Delivering Clinical Services

1
Delivering Clinical Services Rural Practice
Training
Dr Peter Rischbieth Vice President Rural Doctors
Association of SA

• West Lakes
• Saturday 8th November 2008

2
(No Transcript)
3
Rural Communities Health Needs

• Locally based services
• Health professionals with a broad range of skills
  in Primary health care
• Members of the Health team also have a depth of
  skills in
• Secondary care
• Emergency care
• Maternity and Surgical services
• Mental Health, Aged care, Palliative care

4
The Big Cs for rural communities

• Challenges of Country Living
• Capacity - service delivery teaching
• Co-location Coordination Services
• Computerisation- IT opportunities
• Communication-local networks, metro
• Country specific issues distance
• Canberra - commitment of resources
• Capacity of Workforce
• Costs patients and families
• Change opportunities

5
Building a better Rural Health System

• Good Primary Health Care produces Better health
  outcomes
• Prevents disease complications
• Decreases rate of hospitalisation
• Decreases Health Costs to Community and
  Governments
• Well trained and better resourced
• Rural
• Health Workforce needed

6
Estimated Rural GP shortfalls by 2012
RDWA SA RRMA 4-7
133

• RDN NSW RRMA 3-7
  275-410
• RWA Vict RRMA 3-7
  311
• WACCRM Rural
  230
• HW Qld RRMA 4-7
  79-178
• Rural
  Workforce agency Data
• Why?
• Increased demand for services
• Decrease in hours worked Gen Y ,feminisation
• Ageing GP workforce , average age 54years
• Need 1200 workforce entrants/year 2007-2013
• Currently 800applicants for 600 places 2009
• 
  AHMWAC

7
Rural Doctors in Australia

• RDAA estimates 1,600 rural doctors needed in
  2008
• 2008 GPET intake 23 of medical graduates
  choose general practice (cf 50 20 years ago)
• IMGs 45 of workforce 4 x increase over 10
  years outnumber Aust graduates in rural
  Queensland
• Average age rural doctor 54 years
• 70 of rural GPs are VMOs for local Emergency
  Dept
• 22 provide traditional procedural services
• 2007 1913 medical grads
• 2012 3367 medical grads- Where will they go?

8
Aust medical graduates actual/projected,19702016
9
Where the bloody Hell are you?
10
Factors that increase the odds of medical
students transitioning to become a rural doctor

• Rural Origin - 2.5 x
• Rural Schooling - 2.5x
• Rural Spouse - 3.5x
• Rural student experience - 2x
• Rural Intern - 3x
• Rural Postgraduate education
• gt50 of the training time 4x
• BUT
• Only 5 Queensland/NSW graduates over the last 15
  years chose to work in RRMA 4-7
• Only 2 Tasmanian graduates in past 10 years
  chose rural career path

11
Rural Doctors Workforce Agency
2006 RDWA Rural Doctors Survey

• 430 rural doctors in SA (70 health
  units/hospitals)
• 326 respondents (76 response rate)
• 42 doctors aged 55-79 yrs
• 48 practices had vacancies
• 26 doctors intend to leave within 5 yrs
• 47 Registrars - 12 of workforce
• On call average - 13
• 86 rural GPs emergency A/Hrs work
• 75 had students/ 42 registrars/ 12 interns
• 1 in 8 practices have practice nurse
• 38 procedural skills obs, anaesth, surgery

12
Capacity to increase GP numbers

• Challenges of ? teaching/training demands
• To deliver positive experiences for
  registrars/interns/students in general practice
• To maximise utilisation of available teaching
  time
• To provide medical practice infrastructure
  supports
• consulting area, practice equipment
• computer facilities/access IT/IM
• accommodation
• social recreational opportunities

13
Purpose-built rural clinic model Murray Bridge
South Australia

• 4 Consulting/examination rooms
• 2 Nurse treatment rooms (including immunisation
  fridge), emergency/retrieval equipment, ECG,
  Spirometry (defibrillator/oxygen)
• 3 Work-station reception area
• Office manager work area
• Waiting room for 20 patients
• Staff room
• Student / doctor resource area
• Public and staff toilets
• Storage
• Car parking for 18 vehicles
• Metro clinic comparative cost approx
  50,000/room
• to add on to existing clinic

