More GPs.

Thankyou Ms.Roxon

2009-11-05T16:52:00.001+10:00

We note that you have made changes to the 10 year rule for some overseas-trained doctors, and thankyou. It is a start, Ms. Roxon.

Critical GP shortage in Launceston.

2009-10-13T06:44:00.000+10:00

This blog may have been quiet lately, but the shortage of GPs continues to hurtle on towards the cracking point.

It looks like that point is about to be reached in Launceston. See the article in The Examiner here.

Taking it back to Mr. Rudd.

2008-11-04T14:24:00.002+10:00

Members of the Need More GPs group met with the Prime Minister Kevin Rudd’s representative on October 31, at his Griffith electorate office.

We pointed out that the ideas (in respect of the critical GP shortage) that we put to Mr Rudd at a meeting in May (and to Nicola Roxon in September) still have not been satisfactorily addressed despite a welter of correspondence from Canberra public servants. Mr Samuel Walker, of the Prime Minister’s Griffith electorate office, said he could understand our concern, and undertook to refer the issue back to the relevant Departmental officers.

In summary, our suggestions to relieve the GP shortage in the short to medium-term are:

1.To assist the urban crisis: a short moratorium (say, 6-12 months) on the provider number restriction, with some other conditions: only Australian residents or citizens who are fully registered and have a demonstrable urban commitment. This could allow an uptake of IMGs into urban practices at risk of closing, without causing an exodus from the bush

2.A reduction of the time-limit on IMGs obtaining unrestricted provider numbers from 10 to three years. Three years seems a reasonable amount of time to demonstrate a commitment to the country. It is also short enough to make up skilling not too much of an issue for IMGs who have not found work in Australia for whatever reason. We also suggest that as a three-year requirement is less intimidating than a 10-year one this may increase the number of doctors prepared to consider going to the bush.

3. A ‘Welcome Back’ package; an up skilling and mentoring program to assist doctors return to work and temporary assistance to GPs who wish to work part-time while their children are under-school age, in the form of a subsidy of their medical indemnity cost, to be repaid (as is the student HECS bill) when their working hours increase substantially.

4. Increase rural Medicare rebates by 20-30%. At present there is no difference income-wise between rural and urban doctors.

For a fuller discussion, please go to "The Solutions Discussion" link at the top of the sidebar.

Aussie Doctor, Aussie Trained, Overseas Rules Apply.

2008-10-30T16:56:00.002+10:00

“How can you call someone a foreign doctor when they are an Australian doctor with an Australian degree, and they were classed as a local student from day one?”

Good Question, Dr .Belich.

Mike Belich was born in New Zealand, but has lived in Australia since the age of 14. He graduated from the Medical School of the University of NSW in 1999, and is currently working in Byron Bay where he is completing his RACGP training. When he passes his Fellowship exam however, as he is classed as "a former overseas student" (although he was considered a "local student" when he enrolled) he is subject to the same regulations as International Medical Graduates - in other words must work for ten years in a District of Workforces Shortage before he will be eligible for an unrestricted provider number.

There are apparently about a hundred doctors in the same situation as Dr. Belich.

Dr Belich's story was in the The Australian on Wednesday October 29 (first edition), and a link will be made to this just as soon as it is available.

A spokesperson for Health Minister Nicola Roxon said that she (Ms Roxon) he is "aware of the situation and is currently looking into what can be done."

Representatives of The Need More GPs group specifically mentioned Dr Belich's case to Nicola Roxon when they met with her in September (see post below) to discuss GP workforce shortage issues.

Our Meeting with Nicola Roxon.

2008-09-13T16:21:00.005+10:00

Representatives of our Need More GPs group were invited to a meeting with Nicola Roxon on Tuesday 9th September. We are still considering our formal response at this time, but in summary, we feel that:

Nicola Roxon knows the horse is sick

She knows the cart needs repairs

However she is focused on building the barn.

Do we need to say that we fear that the GP section of the barn will be empty, unless some urgent interim action is taken?

The German Press.

2008-09-13T16:17:00.002+10:00

The article in Die Welt has been translated by a colleague. This is how the German Press understand the situation in Australia as regards the GP shortage and the employment of international medical graduates.

Flying Doctors in Australia face an Emergency.

On this fifth continent, the scarcity of country doctors necessitates the Royal Flying Doctors to take over. But the RDFS are now facing great shortages in manpower.

They land with their propeller driven aircraft among grazing kangaroos. They fly into Aboriginal camps to pull teeth, and they save stranded tourists who have accidents with their camper-van. They are the physicians of the Royal Flying Doctor Service (RDFS). They are the most prestigious relief organisation in Australia, and this has brought them global fame. Yet in this year in which they celebrate their 80th birthday, the organisation finds itself in an acute state of distress despite incoming donations and continued government grants.

The new generation of the medical profession are missing in taking up the challenge of servicing the inland, leaving the present staff stretched to the limits of their capacity. They must cover ever larger areas with less and less personnel. The crisis has become so acute that the flying doctors can only maintain this enterprise with the assistance of foreign help. “The demand for our services becomes ever greater” said Roger Petheram, the manager of the regional RFDS based in Dubbo, – a town in the interior of the Australian east coast State, NSW - with a population of 40,000. A place where it rains rarely, and where the wind-dried tufts of grass blow into the aircraft hangers.

From here, several times a week, rescue teams are deployed into the Outback. To meet further emergencies, a second airplane and an additional surgeon is needed to ensure a smooth service. But the response has been sluggish. “We have been looking for a qualified physician since the middle of July – so far the interest has been low” says Ingo Stormer, a German anaesthetist. Scarcely two years out from Cologne, he now holds a senior rank with the RDFS at the Dubbo base. His emergency colleagues are doctors from Holland and Zimbabwe.

The reality is that without foreign trained doctors, a large part of the Australian health system would have long broken down, with 43% of all medical practitioners in the vast rural areas of the continent having gained their qualifications abroad. These fill the gaps due to the fact that Australian trained doctors are unwilling to dedicate their skills to the Outback, but rather prefer to establish their careers in the larger coastal cities. Presently, the RDAA has announced an urgent need for approximately 1600 more doctors, with at least a dozen needed to maintain the work of the Flying Doctor Service.

