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.”
And that:
“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.
Interesting blog and some insightful commentary. However, needs some correction (apologies, my comments are in capitals, dunno how to do italics/bold):
“It is important to understand that this payment is not for actually doing anything. It is simply an on call allowance. If there is a callout, doctors are paid an additional $224 per hour of patient contact time, plus $144 per hour for any travelling time. These figures, sample contracts and other documents are available on the RDASA website.”
SADLY NO – THE CONTRACT DOES NOT ALLOW FOR $224 PER HOUR OF PATIENT CONTACT TIME PLUS $144 PER HOUR OF TRAVELLING TIME. I SUGGEST YOU READ THE CONTRACT AGAIN. IN FACT, AN ONGOING CONCERN IS THAT DOCTORS ARE NOT PAID FOR CERTAIN SERVICES WHEN CALLED TO ATTEND THE HOSPITAL (CAR CRASHES, WORKCOVER, NON-MEDICARE PATIENTS)
This means that if a doctor on call had, for example, three callouts and two hours of consulting time, his/her income for the day could easily approach or even exceed 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.
AS ABOVE; YOU ARE BASING THIS ON INCORRECT DATA (read the contract). HOWEVER, LOCUM TRAVEL & ACCOMMODATION IS COVERED BY CHSA – AND THE LOCUM DOESN’T HAVE A STAFF TO PAY AND PRACTICE COSTS TO PAY WHEN HE/SHE IS ATTENDING THE HOSPITAL
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.
LOCUM MAY BE PAID $2000 PER DAY – TO DO NOTHING…OR TO DO SOMETHING, DEPENDS ON HOW BUSY THE HOSPITAL IS THAT DAY. $220 COVERS AN HOUR OF MY PRACTICE COSTS ALONE…AND I”M STILL PAYING THESE COSTS WHEN CALLED TO THE HOSPITAL. I HAVE NEVER BILLED OVER $1000 PER DAY AT THE HOSPITAL INCLUDING ONCALL FEES AND FEE_FOR SERVICE – AND I STILL HAVE TO PAY MY STAFF WHEN I”M WORKING AT HOSPITAL
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.
UNLESS OF COURSE ITS DOCS IN THE RIVERLAND – CHSA WAS HAPPY TO NEGOTIATE A DEAL THERE IN APRIL THIS YEAR, WELL AFTER THE STATEWIDE DEAL WAS ANNOUNCED. KIND OF MAKES THAT ARGUMENT FALL FLAT. BUT THEN AGAIN, RIVERLAND WAS IN MARGINAL SEAT…
YOUR BLOG ALSO ASCERTAINS THAT CHSA HAS MADE PROVISION FOR LEAVE AND LOCUMS – THE WORDING OF THE CONTRACT DOES NOT REFLECT THAT AND INDEED SUGGESTS THAT THE CONTRACTING MEDICAL PRACTITIONER IS RESPONSIBLE FOR PROVIDING HIS/HER OWN LOCUM RELIEF – AT $2000 PER DAY THAT MAKES ANY BENEFIT OF THE INCREASED ONCALL RATE DISAPPEAR VERY VERY QUICKLY.
OK, CAPS LOCK OFF NOW. For what it’s worth, you make good points. There are many complex issues with this contract – I’m concerned that CHSA states a A&E oncall doctor only has to be available within 40 minutes for a triage one patient (ie: not breathing) – the doctors all live within 10 mins of the hospital to be available ASAP – I think 40 mins is too long if you are not breathing, what do you think?
Also ignores that CHSA contract still doesn’t pay for non-admitted patients, nor for admitted patients involved in car crashes, under WorkCover, or from overseas. Given many of the call outs the hospital in summer are for overseas tourists, it is not uncommon for CHSA to owe several thousand dollars per month for callouts on these patients in hospital – then claim they are somehow ‘private patients of the doctor’ and doc must get fee off them direct. My practice doesn’t include the protocol of “intubate-ventilate-rifle through the wallet” of the tourist in a car crash whilst waiting for the chopper – call me naiive, but if CHSA call me to do a job I expect to get paid.
Fact remains, we are struggling to recruit and retain doctors in rural communities, and KI is in competition with other communities for medical services. Victor Harbor is under the same director as Kangaroo Island – yet Victor Harbor is advertising for 12 hr shifts at $1500 to $2500 per night for Dec/Jan. And we wonder why can’t get doctors to come to KI…
I don’t like it, and I fully understand that this argument can be twisted into ‘greedy doctors’. Sadly though, the Govt is pissing away heaps on locums and has done little to reach a solution. Peter Rischbieth thinks KI will be able to negotiate a special deal in Nov 2011 – I am not sanguine and indeed your comments would suggest this is not appropriate.