14
New Rural Clinic consulting rooms Southside
Clinic 2007

• 2 GP Supervisor rooms, intern/student room 2
  practice nurse rooms, pathology collection room
• Cost to lock up/fit out with floor coverings,
  cabinetry, 720,000
  
• Demolition/asbestos removal of existing
  structures     40,000
• Air conditioning units                 
                     45,000
• Security system                                   
           5,000
• Cabling/phones                                    
            10,000
• Fire hoses extinguishers                         
          5,000
• Landscaping/irrigation                            
           15,000
• TOTAL CASH INVESTMENT 840,000 interest on 8
  borrowings over 10 years
• 1,100,000

15
Training Rooms
16
Rural GP intern placements (PGPPP)

• Income
• Program payment to cover the 5 placements/yr   
    82,500
• Income from the Intern consultations approx    
  57,000
• Annual income                        
  139,500 
• TOTAL INCOME PER WEEK                
  2,790
• Costs                                             
                 per week
• Coordinator (6 consult/week)      
                           300
• Supervisors (24 consult/week)                     
          1,000
• Room rental 20.00/hr
• Specialist rate 28/hr                       
                      700
• Admin (orientation)                               
              20
• Computers                                         
              10
• Utilities (power, phone, security,
  insurance)         50
• Reception, nursing, typing, scanning, cleaning  
  800 
• (based on 1.9FTE support staff per F/TGP
  equiv)
• TOTAL EXPENSES PER WEEK                  
   2,830

17
Registrar Training Program
Sturt Fleurieu RTP

• INCOME
  Per Week
• Registrar generated fees
  3,500
• Program teaching (3hrs/wk)
  300
• On-costs subsidy (rent/admin)
  400
• Residential rent subsidy (50)
  100
• 
  4,300
• COSTS
• Registrar salary (according to level
  Basic/advanced)
  1,600
• Super _at_ 9
  150
• Relinquished consults by supervising GPs (8)
  400
• Rent paid (100)
  200
• On-call/SIP 100
• On costs-support staff, facilities, equipment
  450
• 
  2,900
• Net Financial gain per week
  1,400

18
Additional Patient Service Providers In Rural
Practice

• Specialist medical practitioner
• Allied health professional
• eg mental health worker, psychologist,
  counsellor
• SA average 3.5/practice
• Practice nurses 1.4 FTE per practice
• Nurse practitioner
• Physician assistants?
• RDWA South Australian survey 2006

19
Potential Income/Service Comparisons

• NURSE (per 4hr session)
• Nurse prepares assessment/measurements/advice
• 4 patients _at_ 1hr each
• Hypertension-assessment/advice (dietary/lifestyle)
  
• GPMP Review (725) 4 _at_ 65 260
• DMMR (900) 4 _at_ 140 560
• 45 yo health check (717) 4 _at_ 104 416
• NURSE PRACTITIONER
• SIP Mental Health 4 _at_ 150 600
• PRACTICE NURSE COSTS per session 233

20
Practice Nurse Costs

• Salary 4 hrs _at_ 25 30 (on cost) 148
• Room rent _at_ 20/hr (as per students) 80
• Provision of equipment/IT/utilities
  5
• Total cost/session
  233

21
Service Delivery vs Teaching Opportunities
Cost / Benefit

• Medical Student Loss/week 600
• Intern Loss/ week
  40
• PRCC student Profit / week 2,200
• Registrar Profit/week
  1400
• Specialist rent Profit/week
  1,120
• Psychologist
  ???
• Practice nurse
  variable

22
Getting it right for RuralGeneral Practice ?

• Recognition of true costs benefits of teaching
• Formal costing/modelling project needed by
  Universities/RTPs/GPET/Commonwealth
• Revised remuneration for teaching practices
• Choices -Service delivery vs Training
  opportunities
• Increased IT/IM linkages for General Practice
• Commonwealth / State Government commitment (AHCA)
  to training including hospital/procedural posts

23
An impossible dream or achievable reality? Are
there any practical ways to achieve sustainable
general practice ?

• Models of practice
• Range of financial and administrative structures
• GP, nursing,midwife,allied health teams- sharing
  and delegation of work
• Rural generalist
• Community education capacity to deliver