Additionally, more qualified nurses are used to take up the slack. “Positions that should be taken up by those medically qualified,” states Gordon Gregory, the chairman of the National Rural Health Alliance. And the situation becomes graver with many elderly and established country doctors now seeking retirement, leaving their practices, and not being replaced by others within their profession.

“Unfortunately, younger Australian doctors have abandoned the bush – and have no desire to take on the hard work so much evident in the country-practices,” says Janet Clarkson, a female doctor practicing in Brisbane.

Even migrant doctors are unwilling to go into country practise as they must commit themselves up to ten years service in the Bush. And things will get worse due to past negative experiences where under-qualified overseas doctors have brought their profession into disrepute with medical fraud, atrocious surgery leading to mutilation and even death of patients, and other disreputable and unethical practises. To counter this, authorities are intensifying the already complex guidelines for immigrants that wish to work in welfare occupations.

From July 1st 2008, stricter language tests and stricter rules will be in place before foreign medical qualifications are officially recognised. Tracey Green, who is responsible for medical personnel within the Royal Flying Doctor Service in Queensland believes that such hurdles will make it more difficult for German doctors to immigrate. Rather, a greater recruitment for qualified physicians is underway concentrating on England, Canada, and New Zealand. “That is unfortunate,” Green says, “as we genuinely admire the skills of German-trained doctors.” Moreso, if Ingo Stormer is correct, because they may be more willing to accept a job in the Outback.

The flying doctor team has found one promising candidate in Germany. But, even if all the bureaucratic entry hurdles are overcome, it must be recognised that this Australian icon – a non-profit and very famous enterprise – faces serious challenges ahead. Even if the medical situation improves, the RDFS are now desperately seeking pilots to fly their planes.

Translation by Yuri Koszarycz

The International Press.

2008-09-05T12:30:00.003+10:00

More on the GP workforce shortage:

Our campaign has come to the notice of the German press. It is in the newspaper Die Welt (readership of 690,000), in an article on the rural medical problem and the Royal Flying Doctor Service. The article is HERE.

UK - Trained GPs ready to help us.

2008-08-30T06:11:00.000+10:00

It seems that help for our GP workforce shortage problem is waiting in the wings - or could be, if the powers that be would allow it.

We have received the following email from Mr Ron Crause, Chairman of the Australian Association of Medical Recruitment Agencies (AAMRA).

"I have read your submission to Mr Rudd. We at AAMRA would be most supportive of your initiatives. I thought I would also bring to your attention that the last federal government introduced, under Mr Abbot a program in 2004, called Strengthening Medicare which has been very successful in bringing in over 600 GPs into Australia during this period. This program has not been renewed by the current government even though tenders went out for it in December 2007. Submissions have been made to Ms Roxon to entreat her to continue the program but without any success. With the current economic downturn in the UK we have the opportunity to get some really good UK trained GP’s and the continuation of this program or anything similar would also help."

So, Mr. Rudd and Ms. Roxon, what is the go here? Is there some really good reason that that this program has not been continued? If there is, please tell it to us - and especially our rural colleagues.

Recruiting GPs from a developed nation such as the UK avoids the ethical dilemma of taking doctors from countries that can ill-afford to train them in the first place, never mind then losing them to wealthier countries.

More Media Interest

2008-08-28T06:51:00.005+10:00

The media remains interested in our campaign on the GP workforce shortage and provider number issue, in the wake of the 'response' from Mr. Rudd's office (the link to which is in the previous post).

Steve Austin gave us airtime on ABC radio (612) on Tuesday, at 7.35 after the news.

Adam Cresswell, the Health Editor for The Australian on August 23 also featured our story (for the second time). His article is HERE. His article from July 11 is HERE.

Kevin Rudd's Response.

2008-08-22T14:53:00.003+10:00

Well, we did get a response from Mr. Rudd's office.

It is HERE.

A not-very-useful response as it turns out.

It fills up space by repeating our own comments, and fills up more space repeating the same old 'solutions'.
I would like to suggest to the powers that be that the strategies outlined in the letter are
(a) optimistic in the extreme, given that they are based on the hope/wish/expectation that the great increase in medical students will magically result in an increased number of GPs. Two immediate potential sticking points come to mind. (i) a large percentage of the new number of students are from overseas and (ii) there is absolutely no evidence that general practice is going to attract many of them at all. We are leaving the profession in droves. There may be no-one left to run the training program.
(b) even if they have some chance of success, they are long-term strategies, and the situation is urgent.

Also, Mr Rudd - strategies that depend on nurses are great in theory, but - there is a shortage of nurses too!

GP Shortage: The Australian: The Article.

2008-07-11T08:29:00.002+10:00

The Australian has picked up the story of our campaign.

It is HERE if you are interested.

P.S to Mr. Rudd: we are eagerly awaiting your response to our meeting.

P.P.S To readers of this blog. If you are concerned, please consider signing our e-Petition to the State Government, which can be done HERE.

Deadline Day.

2008-06-30T06:09:00.004+10:00

Today is the deadline by which Mr. Rudd himself said to us that Mr. Rod Glover would respond to his office:

"As discussed, my staff have submitted a representation on your behalf to Rod Glover, Senior Advisor in the Department of Prime Minister and Cabinet, to investigate your proposal in detail with a view to national methodology. I have requested he obtain input from the Department of Health and Ageing regarding measurements of GP's and non-specialists across metropolitan areas throughout Australia."

We eagerly await your response being forwarded to us, Mr. Rudd and Mr. Glover.

Conversation: National Health.

2008-05-31T20:52:00.004+10:00

ANU Marketing and Communications have an interesting conversation on Health withAssociate Professor Kirsty Douglas (Acting Director of the Australian Primary Health Care Research Institute and an educator in general practice at the ANU Medical School) and Professor Bob Wells (Director of the Menzies Centre for Health Policy and Executive Director of the ANU College of Medicine and Health Sciences.)

