South Australia's leading doctors' groups have warned the state's rural towns will "wither and die" because of the state government's refusal to support rural general practitioners.
Australian Medical Association of SA and the Rural Doctors Association of SA over several months have called for a comprehensive, long-term agreement for rural GPs.
The groups say they have unsuccessfully engaged with the Department for Health and Wellbeing's Rural Support Services (RSS) seeking an outcome.
They say the rural health situation is reaching crisis point.
The three current associate doctors of the Kangaroo Island Medical Clinic took the extraordinary step of publishing a half page letter in The Islander newspaper this week calling for action.
"It has become clear that the medical workforce across rural and remote Australia is in crisis, and Kangaroo Island is no different; the situation here is only part of a wider problem," the letter reads.
"It is becoming harder and harder to recruit doctors to rural areas like ours and we must be realistic: it is only going to get harder."
You can read the full letter from the KI doctors below.
Rural Doctors Association of SA says GPs, in addition to their general practice work in primary care, are contracted by their local public hospitals to perform essential services.
These include such duties as staffing emergency departments, and providing critical inpatient, surgical and post-operative care; and supporting obstetrics patients.
AMA(SA) and RDASA last week received a response from the Department for Health and Wellbeing's Rural Support Services (RSS) and the regional Local Health Networks that they have described as "unacceptable and deeply inadequate".
The associations are strongly urging RSS to reconsider its response.
AMA(SA) and the RDASA say they sought an agreement that reflects the high workload that rural GPs experience and the regular out-of-hours care they provide their patients and communities through regional hospitals, in addition to their general practice commitments.
They wanted from RSS a package of remuneration, conditions and professional development support that responds to the current and future circumstances confronted by rural doctors.
The previous three-year agreement expired on November 30, 2020.
Country GPs speak out
AMA(SA) vice president and Port Lincoln GP, Dr John Williams said after months of engagement with RSS, the AMA(SA) and RDASA "had expected a reasonable and workable response from the RSS to our responsible offer".
"Our offer was designed by rural GPs to acknowledge our work, inject new life into the shrinking rural GP workforce and support country communities through their rural hospitals," Dr Williams said.
"What we received has led to complete despair and frustration among rural doctors.
"Instead of responding with a realistic solution, RSS has rejected our suggestions, which would fix the rural doctor workforce crisis, make workable SA Health's own Rural Health Workforce Strategy, and demonstrate SA Health's commitment to the health of South Australians living outside metropolitan Adelaide.
"RSS knows there is a rural community health crisis across South Australia yet continues to make it impossible to attract and retain GPs and GPs in training.
"It seems the South Australian Government is willing to let South Australian towns wither and die as residents lose yet another essential service."
RDASA president and Murray Bridge GP, Dr Peter Rischbieth said the doctors' suggestions were aimed at fixing a crisis that many rural South Australian communities in the past 10 years had lead to "their emergency departments on bypass, their maternity units close and a mass exodus of highly skilled GPs from regional South Australia".
"Many practices are crying out for more GPs to support their primary care clinics and to also provide services at their local hospitals," Dr Rischbieth said.
"We recommended to RSS a package that would reflect the care and expertise GPs provide and create an attractive environment for younger doctors looking to commit to regional South Australia, now and in the future."
Dr Rischbieth said GPs had been working on a day-to-day basis at rural hospitals since their hospital contracts expired in November.
"GPs have done this expecting their continued willingness to work tirelessly for their patients and communities - despite not having a new deal in place - would eventually be recognised by RSS.
"But this response is a slap in the face, for rural doctors and the communities they work for," Dr Rischbieth said.
"The RSS response also highlights the ineffectiveness of the decentralised model that has six Local Health Care Networks responsible for implementing State Government policy.
"It demonstrates a clear absence of LHN accountability coordination, efficiency and collaboration."
Dr Rischbieth said there had been a large decrease in the number of GP registrars (GPs in training) applying for rural placements, from 72 in 2021 to 26 for placements in 2022.
"The only way to fix this decline is to ensure rural medicine is and will be attractive to the next generation of doctors," Dr Rischbieth said.
"A country town without well-trained GPs, nurses and allied health workers, and a viable local hospital, risks losing the families who want local health services, the businesses they own and the workforce they employ, with massive impacts on our regions and their economies."
Minister commits to services
Minister for Health and Wellbeing, Stephen Wade was on Kangaroo Island on Tuesday to announce the state government's $1.5 million acquisition of the Island Motel for the expansion of health services on the Island.
Joining him was Barossa Hills Fleurieu Local Health Network chief executive Rebecca Graham, who said the land purchase would support the delivery of health care at the hospital and existing aged care facilities.
The Islander raised local concerns about the future of obstetrics and births on the Island, given the retirement of local doctors.
But both Ms Graham and the Minister said preserving services on the Island, including obstetrics, was a priority.
The network was aware of the pending skill shortage and was actively recruiting for rural generalists capable of obstetric care to be based on KI, she said.
Acting mayor Bob Teasdale and the council chief executive also met with the health minister on Tuesday to discuss ongoing mental health needs on the Island.
Labor weighs in on debate
The SA Labor party meanwhile weighed in on the debate stating the relationship between the government and regional doctors was now at a crisis point.
Labor says the warning came as the government rejected a proposal from Australian Medical Association (AMA) and Rural Doctors Association (RDA) for regional GPs, which has led to "complete despair and frustration among rural doctors."
Shadow Minister for Health and Wellbeing, Chris Picton said this was a shocking appraisal from the state's leading medical groups about the neglect of regional health by the current government.
