Dr Maree Puxty did everything right.
The highly experienced rural GP, who is also a Senior Lecturer with the UNE School of Rural Medicine and until recently the chair of the New England Division of General Practice, has served the Armidale community faithfully and well for 18 years, and Moree for 10 years before that. Working alongside her husband Dr Terry Bohlsen, both were passionate about training new rural GPs while serving their patients of the West Armidale Medical Centre.
“Rural GP practice has been a brilliant life for me,” Dr Puxty said.
They had a succession plan. And when the time came to move to be closer to their ageing parents and older children, they sold the practice to a charity called The Healthy Communities Foundation Australia (previously known as Rural and Remote Medical Services or RARMS). The Foundation specialises in helping to keep rural medical practices open. They built in to the deal a transition plan: Dr Puxty and Dr Bohlsen would stay on for 12 months to give the Foundation time to recruit doctors to replace them, they would complete the training of their existing GP registrars, and assist in the handover.
Now, the 12 month transition is up. Unfortunately, the Foundation have not been able to recruit anyone for the posts at West Armidale Medical Centre. So, when Dr Puxty and Dr Bohlsen leave on February 3, despite doing everything anyone could reasonably be expected to do when moving on and then some, the clinic across the road from Drummond school that they have built for over a decade will become a telehealth centre. A nurse will be on site, but the doctor will be on a computer screen from somewhere else.
Mark Burdack, CEO of The Health Communities Foundation Australia, says their recruiters continue to seek out GPs both in Australia and the UK.
“The virtual option is not permanent. It is only to allow us to continue to ensure Dr Puxty and Dr Bohlsen’s patients receive care after they retire from Armidale and until we can recruit new GPs,” Mr Burdack said.
They are also looking at getting GP Registrars (trainee GPs) to staff the centre with remote supervision, but that will not be able to begin before August.
What happens to the patients?
Of the 4000 patients on the books at West Armidale Medical Centre, 2300 have had an appointment in the last 12 months. 715 of them are over the age of 60. While some will be fine with a telehealth doctor, many will not. For anyone hearing or vision impaired, or just not that comfortable with this new-fangled technology, it won’t be a suitable option.
“Fortunately, there will be a nurse on site.”
“Nurses are fantastic, they really are remarkable clinicians, so that’s certainly better than nothing, but it’s not ideal,” Dr Puxty said.
“You can’t do a cervical screen by video link; you can’t remove a skin cancer by video link.”
Problem is, the 4000 patients on West Armidale’s books have nowhere to go, as Dr Puxty and Dr Bohlsen aren’t the only doctors leaving town. The two full time doctors at UNE Medical Clinic finish up next week, leaving just one part time doctor who works 3 days a week. Armidale Medical Centre, Ochre Health, Faulkner Street Medical Centre, and Rusden Street Medical Centre, have all lost one GP each to either retirement or resignation.
Widespread impact expected from the compounded loss of doctors
The impact of Armidale losing 8 experienced GPs all at once is hard to fathom. Some will be accommodated by other doctors in the various clinics, but Dr Puxty estimates around 6000 patients in Armidale, which for non-locals has a population of around 25,000 people, will be in need of a new doctor.
There will also be flow on effects to surrounding towns such as Inverell and Glen Innes, where long term doctor shortages has seen those communities leaning on Armidale’s doctors and the Armidale Hospital for their health care.
Of particular concern is that 3 of the 8 departing GPs also did locum work, and will no longer be available to cover for other doctors.
Dr Bohlsen is a GP anaesthetist and obstetrician; the loss of his skills, combined with the retirement of specialist Ob/Gyn Eugeni Mihaylov last October, means there will only be two GP obstetricians left in town… and one of those is herself on maternity leave. This isn’t a little problem: Armidale has a relatively young population (median age of 34 compared to 39 for New South Wales according to the 2021 census), so unsurprisingly has a higher than average birth rate. NSW birth registry figures puts Armidale in the top 50 suburbs by number of births with 225 babies born here in 2021.
To add further insult to injury, the only respiratory specialist, Dr Gary Baker, has also retired, in a town ranked with the worst air quality in the country due to the natural inversion layer that covers the centre of the valley and our love of wood fire heating.
Dr Vicki Howell, the new chair of the New England Division of General Practice succeeding Dr Puxty, confirmed the number of doctors leaving town or retiring, but said that’s not the whole story. The number of registrars (trainee doctors) in all the training clinics has been cut, related to the transition of training by GP Synergy to college led training under the RACGP that also comes into effect at the beginning of February.
“Rusden Street have also had their training capacity for registrars reduced from 2.0 to 1.5, so loss of 0.5 there.”
“Integral Health, where I work, have also had their training capacity reduced from 2.0 to 1.5 registrars, another 0.5 drop in capacity.”
All told it is expected five full time equivalent GP registrar places in New England have been lost to the cap reductions, and it may result in more than 5 trainee doctors being lost to the area.
“Very hard to recruit half a GP trainee,” Dr Howell said.
“When you add up the actual workforce loss the numbers are really significant.”
The combined loss of effectively 13 GPs threatens to collapse the local health system and has created a cliff point in the first week of February beyond which many will struggle to access basic medical care.