You can read the conversation HERE.

NHHRC submission.

2008-05-31T20:37:00.004+10:00

You can read our own submission to the National Health and Hospitals Reform Commission on the GP workforce crisis HERE.

NHHRC submission from an IMG.

2008-05-31T06:28:00.005+10:00

An international medical graduate (IMG), or overseas-trained doctor (OTD) in old non-PC speak, has made a submission to the National Health and Hospitals Reform Commission. She has generously allowed us to post the story of her own perspective on the GP workforce shortage.
Take note of the bureaucratic red-tape that has caused her to suffer a period even longer than the obligatory ten years before she has access to an unrestricted provider number.

You can download and read it at NHHRCIMGsubmission.pdf

P.S. If you have not yet signed our e-Petition, please consider doing so. It can be found HERE.

Mr. Rudd's Response.

2008-05-29T06:43:00.006+10:00

We have received a response from Mr. Rudd in relation to our meeting with him at his mobile office on May 10. We discussed with him our suggestions for improving the GP workforce issue (see the link in the sidebar to the Solutions Discussion).

He says:

"As discussed, my staff have submitted a representation on your behalf to Rod Glover, Senior Advisor in the Department of Prime Minister and Cabinet, to investigate your proposal in detail with a view to national methodology. I have requested he obtain input from the Department of Health and Ageing regarding measurements of GP's and non-specialists across metropolitan areas throughout Australia."

Thankyou, Mr. Rudd.

Australian Doctor article.

2008-05-27T15:45:00.001+10:00

The weekly Australian Doctor paper ran a column on our campaign, on page 12 of the May 23 edition.

When time allows, it will be typed out!

e-Petition.

2008-05-26T16:25:00.002+10:00

If you want to fight the fight, please consider signing the e-petition at
http://www.parliament.qld.gov.au/view/EPetitions%5FQLD/CurrentEPetition.aspx?PetNum=1058&lIndex=-1

Please send the link to anyone you think may be interested.

The wording:

Queensland Residents draws to the attention of the House: The imminent national crisis in the GP workforce as exemplified by the widely publicised situation at the Logan Road General Practice in the federal electorate of Griffith.

Your petitioners, therefore, request the House to: petition the federal government to address the issue by:
temporarily suspending the District of Workforce Shortage (DWS) designation (say for 6 months) to allow the employment of International Medical Graduates (IMGs( in inner metropolitan areas;
reducing to 3 years the period after which an IMG has access to an unrestricted provider number;
giving exemption from the provider number legislation to IMGs who have proven commitments (eg. family) that preclude them leaving a metropolitan area;
identifying and supporting Australian trained GPs who have left the workforce, to return (eg. offer up skilling, financial incentives).

Meeting Mr Rudd.

2008-05-11T05:44:00.003+10:00

Two of us (Barbara and Janet) met with Kevin Rudd at his open-air "street office" in West End, Brisbane yesterday. We were delighted with the meeting. We had Mr. Rudd's undivided attention for nearly 25 minutes. He listened to our story, he asked a lot of good questions, and he was clearly aware of the issue in both its local and national aspects. What was particularly gratifying was that he specifically read and responded to each of our suggestions [see the Solutions debate, link in the sidebar]. He did not simply make bland reassuring noises [as we expected], but has undertaken to respond to us on some very specific points.

We are optimistic that our concerns and our suggestions will be considered.

Thankyou, Mr. Rudd.

In the meanwhile, we are not going away, and the campaign is not closed.

Mr. Rudd's Office.

2008-05-09T08:50:00.015+10:00

As we said in the previous post, we may have been quiet on the blog, but we have not been quiet elsewhere.

Barbara Reynolds-Hutchinson outside our local members office, petitions in hand.

And here are a few more pictures, just to show you our human face.

Our little community practice:

[Of course, if medicine in the community is not your thing, you will be able to visit the nearest Super Clinic instead - a mere $46 cab ride or minimum of two buses away.]

One of our friendly receptionists:

Our friendly neighbourhood pharmacist:

The Case of the Vanishing GP.

2008-05-09T08:43:00.002+10:00

This blog may have been quiet lately - but we have not. Regardless of the total lack of serious response from government (we do not count 'form' letters, of which we have quite a number), we will pursue our attempts to find a solution for the Vanishing GP.

You can now read Barbara Reynolds-Hutchinson's Online Opinion article on this topic via this link HERE.

Not The Impossible Dream.

2008-04-19T06:20:00.006+10:00

It seems that not everyone in the world thinks it is an impossible dream to have affordable excellent care for everyone. The Institute for Health Care Improvement based in the USA has been in pursuit of radical health reform for some time now, and in June will hold a seminar on Achieving the Triple Aim: The Simultaneous Pursuit of Excellent Heath, Ideal Care, and Controlled Costs.

Is anyone from Australia with the Triple Abilities of Power, Influence, and Positive Attitude going to go to this?

June 23-24, 2008
Washington, DC

The Institute for Healthcare Improvement (IHI) is now offering Achieving the Triple Aim: The Simultaneous Pursuit of Excellent Health, Ideal Care, and Controlled Costs, a seminar in which we’ll share with a wider audience the work conducted through our innovative Triple Aim initiative. The “Triple Aim” refers to the pursuit of optimal performance across three areas: the health of the population; the health experience of individuals; and the per capita cost for a population. Organizations working on the Triple Aim may focus, for example, on:

Planning and customizing care at the level of the individual, targeted to the best feasible outcomes
Cooperating and coordinating with other specialties, hospitals, and community services related to health
Customizing services efficiently, based on appropriate segmentation of the population using a health risk assessment tool or equivalent

You can read more about it by going to the IHI main page (linked above) or to the exact page HERE.

Online Opinion.

2008-04-16T10:26:00.003+10:00

Barbara Reynolds-Hutchinson has summarised the current situation beautifully in an article published today in Online Opinion. You can read it HERE.

