The Statewide Rural and Remote Clinical Network is a multidisciplinary group of people who raise the real issues that face rural people to the notice of Queensland Health. One of the greatest challenges is finding the right people to delivery good care, to people in the country, as close to their homes as possible.
The Network is looking at the various challenges to delivering quality care to rural people in a workshop today. We live in an environment where there are too many doctors and a major maldistribution of health professionals. We are training too many medical students and still importing large numbers of foreign graduates, and have the highest number of subspecialist disciplines in the world (64 Registered Specialties).
Yet we still have poorer health outcomes in the Bush, we have poorer access to care, and more people are dislocated from their homes at times of critical illness.
My brief in the workshop is to talk about the role of the Visiting Medical Officer (VMO) in supporting public health services, the opportunities and the challenges. In this presentation I will look at the past, present and future of primary care (general practice) in the Bush.
Visiting Medical Officers have largely disappeared from rural practice in Queensland. These are doctors who have advanced skills such as Obstetrics, Anaesthetics, Surgery etc… who worked in General practice and practiced those skills at the local Hospital.
VMOs often worked after hours and on call for the local health service, assisting the full time employed Hospitalists.
In early 2000 indemnity insurance failures saw most of the VMO workforce disappear from Rural Hospitals, almost overnight.
This led to service failure, closure of birthing units, increasing use of retrieval medicine and a greater demand on Public Health Services to deliver chronic disease and preventative care services; that they are not necessarily funded nor geared to do.
The rise and rise of the Rural Locum can be, at least in part, an outcome of the withdrawal of the rural VMO; contributing significantly to the costs faced by health entities.
The history of the VMO is a rich one. My mentor as a second year doctor was Dr Louis Ariotti, a rural general practitioner and surgeon, resident of Charleville since World War Two.
Dr. Ariotti taught me much about resilience, flexibility, self reliance and acceptance of risk, lessons that have helped me through some 26 years of rural clinical practice as a GP and GP Obstetrician in my own town of Emerald.
The lessons learnt and the cases shared in Charleville reinforce for me the importance of ensuring that the care of rural people happens in primary care.
Hospitals should be secondary and supportive places for delivering higher complexity care within a community context and across the continuum with the same clinical workforce in both environments.
Presently Rural Queensland sees an over-reliance on International Medical Graduates to deliver clinical care. These doctors are often unsupported, placed in challenging clinical environments, poorly selected for the skills needed to support local health care, and disconnected from secondary care and Queensland health facilities. District of workforce shortage selection does not reflect the health care needs of communities.
Care is siloed, VMOs are falling in numbers and skill sets as primary care general practice becomes less viable and opportunities for practicing their advance skills dry up. GPs often find themselves disregarded by policy makers and service planners when looking to address health care gaps.
The Queensland Rural Generalist Pathway (QRGP) is the dawning of a rediscovery of the value of rural medical practice. This pathway selects Medical Students with an interest in rural practice, mentors and supports them through their student and early clinical years. It ensures those young doctors receive advanced skills applicable to rural community needs. The program has been enormously successful with over 400 interns enrolled and 110 doctors staying in rural practice since its inception in 2008.
The product is perhaps not a new creature but the relabelling of the quintessential rural doctor as the Rural Generalist.
Some challenges remain in that the training of generalist clinicians isn’t always accepted by other healthcare disciplines such as nursing and allied health.
Hospital and Health Services (HHS), the organizations tasked to govern regional public health services, have been variously embracing of Rural Generalist Medicine.
To many planners health service delivery remains all about the numbers and not about providing a team of people who will stay for a significant portion of their career in a rural area.
Sadly Specialist Outreach remains the principal mechanism for supporting rural people.
An Elephant in the room for the QRGP is the transition of hospital clinicians into rural general practice. There are only so many positions for Rural Generalists in Hospitals, and where there is no hospital for the generalist to maintain and practice their special skills.
The transition from Employee to VMO is yet to be mapped and understood, yet is critical to developing a sustainable response to rural health equity and access.
So what of the future? What role will VMOs play in Secondary Care in Queensland?
To truly design a resilient health workforce for the future integration of resident community health professionals into Public Health Systems has to happen.
Service redesign must start with a community stocktake, an assessment of the unique health care needs of a town and region, coupled to an understanding of the human capital already invested in long term connections with their homes.
Service redesign of workforce must enable VMOs to be a part of the team.
A community must have an accessible medical home, that connects and assists them through their own health trajectory. For many people this will involve managing chronic disease in the community with journeys in and out of secondary and tertiary care.
A well connected primary care workforce becomes critical to holistic care with the clinicians able to extend their skills into Hospitals; as and when needed. The VMO should be central to health service responses in rural areas.
An integrated health care team is key.
This team should train together, work together and communicate well with each other.
The great enabler for this is a willingness to allow VMOs to train future rural generalists in primary care, to allow VMOs access to caseload in hospital, and to support VMOs explicitly by ensuring access to appropriate training, skill maintenance and transparent credentialing in advanced clinical care.
Future VMOS, our current Rural Generalists need to remain valued, connected and supported.
VMOs are a significant part of the Rural Renaissance in Queensland.