e.g. computerised records, good recall systems, chronic disease registers, better information management, greater capacity to engage practice nurses and train (support) staff.
  • The continuity of patient records even when there is a high turnover of doctors.
  • A better relationship with the local Area Health Service resulting in a more productive and less stressful working environment.
  • Elimination of the previously frequent crisis situations that occurred in scrambling to provide hospital and medical cover whenever a doctor was ill, or took a few days off for leave, training or personal reasons.

The benefits to the GP are that the entity:

  • Owns the practice infrastructure, employs all staff, is responsible for all paperwork and supplying IT support and other services.
  • Enters into all leases for housing and surgeries (or can broker such leases).
  • Negotiates with the Shire.
  • Negotiates with the Area Health Service.
  • Manages the VMO agreements.
  • Takes many of the financial risks including provision of operating capital (although the key financial risk to the GP remains medical liability).
  • Lowers stress levels and provides a more regular doctor income as well as more control over hours worked.
  • Creates ease of entry into a general practice and simple exit from it, when the doctor decides the time is appropriate.

4. Key concerns

Private practice in remote Australia is not sustainable in the traditional small business model.[10] For example in NSW, in the past it has been subsidised by regularly indexed payments (in line with the Rural Doctors Association Settlement Package) from Area Health Services to doctors for VMO services. The doctor, and sometimes the doctor’s spouse, performing unpaid administrative services after hours. This often creates a secondary problem that when the doctor leaves town, the practice company structure and the practice management is also lost.

There is often a serious shortage of people with practice management, management, IT, nursing and financial skills in remote areas. There is limited opportunity, because of remoteness, to share human resources, and this problem is compounded by the increasing complexity of medical practice management and small business management.

More importantly, without some form of subsidy, income generated through bulk billing does not sustain quality general practice and its administration in a remote area. Maintaining a sustainable community based bulk billing practice is also challenging due to the difficulties associated with achieving the correct fee, billing and contract structures to account for “opportunity” costs such as those arising from the absence of a GP from the practice whilst undertaking VMO, public health and other activities.[11][12][13]

There is evidence to suggest that the Easy Entry, Gracious Exit model is best suited to towns with somewhat larger populations, where there is adequate opportunity to establish a discrete general practice and provide VMO services. Smaller rural and remote areas or catchment populations may be better suited to an outreach, fly-in fly-out or satellite/hub-and-spoke model of service delivery.

 

5. AMA Key Principles

The AMA supports the Easy Entry, Gracious Exit model to improve access to quality health care for people in rural towns experiencing chronic shortage of doctors with the following key principles:

1.      The arrangement must ensure continuity and support good patient care.

2.      The doctors should have complete independence in clinical decision-making.

3.      The entity set up must be cost effective to ensure the sustainability and financial stability of the service/model of care promoted.

4.      Where possible, the practice should be accredited.

5.      The entity set up should not be in competition with a local practice (if there is one) and that local doctors (if any) should not be disadvantaged in terms of remuneration.

6.      In order to ensure that services match the needs of the community, planning should involve the local community and all relevant stakeholders and strong linkages should be established and maintained with local government, relevant doctor organisations, allied health, the local hospital and Area Health Network, neighbouring towns and relevant Aboriginal health services.

7.      The practice must remain responsive to the changing needs of the community and encourage rural capacity building.

8.      The full infrastructure must be provided by the entity rather than by the doctor including:

o   Surgery space

o   Staff, including where possible a practice manager and nurse

o   Consumables

o   Medical equipment

o   IT

o   Utilities

o   Doctor support

o   Continuity and security of medical records as doctors change.

9.      The arrangement must ensure doctors have access to appropriate training, skills, experience or cultural preparedness for rural and remote areas.

10.  Doctors who work at the practice must be supported if they choose to provide education and training to medical students and doctors in training.

11.  The arrangement should provide a realistic and sustainable work environment with flexibility, including locum relief.

 

 

[1] AMA position statement Regional/Rural Workforce Initiatives 2012  https://ama.com.au/position-statement/regionalrural-workforce-initiatives-2012

[2] NSW Rural Doctors Network (2003) Easy Entry, Gracious Exit http://www.nswrdn.com.au/client_images/246595.pdf

[3] Kamien, M. (2004) The viability of general practice in Australia. MJA Vol. 180, 2004. https://www.mja.com.au/journal/2004/180/7/viability-general-practice-rural-australia

[4] NSW Rural Doctors Network (2003) Op. Cit.

[5] Rural and Remote Medical Services Ltd (RaRMS). http://www.rarms.com.au/site/index.cfm

[6] NSW Rural Doctors Network (2003), Op. Cit.

[7] NSW Rural Doctors Network (2003), Op. Cit.

[9] NSW Rural Doctors Network (2003), Op. Cit.

[10] NSW Rural Doctors Network (2003), Op. Cit.

[11] NSW Rural Doctors Network (2003), Op. Cit.

[12] Jones et al A Textbook of Australian Rural Health Chapter 7 (2008) Australian Rural Health Education Network http://www.arhen.org.au/images/publications/Text_Book_of_Australian_Rural_Health.pdf

[13]  Wakerman and Humphreys et al Primary health care delivery models in rural and remote Australia-a systematic review (2008) BMC Health Services Research http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2642801/


Published: 02 Sep 2014