It is Happening ... Elsewhere

2008-04-16T06:20:00.004+10:00

We here in Mr Rudd's electorate are not alone, which may or may not be reassuring.

In Tasmania, from the ABC: Northern GP shortages for another 6 years
http://www.abc.net.au/news/stories/2008/04/15/2217445.htm

In WA, from the ABC: Acute GP shortage in rural WA
http://www.abc.net.au/news/stories/2008/04/15/2216999.htm

P.S Still no response from Mr Rudd on our specific suggestions to alleviate this problem (see the Solutions Discussion link in the sidebar.) Tell us they are good suggestions, Mr. Rudd. Tell us why they wont work, Mr Rudd. Tell us we are crazy for trying. Tell us anything at all, just for the sake of good manners.

Front Page News.

2008-04-14T06:33:00.008+10:00

The South East Advertiser gave us front page coverage in the issue of April 9.

The SEA's intrepid reporter, Luke Royes tested out the trip to the nearest proposed super clinic site from this little community. Apparently the Stones Corner / Greenslopes GP shortage is going to be solved by a clinic in Coopers Plains (near QE II hospital) a $46 cab ride away - or a series of buses taking 45 minutes minimum.

How is that for solving the local problem? Elderly frail pensioners with crook knees and Mums with sick kids are gonna find it very convenient, aren't they?

[The full text of the SEA article can be read HERE, and the newspaper invites your letters of comment.]

"Medical Mess"

2008-04-07T15:37:00.009+10:00

A letter from a patient published in the Courier-Mail today, April 7.

Medical Mess.

As an 88-year-old* patient of one of the practices referred to in Madonna King's article "Patients before Paperwork" (C-M, Apr 5-6) I applaud her turning the spotlight on this anomaly in medical care.
I realise this anomaly was not of Kevin Rudd's making but it is now within his power, and it is his responsibility, to bring common sense to bear on the problem.
To suggest that, if my GP's practice has to fold, I could go by public transport to the proposed superclinic 10 km away (which may take a year or two to set up), when there are qualified, competent GPs in my area, is ludicrous. I have been a patient of this practices for the past 12 years, and they have all my medical records, and my doctor is familiar with my care. The solutions suggested in Ms Kings's article are sensible and practical - and the need is now, Mr Rudd, not in a couple of years' time.
V.A.H....
Holland Park West

[small correction: Vi is a mere 80 years old]

Support from the Courier Mail.

2008-04-05T09:06:00.002+10:00

Madonna King, the ABC journalist and Courier Mail columnist has given over her Saturday column to our issue today.

Thankyou Madonna, for helping the general public understand the many issues underlying the imminent crisis in general practice.

Madonna's article can be read HERE.

Letter to the Editor.

2008-04-03T05:32:00.001+10:00

The press coverage continues with the publication this week in the South East Advertiser of my letter to the editor.

Press powers GP crisis solution.

Dear Editor,

I would like to thank you for your recent articles in respect of the general practitioner shortage in Stones Corner and Greenslopes, in the Prime Minister’s electorate of Griffith. You have drawn attention in your newspaper to the imminent crisis in GP supply, and to the campaign started by a concerned local citizen with the aim of addressing the issue. I am the principal of one of the practices featured in your newspaper as being at risk of closing due to the shortage of GPs.

We believe that good general practice is the cornerstone of good primary care, and that everything possible must be done to ensure that it survives and thrives. Any further worsening of the GP workforce will have serious impact on health care in the community, and will put further pressure on the already over-burdened hospital system. We know that the situation is similar in other urban areas in Queensland as well as interstate, and we are determined to put the focus onto finding a solution to the problem, rather than eternally analysing it and complaining about it. We hope that our blog at needmoregps.com will help publicise the issue and act as a forum for ideas.

I would like to inform you and your readers that the local campaign has attracted interest from the broadcast media and the national press. This would not have happened without your enthusiastic support. You have provided a fine example of the power of the local press.

Dr Janet Clarkson,
Logan Road General Practice.

Yes, Minister.

2008-04-01T05:53:00.000+10:00

Yesterday The Australian featured an article by former Labor senator John Black on the GP workforce issue as it is impacting on us here in the PM’s own electorate of Griffith. We are immensely grateful to him for generating interest in our little problem. The full article is HERE.

John drew an irresistible parallel with the Yes, Minister episode called The Compassionate Society (first screened in February 1981). In case you have forgotten, the story is centred around the new St Edward’s hospital which is staffed by 300 administrators but has no doctors, nurses, or – heaven forbid – patients.

Purely for your amusement, I offer the following snippets of dialogue from the episode.

Jim Hacker: "The National Health Service, Humphrey, is an advanced case of galloping bureaucracy."
Sir Humphrey: "Ooooh, certainly not galloping. A gentle canter at the most."

And …

Sir Humphrey: "Minister, you said you wanted the administration figures reduced, didn't you?"
Jim Hacker: "Yes."
Sir Humphrey: "So we reduced the figures."
Jim Hacker: "But only the figures, not the number of administrators."
Sir Humphrey: "Well of course not."
Jim Hacker: "Well that is not what I meant."
Sir Humphrey: "Well really Minister, one is not a mind-reader, is one? You said reduce the figures, so we reduced the figures."

Twenty-seven years down the track, and it still resonates ….

Letter to Medical Observer.

2008-04-01T05:30:00.001+10:00

The Medical Observer featured my letter to the Editor in the edition of March 28. This is what I said:

Dear Editor,

The GP workforce issue has been recently reinforced with a vengeance for me, as you highlighted in your article last week. My practice is in a designated ‘Inner Metropolitan’ area of Mr. Rudd’s electorate of Griffith. Once upon a time this little shopping precinct had eight busy doctors, in a few weeks time there will be two. I am sixty years old and have no succession plan for my practice. I admit to completely giving up trying to find a solution to the problem two years ago.

I have been shaken out of my resigned, cynical sloth by the loyalty and support of patients and locals, who are enthusiastically researching the issue, coming up with ideas, and signing a petition.

