Full and accurate information is an important precursor to any debate, and to making appropriate decisions. One of the frustrations in the recent debate over the provision of medical services on Kangaroo Island has been the limited information available to island residents about the form of the contract and the amount of remuneration on offer to rural doctors.
For most of my adult life I have lived in small rural communities. In most of those communities I have been involved in the delivery or governance of health or social services.
Most recently I was a member of the Murray Bridge Hospital Board. With representatives of other hospital boards from around rural SA I participated in discussions with the Health Department on the State Government’s plans to make significant structural changes to rural health governance, including the proposal to combine the various rural health regions into Country Health SA.
One positive outcome of the formation of CHSA was the opportunity to implement a uniform contract for the delivery by rural GPs of medical services through local hospitals.
The earlier system had resulted in considerable inequities, with wide variations in remuneration to doctors, based not on differences in remoteness or the size of the community serviced, but on the strength of negotiators appointed by individual practices. The result was often that the greatest financial rewards were offered to doctors who were willing to threaten to withdraw essential medical services, and to use those threats as a means to increase their own pay packets. This was unfair to their communities and to taxpayers who had to pick up the extra burden. It was also unfair to other doctors who worked in equally (and often more) stressful or remote locations for less money.
Over a period of eleven months, representatives of SA Health, the AMA and the RDASA met as a working group to formulate a contract that would ensure supply of key medical services to residents of remote and rural communities, and provide fair remuneration to doctors. Rural practitioners from across the state were consulted, and doctors had opportunities throughout that time to have input, either individually, or through their member organisations.
On 19th February 2010, Dr Peter Rischbieth and Dr Graham Morris, President of the RDASA, wrote to members informing them of the final form of the contract and offer from CHSA, and advising them:
“The RDASA negotiating team feel that the offer that has currently been presented to rural doctors is an acceptable one especially in regards to the oncall payments and taking into account a number of changes that CHSA have made in response to significant concerns from RDASA and its rural doctor membership.”
“The RDASA negotiators and Executive believe that the current offer even though there are some short comings should be accepted by rural doctors.”
The contract did not attempt to direct practitioners about how their practices were to be managed. Doctors were free to make whatever business structure, practice management and rostering arrangements they liked, as long as contracted services were provided in a competent and timely way.
Of course, doctors were not under any obligation to accept the RDASA’s advice, or the contract on offer. Where the contract was not accepted, Health SA would endeavour to provide essential services, including oncall emergency services, either through locums or by setting up hospital based clinics.
Doctors were free to accept the contract or not. What they could not do (because this would make consistent provision of essential services across the state simply impossible) was accept parts of the contract they viewed as easy or profitable, and decline to perform others which were less profitable or might mean some rearrangement of practice rosters.
A sticking point for some seemed to be the requirement to provide oncall emergency services, and the remuneration offered to doctors to be available if required.
Some of the conditions might be onerous for sole practitioners in remote communities, who would effectively be contracting to be on call 24/7. However, the contract includes provision for regular leave, and for CHSA to fund replacement services during emergency leave, for example if the local doctor is ill or has a family emergency.
But it is not sole practitioners in remote communities who have indicated they are unwilling to accept the terms of the contract and the allowance on offer, but doctors in a small number of monopoly practices.
That allowance is $220 per day Monday to Thursday, and $550 per day Friday to Sunday, a total of $135,000 per year per roster.
The $135,000 is simply an on call allowance. If there is a callout, doctors are also paid standard fee for service rates. Where no other fee is applicable, GPs are paid $224.20 per hour of patient contact time. The same rate applies per hour for travelling time for emergency calls during normal comsulting hours, plus a mileage allowance if they travel further than 20kms.
These figures, sample contracts and other documents are available on the RDASA website.
This means that if a doctor on call had, for example, three callouts and two hours of consulting time, his/her income could easily exceed $1000 per day, and, depending on circumstances, be in the region of the $1800 paid by CHSA to a locum. Locums of course have additional travel and accommodation costs, as well as the inconvenience of being away from their own homes and families.
It is hard to understand how it is not deliberately misleading to claim that locums are being offered $2000 per day, while local doctors are being offered $220 per day, as if that were the entire amount of their income.
The contract and offer made by CHSA has now been accepted by an overwhelming majority of SA’s rural and remote GPs. No matter how long threats to withdraw services continue, or what the cost to South Australia’s taxpayers of providing alternative care arrangements, Country Health SA cannot agree to pay any particular doctor or practice an amount greater than that contracted to other providers.
There are two reasons for this.
First, to offer one group of doctors an amount greater than that offered to other GPs would be a betrayal of the good faith of the RDASA, and of the many doctors who have accepted the contract and offer despite reservations. Doctors have accepted the contract as a first step in moving on from a system of negotiation where level of income was frequently based on threats of withdrawal of service, and which everyone acknowledged urgently needed to be changed to provide consistent services for rural communities, and fair remuneration for doctors.
Many who had reservations, or believed a higher rate of on call allowance would have been appropriate (and this included representatives of the AMA), nonetheless recommended or agreed to the contract because it was openly acknowledged as an interim measure. Negotiations and discussions between the RDASA and CHSA would continue, doctors would have opportunity to air their concerns, and a new contract incorporating any changes, including changes to on call allowances, is planned to come into effect from the beginning of November 2011.
Secondly, to offer one group of doctors in a monopoly practice a higher allowance would completely undermine any future negotiations for a uniform contract. Doctors are no more immune to greed and envy than the rest of us. There will always be some who think their situation is special, and that they should be paid more than anyone else, or who suspect that someone else may be getting paid more than them. If CHSA gives way now, every practitioner would be aware that any negotiations or agreements count for nothing, and all that is required to gain a higher rate of pay is to threaten to withdraw services.
That is not a fair outcome for the majority of GPs, for rural communities, or for SA’s taxpayers.
I am no supporter of the present State Government, but in this instance, the Minister for Health and CHSA executives could not responsibly have acted in any other way.