When Dr Rebecca McGowan referred a severely asthmatic patient from Albury Wodonga to a local respiratory specialist, she considered the patient lucky to get an appointment in February.
“No, February 2023,” the patient told her in tears.
The respiratory clinic told McGowan it was at a point it could not take any more patients.
So she pulled strings with a Melbourne specialist she knew at medical school. Her patient’s asthma is so bad that she cannot drive herself, so her sister will drive her to the capital, three and a half hours away.
“It’s something rural people put up with, but it’s appalling,” McGowan says.
The 17-month wait to see a respiratory specialist is the worst, but McGowan says the waiting times for endocrinologists, neurologists, pain specialists and ADHD/ASD psychology assessments are all over six months, and psychiatrists and rheumatologists are taking no new patients at all.
Albury Wodonga is a large rural town of more than 100,000 people. Its oncologists service 500,000 people as they cover a lot of rural Victoria and New South Wales, who prefer to travel to Albury rather than Melbourne for specialist services such as radiation.
The situation has been exacerbated recently because so many appointments and elective surgeries have been delayed due to Covid-19.
Dangerous health inequity
Dr Marco Giuseppin, the chair of the Council of Rural Doctors at the Australian Medical Association, says “many areas of rural Australia face long wait times to see non-GP specialists … the AMA has long been concerned about this and its effect on health inequity in rural and remote Australia”.
“The consequences of delay to care can mean that conditions progress, making them more difficult to treat and increasing potential suffering in our vulnerable remote communities,” Giuseppin says.
McGowan says further consequences include increased anxiety for the patient as well the GP, frustration and anger, increased instances of chronic disease and hospitalisation, as well as increased instances of death.
“Rural people have much higher death rates because we don’t have the same access to quality medical treatment,” she says.
In a submission to the inquiry into health in rural, regional and remote NSW, the Cancer Council said residents there had poorer cancer survival outcomes compared with their city counterparts, citing distance from, and availability of specialists and diagnostic services as a significant factor.
“Nationally, five-year all-cancer survival decreases with increasing remoteness, from 62% for major cities to 55% for very remote areas,” the submission said.
Because of the longer wait times locally, McGowan will routinely advise her patients to go to Melbourne or Sydney for a specialist opinion.
They must add the cost of taking time off work and accommodation expenses to the specialist’s fees.
But even this is often not possible for anyone who cannot drive, including many elderly and disabled patients, as public transport is “abysmal”, McGowan says.
The federal regional health minister, David Gillespie, a gastroenterologist, says the medical profession needs to shift its mindset to solve the problem.
“The problem we face is that too many of our GPs and non-GP specialists are bedded down in the bright lights of our capital cities, aided by the metro-centric focused training of specialists required by the colleges, and the metro-centric employment and placement of interns, residents and registrars in metropolitan public hospitals rather than regional and rural hospitals,” Gillespie says.
“This is not an overnight problem – it takes at least 12 years of study and training to become a doctor, sometimes longer to be a sub-specialist. And it is not a problem that the federal government can resolve without the involvement and mindset shift of the medical profession itself.”
The federal government is supporting the training of non-GP specialists in regional and rural areas through the specialist training program, with rural targets for each of the 13 participating medical specialist colleges.
The program has increased the proportion of training delivered in regional, rural and remote areas from 309 training posts in 2018 to 413 in 2021. The program’s integrated rural training pipeline has provided a further 93 funded rural posts in 2021.
‘Dudded for access’
Peter Wakeford is a retired physician who specialised in gastroenterology and during his career serviced the north-west of NSW from Tamworth hospital, with one other physician.
Wakeford describes times he would have a “hell of a day at work, go home for dinner and a guy from Walcha would ring at eight o’clock” which would require an hour’s drive followed by an hour’s consultation.
“My [professional] partner and I made a promise, we would not be the doctor who couldn’t come,” Wakeford said.
Wakeford describes keeping the radio playing loudly on drives to keep himself awake but many times having to sleep by the side of the road.
He was only ever paid for the time spent with the patient, as there was no recompense for travel.
Wakeford says they “always had difficulties recruiting because most people wanted to stay in the larger centres where you had access to second opinions, it wasn’t such a lonely existence.”
He says lower incomes and lack of access to colleagues – essentially “being thrown on your own devices” – made medical professionals reluctant to work in regional Australia.
“Rural people are dudded for access. It’s not understood by the big colleges. You have to live it, it’s not just a statistic,” Wakeford says.
Giuseppin says two solutions have been shown to be effective.
“The first involves the promotion of specialist training in regional and rural areas. The second solution is proposed by the developing national rural generalist pathway.”
A rural generalist is a GP with specialised skills relevant to their community.
But Giuseppin says uptake has been limited by lack of remuneration and recognition of those skills, “as well as resistance from city hospitals who are keen to hold a monopoly on some specialised services”.