We do not need any more statistics: any further government recourse to data-collecting is avoidance behaviour, pure and simple. We resent the patronising reassurances from government (and our own professional bodies) that ‘we understand the problem’. We would laugh at the proposed ‘solutions’ such as Super Clinics if they were not so fundamentally flawed as to be tragic.

We all want this problem solved. It will not be solved without a determinedly problem-solving attitude and genuinely open, vigorously creative debate in which we and our patients are involved. It will most certainly not be solved by bureaucrats. We want to get the debate going and the ideas flowing. To that end we now have a blog which we hope will provoke discussion and stimulate ideas. It is at http://needmoregps.blogspot.com/ , and we invite your comments and input.

Yours sincerely,

Dr Janet Clarkson,
Logan Road General Practice
Stones Corner
Brisbane 4120

GP workforce problem in all states.

2008-03-31T05:30:00.005+10:00

We are in Brisbane, but we know that the GP workforce problem is acute in many urban areas in other states: the Sydney Morning Herald recently highlighted the seriousness of the problem in both Sydney and in Victoria.

If we ask you "Is there a GP workforce shortage in your own area?", how would you respond? Please let us know: email us at brisbanegp@gmail.com with your response.

To: The Divisions.

The following email has been sent to the over fifty urban Divisions of General Practice around the country.

Dear Colleagues,

You may be aware of the national coverage of the GP workforce issue in the Prime Minister’s own electorate of Griffith over the last week. My practice is one of those at the centre of the publicity. In summary, both this and a neighbouring practice are facing closure in the relatively near future due to our inability to find doctors eligible for employment in our inner metropolitan area. I am sixty years of age, with no succession plan for the practice. In the shorter term we will not meet accreditation standards when we are reviewed next March, unless we can find another doctor.

A local campaign was started by a concerned patient several weeks ago and has been received with great enthusiasm by the community. It has received attention from television, radio, local and national newspapers. The first batch of petition signatures has been handed in to Kevin Rudd’s Griffith electorate office; a second batch will follow shortly.

We know that many of you in urban areas in other states are in a similar situation. We believe the problem can be solved, if there is a will to do so. We have some practical ideas and suggestions which we have already forwarded to the Prime Minister and to the Minister for Health (although we have not to date received any response other than the formulaic one.)

We have started a blog at http://needmoregps.blogspot.com/ to publicise the campaign and act as a focus for the debate we have to have if this problem is to be solved. We do not need or want any more analysis of the problem. We welcome your suggestions and comments.

Yours sincerely,

Dr Janet Clarkson.
Logan Road General Practice
Stones Corner
Brisbane
3394 3622
0417 718 375

The Financial Review.

2008-03-28T11:52:00.007+10:00

Doctor's jab sullies watershed moment.

Laura Tingle of The Australian Financial Review has seen fit to comment on our grass roots campaign; the article is in the Opinion section, page 83, in today's edition. Here is an extract:

"Not everyone in Australia loves Kevin Rudd at the moment. At home in his seat of Griffith, a grass roots campaign has begun to try to get some action on a chronic shortage of doctors.

Local patients and GPs have started a website called needmoregps.blogspot.com/ because shortages of doctors-and difficulties experienced by local clinics with the bureaucracy in hiring overseas trained doctors – are claimed to threaten two clinics, leaving 7,500 patients without a doctor.

This isn’t some remote part of Australia but suburban Brisbane in the spotlight, and the PM’s own electorate to boot.

The locals have been underwhelmed with the response from Rudd so far.

In a week in which the Prime Minister is setting off around the world to establish his credentials as a middle-power statesman, and hosting a significant Council of Australian Governments meeting why are we so concerned about doctor shortages in Griffith?

Because in a ‘six degrees of separation’ way, they show how all international and federal politics – and all that talk that seems to be going on – can ultimately rebound locally.

Australia’s reputation abroad after last year’s Haneef affair has made it hard to attract over seas trained doctors to Queensland.

Even the ones who are here and determined to stay are being driven made by bureaucratic processes in which states don’t seem to have had adequate records of who has worked where and, even if they have, require different qualifications for registration in other states.

There is also the issue of which areas are declared as areas of medical workforce shortage – areas that get precedence in the placement of overseas trained doctors. The electorate of Griffith isn’t one of them, so even overseas trained doctors who live in the area have to go and work in areas of designated shortage in the bush."

An Invitation.

2008-03-28T07:59:00.005+10:00

We invite you to join in the Need More GPs Solution Discussion.

We do not need any more data to find out how bad the problem is.

We do not need any more statements about how bad the problem is.

We do not need any more whingeing about whose fault it is.

We need some solutions.

We invite you all to use both halves of your brain, to throw the correctly coloured hat onto the discussion table, to think out of the box, out of left field, out of desperation, and join in the discussion.

Towards this end, and in an attempt to open up the debate, we offer some ideas for discussion. We hope that, with your input, this list will grow.

In no particular order, we propose:

1. To assist the urban crisis: a short moratorium (say, 6-12 months) on the provider number restriction, with some other conditions: only Australian residents or citizens who are fully registered and have a demonstrable urban commitment. This could allow an uptake of OTDs into urban practices at risk of closing, without causing an exodus from the bush

2. A reduction of the time-limit on OTDs obtaining unrestricted provider numbers from ten to three years. Three years seems reasonable to demonstrate a commitment to the country. Three years is short enough to make upskilling not too much of an issue for OTDs who have not found work in Australia for whatever reason. We also suggest that a three-year requirement is less intimidating than a ten-year one - might this increase the number of doctors prepared to consider going to the bush?

3. To encourage doctors to work in rural and remote areas:

(i) They receive a Medicare rebate of 100% of the scheduled fee.

4. To encourage doctors who have left the workforce prematurely to return to practice: (i) A ‘Welcome Back’ package, along the lines of the ‘Golden Hello’ offered to GPs in the UK between 2001-2005. The cost of this would be far less than training a replacement GP.