24
Future Workforce Needs (AMWAC 05)

• Initial estimates are that every year the GP
  workforce in Australia will need
• An additional 316 new entrants to cover workforce
  exits
• An extra 365 GPs to cover changes in the patient
  population due to growth and ageing
• Possibly some additional GPs to cover any decline
  in average hours worked this is expected to be
  between 198 and 386
• Additional GPs to cover areas of current shortage
  this is expected to be between 131 and 245
• 1200 now

25
Rural Health Outcomes

• Rural Life expectancy 3yrs less of urban
  population (avoidable death rate 40 )
• Mortality rates up to 20 higher
• Survival rates lower- Cancer ,cardiovascular
  disease
• Higher incidence -mental illness, domestic
  violence, sexual abuse, alcohol, cigarette
  related diseases
• Significant financial and social costs,
  travelling to access health services - PATScheme
  deficits

26
Rural Health Obligation

• The Rural Doctors Association of Australia
  calls upon Governments
• to set
• An Absolute minimum Standard of Access to
  Rural primary Health care professionals and
  Health services

27
(No Transcript)
28
Threat of Increasing Corporatisation

• City Practice Incentives to join up to 500,000
  per GP-commit to 5 years
• 50 hrs a week - 5 x 10 hr shifts
• ? after hours commitment
• ? holiday/leave availability entitlements
• ? continuing professional development
• ? increasing buy out of rural doctors
• ? teaching training and supervising capability ?

29
(No Transcript)
30
(No Transcript)
31
Medical Clinic Building Costs

• 420 sq m structure on 1400 sq m land site
• 4 consulting rooms
• 2 GP supervisor 2 training
• (med student/intern/registrar rooms)
• 2 treatment rooms
• Clinic Costs to construct 1,700 per sq m
• (Standard house cost in SA1,000 sq m
  brick veneer)
• University funds contribute 1,500/ sq m
• (i.e. funding 1 room 15 sq m)
• University do not consider extra costs of
  corridors, waiting room,
• study areas, parking areas etc

32
Medical Clinic - required Building Standards

• Additional costs
• Fire rated walls / compartments
• Sleuce plumbing
• Commercial grade fixtures/fittings/floor
  coverings
• Security
• Access (e.g. width of corridors)
• Disabled access/toilets
• Sound dampening on doors
• Extensive signage

33
Rural Health resources under spend

• GP services per capita per year
• Remote areas 3/yr Capital city 5.5/yr
• Medicare benefits per capita per year
• Remote 120 Capital city 195
• Rural Medicare Underspend 160million
• Public hospital admission days per year per 1000
  residents
• Remote 301 Capital city 193
• Limited access to services under private health
  insurance (100million)

34
Impact of Increasing Corporatisation

• Incentives to join up to 500,000 per GP
• 50 hrs a week - 5 x 10 hr shifts
• ? after hours commitment
• ? holiday/leave availability entitlements
• ? continuing professional development
• ? increasing buy out rural doctors
• ? teaching training and supervising capability ?

35
Our patients , our communities

• 400,000 live in rural areas others work,
  travel, invest, holiday, families
• Poorer Health Outcomes than urban counterparts
• Life expectancy 3yrs less. Cancer ,cardiovascular
  disease higher
• Cigarette, alcohol related illnesses ,mental
  illness, domestic violence, sexual abuse
• Rural health underspend, both public and private-
  250M/yr
• Access to health services an issue up to 6 weeks
  to see a see GP
• 50 of Australian rural maternity units have
  closed over the last 15 years
• SA 20 hospitals (approx 1/3) now have no
  birthing services
• Risk taking by mother and child in order to
  travel to service
• PATS are quite inadequate dont even cover
  petrol costs often, let
  alone accommodation(50.00/night) and
  basic living expenses

36
Medical Clinic - required Building Standards

• Additional costs
• Fire rated walls / compartments
• Sleuce plumbing
• Commercial grade fixtures/fittings/floor
  coverings
• Security
• Access (e.g. width of corridors)
• Disabled access/toilets
• Sound dampening on doors
• Extensive signage

37
Workforce Barriers

• Inadequate student and doctor numbers
• Inadequate rural medical student intake
• Financial commitments of graduates
• Lack of clear rural path PGY 12
• Lack of explicit financial workforce drivers
• Negative image of rural practice
• Societal trend to Specialization