Medical service provision in rural and remote Australia
Background Paper
Prepared
by
Col White
for
Board - Queensland Rural Medical Support Agency
Queensland Rural Medical Support Agency 2003
This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may
be reproduced without prior written permission from the Queensland Rural Medical Support
Agency. Requests and enquiries concerning reproduction and rights should be directed to the
Queensland Rural Medical Support Agency, PO Box 167, Kelvin Grove DC, Qld 4067.
Suggested citation
White, C. (2002). Medical service provision in rural and remote Australia – Background paper.
Brisbane: QRMSA
Compiled by:
Col White – Queensland Rural Medical Support Agency
1.0
Introduction
This paper has been prepared following a request by Board members of the Queensland Rural
and Remote Medical Workforce Agency (QRMSA). The initial impetus for the briefing paper
was recent claims of significant disparities in access to ‘Medicare’ for Australians living in
rural and remote locations. Some recent claims in the media and conferences emanating from
the Rural Doctors Association of Australia (RDAA) have suggested that rural Australians are
approximately $500 million dollars poorer in terms of their access to Medicare compared
with Australians living in metropolitan areas.
Continuing inequities of access between rural and urban and between Indigenous and nonIndigenous communities have long been acknowledged by funding authorities1. MBS
(Medicare) outlays per capita continue to be lower than the national average in rural and
remote areas although the relationship to the national average has improved slightly in recent
years.
While acknowledging disparities in relation to Medicare access, it should be noted that
Medicare data underestimate usage of services in rural and remote areas because state
provided community health services and Aboriginal Community Controlled Health Services
are not necessarily reimbursed through Medicare. Also, social and cultural factors partly
account for the difference in medical service utilization between urban and rural areas. Rural
males, for example, utilize medical services at significantly lower levels, in part because of
attitudinal differences, which lead them to neglect their health and only consult a doctor for
acute conditions.2, 3 Nonetheless, it is reasonable to attribute a significant proportion of the
difference in Medicare expenditure to the shortage of practitioners in rural and remote areas.
Although access to Medicare services for rural Australians is a continuing concern, a primary
thrust of this paper is to collate and highlight some of the major differences between rural and
urban medical service provision.
2.0
Background
Australia has one of the most urbanized populations in the world, with approximately 70% of
people living in capital cities or major metropolitan areas. Of the remaining 30%, about 45%
live in regional cities or large country or coastal towns and surrounding agricultural areas. A
further 45% live in small country or coastal towns and their surrounding agricultural areas,
and about 10% live in remote areas.4
A possible consequence of this distribution is that resource allocation has been concentrated
on the major population centers and it is only over the past decade that the viability and
sustainability of rural and remote medical practice has become an issue of major concern.
1
Commonwealth Department of Health and Aged Care (2001). Outcome 2: Access to Medicare. Annual Report
2000-2001 Volume 1. Canberra, DHAC.
2
Humphreys, J., S. Mathews-Cowey, et al. (1997). "Factors in accessibility of general practice in rural
Australia." Medical Journal of Australia 166: 577-580.
3
Department of Health and Aged Care (2000). General practice in Australia: 2000. Canberra, General Practice
Branch, Department of Health and Aged Care.
4
Australian Institute of Health and Welfare (2002). Australia's health 2002. Canberra, AIHW: 493.
Medical service provision in rural and remote Australia
1
3.0
Medicare Access
Table 1 provides a breakdown of average expenditure per person on Medicare medical
services provided by non-specialist practitioners for the period 1997-1999.
Table 1. Average expenditure per person(a) on Medicare medical services provided by non-specialist
practitioners, current prices, 1997-98 to 1998-99 by region(b) ($)
Metropolitan centres
Rural areas
Remote regions
Year
Capital
Other
Large
Small
Other
Remote
Other
city
centre
centre
centre
rural
centre
Remote
1997-98
158.25
152.52
149.54
135.38
105.05
103.42
65.70
1998-99
159.30
152.45
150.74
136.57
106.56
99.48
67.17
(a) Population data used are averages of ABS estimates of resident population at 30 June each year.
Expenditure relates to expenditure funded by all sources of funds, including Medicare rebates. Patient copayments and contributions by other third party payers.