(ii) An upskilling and mentoring program to assist their return to work.

5. Temporary assistance to female GPs who wish to work part-time while their children are under-school age, in the form of a subsidy of their medical indemnity cost, to be repaid (as is the student HECS bill) when their working hours increase substantially. There is strong anecdotal evidence that the very high cost of medical indemnity in relation to a part-time income is a contributory factor in women leaving the GP workforce for this reason. A short period of time out of the profession increases the likelihood of the practitioner not returning to it at all due to loss of confidence and de-skilling.

Please leave your comments directly, using the comments link below, or email us at brisbanegp@gmail.com

From the Local Newspaper ....

2008-03-25T19:09:00.003+10:00

STONES CORNER, March 26: "When it comes to improving Australia's health system, as Prime Minister, the buck will stop with me.''

Those were the words Prime Minister Kevin Rudd used in the lead-up to last year's Federal election to convince voters he was the best person to tackle the country's health system.
Four months after being elected, the Member for Griffith has dodged questions on his plans for fixing a shortage of General Practitioners in his own electorate.

Read the remainder of the article HERE.

Older People Speak Out

2008-03-25T05:30:00.004+10:00

We recently received this letter of support from Older People Speak Out (OPSO)

OPSO recognises that the situation of Stones Corner’s Logan Road Medical Practice is merely the thin edge of an iceberg threatening patient security in practices across Australia.

OPSO has continually drawn attention to the chronic shortage of medical doctors and allied health workers in rural and regional areas. There is now an urgent problem in inner city areas.

The restrictions on overseas trained doctors placed there by the previous government are obviously short-sighted: the population in the inner city is growing rapidly as multi-story unit blocks take over the old workers cottages, while the doctors in those areas grow old and retire, or move into the less stressful fields of medical practice.

All this at a time when universities are permitted to take in large numbers of overseas fee paying students at the expense of Australian students.

One professor last year walked out of a final year class in protest: there were no Australian students

Who can blame young students choosing to specialise rather than work in the stressful and over-regulated and generally short-staffed environment of general practice?

We support the solution of a moratorium of six months on the regulations governing overseas trained doctors and inner city practices.

We also support the recommendation to reduce the time by which OTDs can obtain unrestricted provider numbers from 10 years to three. That is, make it just three years before they can practice in any region, including inner city areas.

Val French AM

[the image accompanying this post is of Val French]

OPSO Media Release.

2008-03-25T05:25:00.001+10:00

We have been advised by Val French, President of Older People Speak Out (OPSO) that the following media release has been sent out.

Media Release by OPSO

OPSO supports the patients in the Prime Minister’s electorate in their fight to keep their medical practice alive.

OPSO president Val French said the shortage of general practitioners in that electorate was reflected across Australia.

“This is partly the result of insufficient graduates to replace those retiring through age or moving to less stressful areas of medicine, but in inner city areas it is compounded by regulations making over -seas trained doctors ineligible for a Medicare Provider number for day-time practice.

“A suggested six month moratorium on these regulations would solve immediate problems.

“Long term the recommendation from Stones Corner General Practice Dr Janet Clarkson that there be new legislation to allow doctors who have practised for three years in rural Australia unrestricted provider privileges has a great deal of merit."

Val French,
President Older People Speak Out.
0419020924

Medical Observer observes.

2008-03-19T18:36:00.001+10:00

Workforce Crisis hits home for Rudd.
Desi Corbett

KEVIN Rudd is feeling the sharp end of the GP workforce crisis with his own electorate in Queensland calling on him to relax rules governing the placement of overseas doctors.

Locals have warned the situation in the Prime Minister’s inner Brisbane electorate of Griffith will reach “flash-point” this month when the fifth practice in a two-kilometre radius closes and the Logan Road General Practice loses a doctor, leaving up to 8000 patients without a GP.

Griffith is one of many inner metropolitan areas facing GP shortages, but practices in these areas are unable to employ international medical graduates (IMGs) because federal laws only allow them to work in designated Districts of Workforce Shortage.

Inner metropolitan areas are not eligible for District of Workforce Shortage status.

Dr Janet Clarkson, principal of the Logan Road practice, said three GPs from Canada, New Zealand and China were willing to work but she was unable to take them on.

Patients and GPs in the area called on the government to lift the ban on IMGs working in inner-metro areas with a known medical workforce shortage.

Dr Clarkson, 60, threw down the gauntlet for the government to tell her patients where to go for treatment if she retired.

AMA Queensland president Dr Ross Cartmill said the situation showed the workforce shortage was not only affecting rural areas.

Mr Rudd’s office did not respond to MO’s requests for comment in time for deadline.

The Petition Continues ....

2008-03-19T18:30:00.001+10:00

Another patient signs the petition at Logan Road General Practice ....

“After-Hours”

2008-03-18T09:04:00.002+10:00

An open letter to the Hon. Nicola Roxon, Federal Health Minister.

In response to the local publicity on the GP shortage in the Stones Corner/Greenslopes area you were reported as pointing out that OTDs can in fact work in designated ‘Inner Metropolitan’ areas – provided that they work after-hours (i.e 6 pm to 8 am).

This response, Ms. Roxon, is unsatisfactory. It is clearly the response provided to you by your advisors. It is patronising and unhelpful. It serves only to highlight the abyss that gapes between GPs working at the coal-face and bureaucrats working from their ivory towers.

I one wants to find out about knitting, one does not ask a carpenter. May I respectfully suggest that if you want to find out what is really happening in general practice on a day-to-day basis, that you do not ask a bureaucrat.

I offer the following comments, which I would be grateful if you would pass on to your Departmental advisors during your next discussion.

1. If you are suggesting that each individual practice could solve their workforce problem by employing an OTD after-hours, could you please explain how this would assist a practice which cannot find a doctor to fill the morning shift from Monday to Friday to meet their accreditation requirement (based on the RACGP Standards) to have a doctor available during office hours (8 am to 6 pm)? As you are aware, practice accreditation is linked with remuneration, and hence financial survival.

