Fed up with knocking on politicians' doors with ideas to fix remote health care, Michael Livingston has decided to take on the task himself.
The doctor has worked in Ravensthorpe, a farming and mining town of about 2,000 people six hours' drive south-east of Perth, for seven years, running five private GP clinics in surrounding communities and contracting to the local hospital.
While he is fuelled by the results he and his team have achieved, he believes city-based decision-makers are failing remote GPs, leading to unsustainable practices and shortages across the country.
But he believes he has a solution — a model he calls the "rural generalist hub".
Dr Livingston has recently bought a building in Albany, on WA's south coast, where he plans to open a practice to treat patients while training rural generalists.
He said many GPs did not experience the pressure of working remotely until they ended up in those communities partly because there were few opportunities to train in the bush.
But he said a rural generalist hub would be able to rotate registrars and international medical graduates into his remote practices across the Great Southern and Wheatbelt, ensuring they learnt the skills required by remote doctors from the outset.
He also said the model would avoid the burnout many rural doctors faced and would provide something many of them craved: camaraderie, the chance to learn from others in their field and stability for their families.
"Instead of seeing a burnt-out RG [rural generalist] or a GP in training in the middle of nowhere hanging on by their fingernails and putting off students by the chaotic nature of the job, we have a hub where we can all rotate from, offer support from and consult from," reads the pitch document he circulated to politicians.
He believes if doctors are given the tools and support they need to succeed in remote communities, the nation's entire healthcare system will be better off.
A 'value for money' model of care
Dr Livingston said there was a big difference between working in regional locations — which often functioned as mini versions of city hospitals with teams of health professionals and state-of-the-art equipment — and remote locations, where a doctor often worked alone and with whatever tools available.
When he first moved to Ravensthorpe, the tale of a British doctor who saved the life of a local football player by piercing into his head with a drill found in a nearby shed was still doing the rounds — an extreme example of what the job can entail.
He said remote doctors also tended to work with volunteer ambulance crews, so by the time patients got to hospital they could be in a more critical condition than they would be in the city.
And his schedule is brutal.
On a single day in February, he awoke in Albany, farewelled his family and month-old baby, drove to his practice in Jerramungup, before setting off to Hopetoun for a six-hour shift, and finally, up the highway for another three hours at the Ravensthorpe Hospital.
"There's this idea that you're just on this burnout mission, with no respite, no reprieve and no help," he said.
Despite the difficulties, Australian College of Rural and Remote Medicine (ACRRM) president Dan Halliday said rural generalists were a proven "value for money" model of care.
"[But] we're seeing increasingly that the value placed on the rural generalist scope of practice and model of care … is increasingly undervalued," Dr Halliday said.
For Dr Livingston to treat a person with a deep cut in their arm, in Ravensthorpe, he said it would cost the state a few hundred dollars — his standard fee plus consumables.
But if he were not there, he said the cost of treatment might blow out in excess of $30,000 — factoring in a Royal Flying Doctor flight to Perth, a St John Ambulance ride to the runway, a telehealth consult, an emergency department fee, a public hospital bed fee, a surgeon's fee, and aftercare.
Yet Dr Livingston said support for rural generalists paled in comparison to other models — such as the Royal Flying Doctor Service last year receiving $1 billion over 10 years from the federal government and St John Ambulance receiving $30.1 million for 18 additional paid paramedics and six additional ambulances in regional WA from the state.
"You're facing a system that doesn't really have an appetite for general practice at all — even though it's clearly the best dollar-for-value service that can be given to the Australian population," he said.
He said the $750 million committed by the federal government to implement recommendations from the Strengthening Medicare Taskforce Report was a drop in the ocean.
The last federal budget included $146 million to attract and retain more health workers to rural — and regional — Australia through improving training and incentive programs.
Dr Livingston said the government seriously needed to question how it expected current models to compete with the lure of locum work, where doctors received good money for far less stress and without having to move their families.
Regional versus remote
Dr Livingston also said that by living in Ravensthorpe, a remote town, he missed out on major incentives available from the state government in some regional centres such as Esperance, a tourist hotspot two hours' drive up the road.
According to a WA Country Health Service (WACHS) document, updated in May 2021, a suitably qualified doctor in Esperance can receive both an emergency incentive ($50,000 a year) and a GP procedural incentive ($40,000 a year) — bringing in $90,000 a year in incentives alone.
WACHS said the extra payments available in Esperance were because doctors provided more services and a 24/7 presence at the hospital.
Dr Livingston is eligible for a location support incentive of $30,000 for living in Ravensthorpe, which he said was put back into the business, and earns a fee when called to support the hospital.
A WACHS spokesperson said it was "problematic" to compare incentives available to different doctors, as they were employed through a number of different arrangements.
"We will continue to work alongside our rural generalists, as well as the Commonwealth government and partner agencies like Rural Health West to refine incentive programs and payment structures," the spokesperson said.
Dr Livingston believes the discrepancy is symptomatic of a system that consistently undervalues remote health care and fails to recognise the extra pressure, stresses and workload that come with working in isolation, which routinely see him phoned in an emergency, no matter if he is technically "on call" or not.
A big idea
Across other parts of Australia new models geared at resolving remote healthcare difficulties have been brought in, which have some similarities to Dr Livingston's "hub" idea.
The 4 Ts project, for example, was launched after the collapse of every private GP practice in Tottenham, Trundle, Tullamore, and Trangie in rural New South Wales, and involved rural generalists, nurses, and administrative staff working together from a central location to service the area.
NSW Rural Doctors Network chief executive officer Richard Colbran said the project was showing promising results.
"One of the great and most pleasing aspects has been continuity of care for the people across the towns," Mr Colbran said.
He said early indications suggested it was stacking up financially, partly because retaining a consistent workforce reduced the reliance on locum doctors.
Dr Halliday said Tasmania's Rural Health Inquiry findings, which came out last year, highlighted the "single-employer model" as a key opportunity to improve rural staffing.
The model allows GPs to be employed by the state for the duration of their training, bridging the gap between hospital-based and community-based training placements.
A statewide trial of the model has recently been announced in Tasmania, and other states and territories intend to lodge submissions for other trial sites later this year.
But although Dr Livingston said he had set up meetings with both state and federal government representatives about his idea for a rural generalist hub, he said he never heard a peep in return.
He resolved the only way to see if it could help was to try it himself.
"Because I think we've gone to every level [of government] that we can, we've spoken to those we can," he said.
"[It seems] we aren't going to change their minds.
"If someone won't listen to you, the only way to change that perception is to do it yourself," he said.
Dr Livingston plans to open the doors of the Albany hub later this year.