(b) Rural, Remote and Metropolitan Areas classification of location of service provider.
Source: Commonwealth Department of Health and Aged Care - General Practice in Australia 2000, p253 –
abbreviated table)
Table 2 displays the average number of patient encounters per capita by region for the 199899 period. The table also includes public hospital encounters of a primary medical care
nature and includes bulk-billing rates by geographic location. Again this table demonstrates
that access to medical services decreases as a function of remoteness.
Table 2. General practitioner patient encounters: private practice and public hospital by geographic
location, 1998-99
Metropolitan centres
Rural areas
Remote regions
Capital
Other
Large
Small
Other
Remote
Other
Total
city
centre
centre
centre
rural
centre
Remote
Average patient encounters per capita
Private
6.72
6.51
6.19
5.87
4.62
3.83
2.81
6.24
practice
Public
0.99
0.63
1.09
0.84
0.55
1.49
1.97
0.92
hospital
Total
7.71
7.14
7.28
6.71
5.17
5.32
4.77
7.16
Bulk
85.6
79.6
60.2
59.4
billing
rate - %
of GPs
Source: AIHW cited in AMWAC, 2000 p.415
58.7
66.0
79.6
Also reflective of varying geographic supply of practitioners is per capita Medicare benefits
paid. For 1999-00 these were:
• $195.87 in urban areas;
• $139.70 in rural areas; and
• $83.11 in remote areas.6
As noted previously, Medicare data underestimate usage of services in rural
and remote areas because state provided community health services and Aboriginal
5
Australian Medical Workforce Advisory Committee (2000). The General Practice Workforce in Australia:
AMWAC Report 2000.2. Sydney: 129.
6
Department of Health and Aged Care (2001). The Australian Medical Workforce. Occasional Papers New
Series No.12, August 2001. Canberra, DHAC.
Medical service provision in rural and remote Australia
2
Community Controlled Health Services are not necessarily reimbursed through
Medicare. Additionally, data in relation to primary health care services provided by state,
Aboriginal Community Controlled and Royal Flying Doctor Service do not fit neatly into
measures of service provision as used by Medicare (HIC).
A further measure of MBS outlays per capita is provided by the Department of Health and
Ageing in their Annual Report 2001-2001.7 Again, continuing inequities of access between
rural and urban and between Indigenous and non-Indigenous communities are acknowledged.
The report also notes that analysis by the Department of Health and Ageing indicates an
inverse relationship between public hospital and MBS expenditure by local area, suggesting
that public hospitals play an important role in providing services in areas where the private
sector and MBS do not. Table 3 provides a breakdown of MBS outlays per capita by broad
regional categories. It differs from previous tables in that it includes all services rather than
general practice services.
Table 3. MBS outlays per capita by regional category, 1995–96 to 2000–01
Category
1995–96
1996–97
1997–98
1998–99
1999–2000
$
$
$
$
$
Capital city
397.71
391.67
391.45
404.18
406.36
Other metro
384.95
380.45
380.65
394.97
398.51
centre
Rural and
290.88
288.45
290.95
303.03
308.37
remote
Total
365.90
361.13
361.87
374.77
378.19
Notes:
2000–01
$
403.18
397.15
314.29
377.93
1. Non Farm GDP implicit price deflator used for earlier years.
2. Population figures as provided by ABS to 30 June 2001.
3. The figures underlying this table are based on cash not accrual numbers in order to preserve the time series. The MBS numbers
are based on claims processed during the year.
4. The allocation to regional category is based on postcode of patient enrolment.
Source: Commonwealth Department of Health and Aged Care (2001). Outcome 2: Access to Medicare. Annual Report 2000-2001 Volume
1. Canberra, DHAC.
While the above summary does confirm differential access to Medicare services for rural and
remote populations, a secondary intent of this paper is to highlight and contrast documented
differences between urban and rural/remote practice.
4.0
Rural and remote medical practice
Wainer et al. (1999) have noted that ‘rural medicine is almost the only branch of the
profession with a shortage of applicants’.8 While a catchy observation, it also reflects
continuing difficulties in attracting and retaining medical practitioners in rural and remote
locations.
Rural and remote general practice has a number of special features. Many of these features
have a negative or less than desirable consequence and include:
7
Commonwealth Department of Health and Aged Care (2001). Outcome 2: Access to Medicare. Annual Report
2000-2001 Volume 1. Canberra, DHAC.
8
Wainer, J., D. Carson, et al. (1999). A Life, not a wife. 5th National Rural Health Conference, Adelaide.
Medical service provision in rural and remote Australia
3