2. In any case, to suggest that every small individual practice could afford to employ an after-hours doctor is ludicrous. It would necessitate the employment of after-hours administration and security staff, which would be financially impossible for every practice I know. Some of the large corporate practices tried this in Brisbane some years ago, but even with their economies of scale, they were not able to make it a viable business proposition. There may be two remaining 24 hour practices left in Brisbane.

3. Inner metropolitan practices do in fact employ OTDs ‘after-hours’ – but most do it via a subscription to the commercial After-hours service.

4. This ‘solution’ is equally unnacceptable to the community if it is offered as a substitute for availability during office hours. A mother of an infant is not going to want to take her child for routine vaccination at 9 at night because the practice does not have a doctor available at another time, nor is a frail elderly lady going to venture out on her own late at night to get her blood pressure checked.

I look forward to your response.

Yours sincerely,

Dr Janet Clarkson

Logan Road General Practice.

Thoughts on Super Clinics.

2008-03-18T08:25:00.005+10:00

An open letter to Mr. Rudd and Ms. Roxon, from a GP at the coal-face.

Dear Mr. Rudd and Ms. Roxon,

I would like to make the following comments in regard to the Super Clinics which you have offered as a solution to the GP shortage.

1. Unless there is a net increase in the total number of GPs, this simply represents people-moving.

2. These Super Clinics are apparently to be staffed by the large number of GPs that you 'hope’ will result from the increased number of medical students currently attending our universities.

(i) Assuming that this increased cohort does eventuate, it will not be for nearly a decade. Do you have any strategies for our survival in the meanwhile?

(ii) One quarter of the current Year 1 students at the University of Queensland School of Medicine are overseas students, who will not be allowed to stay in the country after they graduate.

(iii) Of the remaining 303 Australian first-year students, assuming that they all complete their course, is it not a fantasy that a large number will become GPs given that:

(a) it is acknowledged that the popularity of the general practice as a career choice has been declining world-wide for years.

(b) this has been reflected in a decreasing number of applicants for each general practice training place for a number of years. We understand that in the late 1990’s there were three applicants per place, compared to 1.1 applicants per place in 2005.

(c) there are said to be sufficient training places in specialist colleges that every student could access one of these, making it theoretically possible that there could be no applicants at all for the general practice progam.

To build a concept of Super Clinics based on what can only be called optimism of the highest order can surely not qualify as a strategy, can it?

3. The Super Clinics are apparently going to attract these mythical graduates on account of the state-of-the art facilities that they will offer. This sort of statement, Mr. Rudd and Ms Roxon, is, quite frankly, an insult to future and current practitioners.

4. The Super Clinics are to be subsidised by governement. Will not this represent unfair competition to GPs who have struggled to maintain their community practices for years? I do not know if it is unconstitutional. I do not know if it breaches the Trade Practices Act. I do know that it is unfair.

5. And finally, in your reply to our letters regarding the local problem you described the planned Super Clinic concept. As, by your own definition, Super Clinics will be set up in Districts of Workforce Shortage, and, by your own definition, this area (Stones Corner and Greenslopes) is not a District of Workforce Shortage, can you please explain how this will help solve the local area problem?

Yours sincerely,

Dr Janet Clarkson,

Logan Road General Practice.

UPDATE, 27 March, 2008

Proposal to pay incentives to doctors to work at Super Clinics; read the Medical Observer Article.

Some Workforce Recommendations.

2008-03-17T12:07:00.001+10:00

There are three groups of doctors that can help us out of this plight.

1. Overseas-trained doctors (OTDs)
2. Australian-trained doctors who are not currently practicing.
3. Future doctors – the medical students still in training.

We need to consider how each of these might help the workforce crisis, as each group has a different perspective and presents a different set of issues.

The most obvious obstruction for most of us seeking to employ a doctor in our practices is the provider number legislation. The provider number legislation was enacted to ‘encourage’ OTDs to work in rural areas, by restricting the allocation of a provider number to those prepared to work in a “District of Workforce Shortage”. There is great reluctance (refusal) to withdraw this legislation for fear that it will worsen the rural workforce crisis. We believe, and hope to demonstrate, that the legislation is, however, causing a net loss of doctors from the system. Anything that causes a net loss of doctors will not help the rural segment at all.

In order to open up the debate, we suggest the following ideas for discussion:

1. A short moratorium (say, 6-12 months) on the provider number restriction, with some other conditions: only Australian residents or citizens who are fully registered and have a demonstrable urban commitment. This could allow an uptake of OTDs into urban practices at risk of closing, without causing an exodus from the bush.

If some respite can be found for those of us tired of struggling with the issue, so that our practices can remain open, it might buy some time for the underlying issues to be addressed.

We have specifically considered the rural health issue, the issues of medical student intake and GP training, and the under-utilisation of the home-trained doctor, and will present our ideas in future posts.

We welcome your input: please leave your comments, or alternatively email us via the address in the sidebar.

Mr. Rudd's Response ....

2008-03-17T11:41:00.001+10:00

Mr. Rudd did indeed get back to us in response to our letter. Here is the text of his reply, dated 11 March 2008.

"Thankyou for your correspondence of 15 and 27 February regarding the level of medical services and resources available in the Griffith electorate.

As you indicated, ‘Districts of Workforce Shortage’ are classified by the Department of Health and Ageing according to a range of criteria including the supply of General Practitioners in the broader area and the population need.

I understand that the area is not currently classified as a ‘District of Workforce Shortage’ by the Department of Health and Ageing. I understand the difficulties family practices have trying to attract GPs, and I have asked the minister for Health and Ageing, the Hon Nicola Roxon, MP, to examine why the Greenslopes Family Practice has not been classified as having ‘District of Workforce Shortage’ status.

Please be assured that as soon as further information becomes available my Electorate Office staff will be in contact with you.

The Federal Government will seek to invest %220 million in the health system to establish GP Super Clinics in local communities – bolstering frontline health care for Australian familiies. This investment will ensure more Australian families have access to doctors in their local community.