The local Public Health Network is aware of the issue.
The emergency department at Armidale Hospital is expected to bear the brunt.
Where are the politicians?
Dr Puxty has been reaching out to politicians and trying to get some attention to the rapidly approaching cliff point, but has been disappointed by the response. She claims she, and Mark Burdack from The Healthy Communities Foundation, have reached out to both federal Member for New England Barnaby Joyce’s office and to state Northern Tableland’s MP Adam Marshall’s office several times.
Barnaby Joyce has, in recent days, released a press release and written to Health Minister Mark Butler about the issue, as he did when the Uralla Medical Centre threatened to close.
“This is totally unacceptable in a city like Armidale, in a country like Australia,” Mr Joyce said.
“The reduction in the number of doctors will place an additional burden on our already stretched hospital services, and on the doctors that remain as patients seek medical care.
“I am calling on Health Minister, Mark Butler to do whatever he can to address this dire situation,” Mr Joyce said.
Dr Puxty says Adam Marshall has not been in contact with her. Marshall is normally the more responsive of the two local members and a fierce advocate for better health services. He has previously backed striking nurses, demanded the Hunter New England Health District be split in two with a 15,000 strong petition, and called for the health district CEO be sacked over the lack of doctors in the region.
A spokesperson for Mr Marshall said he has offered to meet with the doctors in town to discuss the issues, and that he would do anything he can from a state perspective to help them in their lobbying of the Commonwealth to repair Medicare and help make rural general practice viable and attractive again. He will also be attending a public meeting to be held in Armidale on February 15 about the issue.
However, Dr Puxty says the Medicare Rebate freeze, which has kept the amount a doctor gets paid for an appointment at less than $40 for 15 minutes since a Gillard Government decision in 2013, is only part of the problem, and the GP shortage is not exclusively a Commonwealth issue.
“It is a state issue because the state runs the emergency departments and hospitals. And if people don’t have GPs to go to, they will go to the already overly stressed, underfunded, under-resourced emergency departments in country hospitals.”
So, what’s the problem?
Ultimately, doctors are humans too, and many are reaching retirement age. The problem isn’t that doctors are moving on or retiring, the problem is the inability of local practices to recruit new GPs to replace them. And, according to Dr Puxty, it’s a problem we shouldn’t be having.
“We graduate more doctors in Australia than the US, UK, Canada or New Zealand, but that doesn’t translate into workforce where it is needed.”
“Junior doctors can make more money as a trainee specialists or working within the hospital system.”
“So, we have heaps of doctors, but they are not in the right places.”
Additionally, the extraordinary payments made to locums, necessitated by the severe shortage of GPs and an equally severe shortage of registrars in the state funded hospital system, is also a significant part of the problem making GP practice a financially difficult choice for new graduates. There are reports locums are being paid up to $4000 a day for temporary jobs in state funded and run emergency departments.
“This was obviously meant to be a short-term solution, but is now seen as the norm.”
“You can earn as much doing two locum shifts as you can earn working as a GP registrar for a fortnight,” Dr Puxty said.
A further blow was a policy change by the Albanese Government means that international doctors coming to Australia no longer need to practice for 10 years in rural Distribution Priority Areas (previously called districts of workforce shortage) to be eligible for Medicare payments. As of July 2022, they can work in outer metropolitan areas such as the Penrith or Hornsby.
“Literally overnight, the supply of international medical graduates dried up,” Dr Puxty said.
“40% of rural GPs are international medical graduates… that supply died instantly.”
According to Dr Puxty those factors – the Medicare rebate freeze, the financial disincentives to pursue general practice, and the policy change to allow international doctors to work in urban areas – combine to be the “nail in the coffin of GP training” and make recruiting rural GPs impossible.
“You can’t pay a locum $2,500 a day, for x number of months, and expect to keep a business financially viable with a Medicare rebate of $39 for 15 minutes.”
The pandemic didn’t help either.
What are the solutions?
Dr Puxty says the solutions are many and varied, but include attracting more people to the profession by paying GP registrars at least what they can earn in a hospital, unfreezing the Medicare rebate, and reversing the decision about Distribution Priority Areas.
She added, “for practices like [West Armidale Medical Centre], a government grant to help pay for locums for a few months so the practice can remain open and viable.”
There are other creative initiatives such as the longitudinal integrated clerkship program run by UNE which embeds 5th year medical students in general practice, and a single employer model being deployed in the Murrumbidgee Local Health District, that seek to address the structural and systemic disincentives that prevent medical graduates from choosing general practice.
But these bigger structural reforms will not address the immediate problem of more than 1 in 5 people in Armidale needing a new doctor within the next fortnight.
“GPs are very concerned about how the community is going to manage,” Dr Puxty said.
“But I think if there is community outcry then perhaps the Government will listen and look at the decisions that have been made, and potentially review them.”
A community meeting about the GP shortage and possible solutions is being hosted by New England Visions 2030 on February 15 at the Armidale Bowling Club. Dr Howell will be speaking at the meeting and a number of politicians have been invited to attend. Those wishing to attend must RSVP by email to firstname.lastname@example.org by 5pm on Monday the 13th of February. A $5 donation is requested at the door to help cover the costs of the event.