Relative to population distribution there are fewer GPs. They have a heavier workload,
provide a wider range of services, are on call much more often, and when they are on call
they are more likely to be called out (Britt et al, 1993 cited in GPSR, 1998).9

There are few specialists in rural and remote areas, and many GPs in these areas need
enhanced skills – for dealing with accidents and emergencies and clinical procedures such
as major surgery, anaesthesia and operative obstetrics

GPs in rural and remote areas have a special relationship with their community. This
entails a greater expectation of confidentiality and probity on one hand; on the other hand
it entails limited privacy for these GPs and their families compared with what is expected
in metropolitan areas.

Particular problems confront female GPs in rural and remote locations and may include:
o Role conflict – pressure to work longer hours to meet practice needs, family
responsibilities, employment opportunities for spouses etc.
o Concerns about personal safety
o Lack of social support, especially child care9
Harding (2000) also notes11 that the GP workload in small rural towns and other rural and
remote areas is significantly higher because of increased procedural work and higher
morbidity levels in the population (especially the Indigenous population). Supply
requirements are further increased by GPs in these area spending more of their time
undertaking in-patient and out-patient work with local hospitals than do GPs in metropolitan
and large rural centres. Similarly, studies undertaken as part of the Beach series12 (Britt et al.
2001) have shown that doctors in the country are more likely to provide obstetric care and do
more minor surgery compared with city doctors. Additionally, they provide more after hours
care compared with their city counterparts.
Strasser (1997, 1999)13,14 has also noted that a highly important issue for rural GPs for
sustainable practice is the availability of locums. In rural areas, locum support is essential to
provide the GP with relief from long hours of work and long hours on call and to maintain the
health service while the resident GP is absent. The costs of locum support in rural areas are
generally higher due to the necessity to cover travel and accommodation costs in addition to
salary costs. Other economic influences noted by Hays et al. (1997)15 in respect to rural
practice were:

the cost of air travel for family member to visit relatives;

the costs of boarding school for children of secondary school age
9
General Practice Strategy Review Group (1998). General Practice: changing the future through partnerships.
Canberra, Commonwealth Department of Health and Family Services.
10
Australian Medical Workforce Advisory Committee. (1998). Influences on participation in the Australian
Medical Workforce, AMWAC Report 1998.4. Sydney.
11
Harding, J. (2000). The supply and distribution of general practitioners. General Practice in Australia: 2000.
Canberra, Department of Health and Aged Care.
12
Britt, H., G. Miller, et al. (2001). 'It's different in the bush': A comparison of general practice activity in
metropolitan and rural areas of Australia 1998-2000. Canberra, Australian Institute of Health and Welfare.
13
Strasser, R. (1997). National Rural General Practice Working Papers. Moe: Monash University for Rural
Health.
14
Strasser, R. (1999). Presentation: 'Future workforce requirements for rural general practice'. Paper presented
at the The annual conference of the Australian Medical Association, Canberra, 29 May 1999.
15
Hays, R. B., Veitch, P. C., Cheers, B., & Crossland, L. (1997). Why doctors leave rural practice. Australian
Journal of Rural Health, 5(4), 198-203.
Medical service provision in rural and remote Australia
4