"The Liberals were elected promising they would improve regional health, but over three years later we now have doctors warning that under their watch regional communities will 'wither and die'," Mr Picton said.
"Steven Marshall is much more focused on his $662 million inner city basketball stadium than he is for the plight of regional communities who need local medical services.
"That's why if we are elected we will scrap the basketball stadium and invest an extra $100 million into country health services on top of what is currently budgeted.
"The warnings from the AMA and the RDA must be immediately acted upon and regional doctors should be given a fair deal to ensure the survival of vital services."
Full letter from Kangaroo Island doctors
To our Kangaroo Island Community,
We write to you as the three current associate doctors of the Kangaroo Island Medical Clinic.
We have chosen to write this letter to share with you our concerns about the long-term sustainability of the current medical workforce on Kangaroo Island. It has become clear that the medical workforce across rural and remote Australia is in crisis, and Kangaroo Island is no different; the situation here is only part of a wider problem. We think it is only fair to share with you just how worried we are so that, as a community, we can try to find solutions together.
As well as providing care to our patients at the clinic, our doctors also provide a variety of medical services to Kangaroo Island Health Services, our local hospital: emergency medicine, inpatient medicine, palliative care, obstetrics and anaesthesia. The doctors are not employed by the hospital, but contracted to attend the hospital when needed under a fee-for-service model. For many decades, rural Australia has survived under such a model of care, which relies on rural doctors to be the 'jack-of-all-trades' looking after their local communities. It is a 24-hours-a-day, 7 days-a-week job, requiring us to balance at all times the commitment we have made to be the doctors for our local hospital (which does not employ its own resident doctors) with our commitment to our general practice. The Kangaroo Island Medical Clinic is a private business. Like any small business, we have to make ends meet: utilities and rent payments, our excellent staff to pay and equipment to maintain. Despite this juggle, it is a job that we love and it is immensely rewarding professionally. We consider it a very great privilege to provide 'cradle-to-grave' medicine to you, our community.
But we are in trouble.
It is becoming harder and harder to recruit doctors to rural areas like ours and we must be realistic: it is only going to get harder. There are many reasons for this - a discussion which is too big for this particular letter. In essence, medical graduates are increasingly choosing to train in specialist fields other than the speciality field of general practice.
The number of doctors in more narrow specialty fields is growing much faster than the number of generalists, and this is especially seen in regional areas. This is occurring despite a recognised need for more generalist doctors both inside, but especially outside of, major cities.
Kangaroo Island has managed to maintain its medical workforce through a combination of the calling and dedication of a number of long-term doctors on KI as well as good luck: for many years, one doctor has happened to arrive just as one is leaving. But our good luck is running out.
Despite our very best efforts, it has become increasingly difficult to recruit long-term associate doctors, especially those with procedural skills (namely, anaesthesia and obstetrics).
We have been reliant recently on registrars (general practice specialists in training) to prop up our medical workforce on the island. This is where we have been fortunate: we have employed some truly excellent registrars over the last few years.
With Dr Wells leaving the practice in December, and Dr Steyn currently on leave for three months and then stepping down and looking at full retirement in the foreseeable future, it leaves Dr Cohen with a job that is not viable for one person to do.
Without enough senior associate doctors at the helm, we will not be able to supervise and therefore employ registrars, and so the pyramid quickly topples.
The longstanding model of the local rural hospital relying on its local general practitioners to staff its emergency department, its medical wards, its maternity unit and its operating theatres, is outdated and, sadly, it is dying.
This model, which asks much of each individual, is increasingly unattractive to the new generation of junior doctors forging a career, who do not have to look far to find medical jobs that demand less but remunerate more.
New models will need to be found, and already are being explored and employed across the country, with varying levels of success.
So what can you, our community, do to help?
Firstly, it is time to start petitioning our state government. We need YOUR voice, as voters. The state government knows there is a crisis, but perhaps it does not grasp just how close to the edge of the cliff we are. We have raised this issue many times with both sides of politics but there is still inaction.
Both major political parties have neglected rural South Australia and rural Australia generally, as far as medical workforce is concerned, for many years.
Furthermore - as an island we are, of course, particularly vulnerable. Whilst communities across the rest of the state who once had a local doctor may now need to travel hundreds of kilometres to see any doctor, at least they have a road to get there.
Secondly, we need help recruiting. Whilst the current model of medical service provision is outdated and sure to change, it is the model we work with at the moment.
Appeal to whatever networks you may have, speak to friends across the country, and share our recently-commissioned recruitment video please via social media.
Thirdly, please be patient with us, and kind to new doctors that might come. We can promise that we are trying our best to look after your acute and chronic medical needs as best we can, even though we are spread very thin right now.
We realise that it is difficult to get an appointment at the clinic at the time that suits you best, and this is one of the main reasons that we need and want more doctors to work with us in the clinic.
In particular, we would ask you please not to take out your inevitable frustrations on our hard-working reception and nursing staff, who are also doing their level best to accommodate the health needs of the community in difficult circumstances. We think that we have wonderful staff at the clinic, and we ask you to respect them as highly as we do.
Despite the pressures that the current workforce crisis presents, we can assure you that we will continue to provide you with the very best care that we can at the Kangaroo Island Medical Clinic and at Kangaroo Island Health Services. We do think that we practice medicine at a high level - that remains our core ethos - and the well-being of the community will always remain our priority.
Dr Johannes Steyn
Dr Jeremy Wells
Dr Philip Cohen