But you know what, the thing that REALLY gets my goat is that CHSA has a responsibility to provide A&E services – yet if you are unfortunate enough to fall over and sustain a laceration needing sutures, and attend the hospital, CHSA calls out the doctor – then states that this is ‘not their responsibility’ as the patient is not admitted – and so a private fee is payable to the GP. Funnily enough, if a patient falls over in Adelaide he/she attends the local public hospital and (admittedly after a long wait) is sutured for free. This is a classic case of cost-shifting from State to Federal (CHSA to Medicare/private practice) and is clearly inequitous for rural patients who may be charged a fee by the doctor whilst their metropolitan cousins receive the same service for free.
Still think CHSA are paradigms of virtue? I don’t.
So – what to do? Mediation is a suggestion. Other wise the standoff continues. And of course, CHSA continue to hold the threat of building a co-located GP clinic at the hospital…in a building currently used to house low level aged care residents. The islanders need a low level aged care facility, not another GP clinic. And this option is STILL more expensive than negotiating – and risks collapsing the KI medical clinic private practice, laying off staff and doctors moving elsewhere – and there goes the obstetric and anaesthetic services, meaning no more births on KI and no more elective surgery. Hardly a win.
Hi Tim. Thanks for your response. You are right about the amount per hour of patient contact. I misread that and will fix it (now done). The situation/contract in Berri is different (24 hour service to the hospital rather than on call), so it is reasonable that payment there should be different. There are certainly shortcomings that need to be addressed, and any situation where you are expected to attend/perform procedures,etc, and then find that CHSA does not take responsibility is not acceptable. This is a different matter from callout rates, etc. I would be very sorry if a ‘special deal’ were done for KI – this would be a continuation of the old system that everyone acknowledges did not work, and would undermine the attempt to find an equitable solution across rural and remote SA. Better, I think, to accept the current offer, acknowledging its shortcomings, as the best that could be done as a first attempt, and work to make the next contract one that is more acceptable (and fairer) to you.
I agree this should not be about ‘greedy doctors.’ But there also needs to be some sensitivity, given that the on call allowance alone is more than four times the annual income of the average Kangaroo Islander.
DR Tim, what is it you want? I saw in teh Islander that you wanted an extra $20 a day when you were on a couple ofweeks ago to make it $240, I guess that’s Monday to Thursday? So not perfect, but an extra $80 a week, and you could live with that?
Whatever Peter or Tim want, it IS about greedy doctors. $360 a day for being available? That’s as much as I earn in a week. I live in an isolated community too, and this nonsense doesn’t do anything for KI. Do the job or not, but stop complaining,a nd don’t blame the government if it takes responsibility and provides services when you won’t.
Everything has to be done the doctors way. You can’t even make an appointment in advance. Now they are causing all this disruption becasue they think they are entitled to an extra eighty dollars a week, even though they alreay earn ten times more than the rest of us. It’s riduculous. No wonder they dont want the government to start up a clinic here. I for one would be going there.
I don’t want to be critical, but there is still no clear answer – how much more money do teh DRs want? We need DRs on the island,a nd if the government can’t or waon’t pay them the extra, maybe we could could take up a subscription, $10 per island resident or somehting.
There is not one of the doctors I don’t like, and I am sure they are all doing what they think is right.
Here are some points to consider.
The $135000 per year is the highest on call allowance paid in any state.
There will always be some people who get paid more than you. There are also lots of people, including gps, who are paid less than you.
It woud be a pity id the government started a clinic on KI. It would reduce business to the medical centre, and some of thsoe doctors might leave.
On the other hand, we are well supplied for doctors on KI considering the size of the population, and I can’t see what else the government is supposed to do to fulfil its obligation to provide services, if local doctors won’t.
Doctors on the island have built up a lot of good will over the years. This is beginning to disappear, despte attempts by doctors, Michael Pengilly and the Islander to pin the blame solely on the government.
I have heard people say it is not about the money, its about the principle, but the only principle seems to be that the doctors think they should be paid more.
Risking the practice and holding servies to ransom for the sake of an extra $4000 over the next 12 months seems selfish and irresponsible.
So please Tim and Johannes and Mark, just get on with it.
I don’t want this to become an opportunity to bag the doctors.
We are fortunate to be well serviced by a reasonable number of GPs, all of whom are personable and competent.
I do not doubt that even with the $135,000 on call allowance, when non payment for motor vehicle accidents and overseas visitors is taken into account, the Medical Centre makes a loss on providing A & E services to the hospital.
There are parts of any business that do not make a profit. I make no money on camera sales (I could not compete with EBay or city stores if I did), and lose money on film processing. Fortunately, there is enough margin in some other areas for me to be able to offer those things as a service.
Ditto with a medical practice.
That is not to say shortcomings in funding arrangements should be ignored. They do need to be addressed, not just for our GPs, but for all rural doctors who are expected to provide such services.
But with Sharon, I have to ask, when there is opportunity to have input into a new contract and funding arrangements to be put into place in twelve months, is it really worth the harm to the community caused by declining to provide essential services, and risking the continuing profitable running of the Medical Centre, for the sake of a measly few thousand dollars over the next year?