the higher daily cost of living in a small country towns and the need to travel to larger
centre to purchase a range of household items
In addition to workload, procedural and social demands placed on rural and remote
practitioners, AMWAC (1998)10 has noted that the economics of General Practice and
infrastructure requirements make it desirable that four or more practitioners are employed in
a location. This is seen as being of increasing importance for standards of care and to allow
practitioners to undertake professional development and provide after hours care. AMWAC
also notes that four or more practitioners require a minimum catchment population of
between 4,000 and 5,000 people. While population dispersion in many rural and remote
communities makes this impractical, every rural centre of 1,000 or more people desires a
resident and GP and therefore small and solo practices are common. Significant subsidies are
necessary to recruit and retain practitioners in areas of particularly low population density
and to make practices financial viable under Australia’s health financing arrangements.
Access to health services for people living in regional Australia is influenced by the lower
number of GPs, lower rates of bulk billing5 and lower levels of access to specialist and major
hospitals as a consequence of longer travel distances. In addition, people who live in rural
and remote areas generally have lower levels of education with household incomes in these
areas also lower compared with metropolitan areas (Garnaut et al. 2001 cited in AIHW,
2002).4 Coupled with lower incomes for people in regional and remote areas, the price of
commodities such as food and petrol is higher. In rural and remote communities, the cost of
basic food is frequently up to 10% higher (and sometimes up to 23% higher) than in
metropolitan and regional centres.4
The health status of rural Australians declines with distance from metropolitan and regional
centres. Mortality rates are higher in rural areas, reflecting the higher proportion of
Indigenous Australians in rural areas.16 Rural Australians, when compared with metropolitan
residents have:
 a higher rate of premature death from injury or accidents particularly among men
 higher rates of road injuries and fatalities
 higher mortality related to coronary heart disease, diabetes and asthma
 among people over 65 years, higher rates of hospitalisation and death from falls or burns
 in remote areas, higher incidence of low birth rate and infant mortality
 lower incidence of early cancer detection
 among rural women, higher rates of obesity, higher alcohol intake in small rural centres
and higher rates of smoking in remote areas
 suicide, depression and other mental health problems, with suicide rates among men
noticeably higher in rural areas.
General Practice in rural and remote communities is characterized by extreme diversity,
marginal sustainability and a continuing difficulty in recruiting and retaining a stable medical
workforce. Due to factors such as distance, population dispersion and the small number of
GP’s in many rural and remote locations, cooperation and collaboration between individual
providers is often essential in order to provide adequate services and continuity of care for the
communities they serve. It is ‘different in the bush’.
16
Department of Health and Aged Care. (2001). The Australian Medical Workforce. Occasional Papers New
Series No.12, August 2001. Canberra: DHAC.
Medical service provision in rural and remote Australia
5
Current models of remuneration through the MBS provide little recognition of differences
between urban and rural/remote medical practice and the difficulties inherent in sustaining
viable models of practice in rural and remote locations. The marginal sustainability of many
rural and remote practices combined with the poorer health status of these populations
suggests that differential rebates for medical service delivery in rural and remote
communities may be appropriate and that models of remuneration should be based on factors
other than volume of services.
5.0
Summary
A significant factor that impacts on medical service delivery in many rural and remote
communities in Queensland is subsidized competition by Queensland Health employees who
also have the right to private practice. These employees are provided a base salary and can
also undertake fee for service provision. Additionally, they are provided with
accommodation, surgery, vehicle, locum relief, award leave and professional development
entitlements and have a supportive hospital infrastructure. In such a marketplace, it is often
very difficult for a private practitioner to compete bearing in mind establishment, practice
maintenance and insurance costs and the well-documented difficulties in selling medical
practices or obtaining a return on investment in rural and remote locations.
The viability of private medical practice in many rural and remote communities will continue
to be marginal. The emerging generation of medical graduates is characterised by a greater
number of female practitioners and an expressed need by both female and male graduates for
flexibility and choice in working hours and arrangements.
Traditional models of General Practice service delivery in Australia as characterized by:

Private ownership and/or associate practices

Fee for service modes of remuneration

The rural SuperDoc accessible/on call 24 hours a day, 7 days a week
are becoming less attractive for many of our younger doctors. The exploration and
development of new/alternate models of medical service delivery that do not entail
substantial capital investment and incorporate flexible working conditions is crucial in order
to maintain appropriate levels of health service provision in rural and remote communities.
In light of subsidized competition incorporated in the Queensland Health model of Medical
Superintendents/Officers with the Right of Private Practice, it is unlikely that many of our
emerging generation of doctors will be willing to invest or contemplate buying into marginal
practices that are likely to produce poor returns on investment and be largely unsaleable.
Without appropriate incentives and to some extent cross-subsidization, health service
delivery by GPs in rural and remote communities will remain marginal and continue the
current decline with adverse effects on already disadvantaged populations/communities.
Alternate models of health service delivery need to be explored and trailed in order to
improve access to, and health outcomes for rural and remote communities.
Medical service provision in rural and remote Australia
6
References
1
Commonwealth Department of Health and Aged Care (2001). Outcome 2: Access to Medicare. Annual Report
2000-2001 Volume 1. Canberra, DHAC.
2
Humphreys, J., S. Mathews-Cowey, et al. (1997). "Factors in accessibility of general practice in rural
Australia." Medical Journal of Australia 166: 577-580.
3
Department of Health and Aged Care (2000). General practice in Australia: 2000. Canberra, General Practice
Branch, Department of Health and Aged Care.
4
Australian Institute of Health and Welfare (2002). Australia's health 2002. Canberra, AIHW: 493.
5
Australian Medical Workforce Advisory Committee (2000). The General Practice Workforce in Australia:
AMWAC Report 2000.2. Sydney: 129.
6
Department of Health and Aged Care (2001). The Australian Medical Workforce. Occasional Papers New
Series No.12, August 2001. Canberra, DHAC.
7
Commonwealth Department of Health and Aged Care (2001). Outcome 2: Access to Medicare. Annual Report
2000-2001 Volume 1. Canberra, DHAC.
8
Wainer, J., D. Carson, et al. (1999). A Life, not a wife. 5th National Rural Health Conference, Adelaide.
9
General Practice Strategy Review Group (1998). General Practice: changing the future through partnerships.
Canberra, Commonwealth Department of Health and Family Services.
10
Australian Medical Workforce Advisory Committee. (1998). Influences on participation in the Australian
Medical Workforce, AMWAC Report 1998.4. Sydney.
11
Harding, J. (2000). The supply and distribution of general practitioners. General Practice in Australia: 2000.
Canberra, Department of Health and Aged Care.
12
Britt, H., G. Miller, et al. (2001). 'It's different in the bush': A comparison of general practice activity in
metropolitan and rural areas of Australia 1998-2000. Canberra, Australian Institute of Health and Welfare.
13
Strasser, R. (1997). National Rural General Practice Working Papers. Moe: Monash University for Rural
Health.
14
Strasser, R. (1999). Presentation: 'Future workforce requirements for rural general practice'. Paper presented
at the The annual conference of the Australian Medical Association, Canberra, 29 May 1999.
15
Hays, R. B., Veitch, P. C., Cheers, B., & Crossland, L. (1997). Why doctors leave rural practice. Australian
Journal of Rural Health, 5(4), 198-203.
16
Department of Health and Aged Care. (2001). The Australian Medical Workforce. Occasional Papers New
Series No.12, August 2001. Canberra: DHAC.
Medical service provision in rural and remote Australia
7