Over the next few yearrs, our government’s GP Super Clinics policy will also help to encourage the large number of doctors who will be graduating from our medical schools to work in general practice. GP Super Clinics will provide attractive environments for new medical school graduates to work in so we hope to see more doctors interested in becoming GPs as a result.

Further information regarding the Federal Government’s outline for GP Super Clinics may be obtained by visiting:
http://www.alp.org.au/download/now/new_directions_for_australias_health_gp_super_clinics_final.pdf

As you are aware, I recently announced the establishment of the Health and Hospital Reform Commission.

The Commission is developing its own website which will be available in the near future.

Should you wish to contact the Commission with suggestions for health and hospital reform, you may contact 1800 017 533 or email hhrc@health.gov.au

Given your interest in this matter, I have enclosed a brief outline of the Health and Hospital Reform Commissions’ objectives to further address your concerns.

Thankyou for taking the time to write to me on this most important concern. I trust this information will be of assistance to you.

If there are any other Federal Government matters with which I may be of assistance to you, please do not hesitate to contace my office on 3899 4031. "

Yours sincerely,

The Honourable Kevin Rudd, MP
Prime Minister of Australia
Federal Member for Griffith.

Dear Mr.Rudd ....

2008-03-17T09:02:00.001+10:00

15 February, 2008

Dear Mr. Rudd,

I wish to bring to your notice the problem concerning the impending closure of a yet another general medical practice in your electorate.

It was reported recently in the South-East Advertiser (local newspaper) that another general practice, namely Logan Road General Practice, 329 Logan Road, Stones Corner, Brisbane, is likely to close in the near future as they are unable to employ suitable doctors to join the practice.

This is not the first medical practice in this area to be closed in recent times. Greenslopes Family Practice is in the process of closing and recently at least three medical practices that I know of, in the close vicinity of Stones Corner, have closed. All experienced the same problem – inability to employ overseas trained doctors (OTDs).

This is not because there are no doctors interested in joining them. It is due to the federal government’s policy with regard to overseas trained doctors. The area serviced by the Logan Road General Practice and the other medical centres that have closed is not classed as a ‘district of workforce shortage’ (DWS), therefore overseas trained doctors cannot be employed as they are not eligible for provider numbers for work in this region.

This is a region of high density population which includes a significant number of aged people, a migrant population, and pockets of people of low socio-economic background, as well as the young families that are moving into the area. I know that the Logan Road General Practice serves the community well as they work with interpreters and other support groups.

There is a public hospital in this area (The Princess Alexandra Hospital) that may be able to service some of the people’s medical needs, but this would be an added burden to the already stretched public hospital system.

So this inner city, high density area is not classed as a DWS. In light of the fact that several medical practices have already closed and others are about to close, and the fact that most existing medical centres in the area have closed their books to new patients, where will people go for medical care?

Will the Princess Alexandra Hospital and the Mater public services and existing GP services in the area be able to service the needs of this population? I think not. Already the hospitals are overburdened and existing medical services have closed their books. I was told by a local chemist that some people have had to go as far afield as Springwood to find a doctor who would be able to attend to them.

The closure of these medical centres therefore pushes local people further afield to find medical care. This is not a viable, let alone easy, option for elderly or chronically ill people.

This region may appear to have a good doctor to population ratio. A check of the Yellow Pages however, indicates that many of the doctors listed for this area are specialists or GPs specialising in particular areas, e.g. mole clinics, weight loss clinics, etc. This, together with the fact that many clinics have closed their books to new patients would indicate that this is not so.

As it is well acknowledged that primary health care is the cheapest overall approach to health care, it seems to me that it is in the interests of the community, the hospital system and the economy, to help sustain GP medical centres such as Logan Road General Practice.

In a good GP clinic, as opposed to the proposed ‘super clinics’, patients with chronic illnesses, age related illnesses and certain psychiatric conditions, are monitored and treated. This often means that people are treated before they reach the stage of hospitalisation. This requires time, building a relationship between patient and doctor and enough doctors to make this primary care viable.

I do not know the criteria for determining whether a region is a ‘district of workforce shortage’, however, perhaps the criteria need to be reviewed in the light of demographic conditions that would indicate potential medical needs of people in the region.

The situation in regard to medical care that this area is facing is dire. It would seem to me that there are two aspects to a solution: the short term and the long term.

The long term solution is being attended to by government through increased medical places at university.

In the short term is it possible to:

ease the placement requirements for certain overseas trained doctors? For example, if an overseas trained doctor comes to Australia with her spouse who is on transfer, because of federal policy, she is unable to take work in a local area so that she can remain with her family. Her skills are lost to the profession, the community, and the economy.
make access to re-skilling easier for doctors who have left the workforce for various reasons and who may be induced to return? This would include help with medical indemnity and cost of re-skilling.
give support and incentives to doctors who would prefer to work part time?
make bulk billing more attractive for GPs? (In this electorate the bulk billing rate is 10% below the national average.)

The most recent edition of the South-East Advertiser the federal health minister, Ms. Nicola Roxon is quoted as playing down the concerns about health services in this region and ‘said because the area was classified as “inner metropolitan”, it was not entitled to employ OTDs to work conventional hours’. This is unrealistic as it does not take into account zoning laws and people’s actual needs. Should we plan to visit our GP at 10.00 p.m. or midnight?

So, in the light of general practice closures, the inability of many existing medical centres to take on new patients, and a high density of population, I ask for a review of the criteria for the placement of OTDs so that existing practices are able to continue to serve the community.

Should this review not be possible, give the patients of these clinics directions as to where they will be able to receive their primary health care within a reasonable distance of their residence.

Finally, Mr. Rudd, I offer you my heartfelt congratulations on your election victory.

Yours faithfully,

Dr. Barbara Reynolds-Hutchinson, Ph.D.

7 Rowland Street,
Coorparoo Qld. 4151

Cc:

The Hon Nicola Roxon MP,
Minister for Health and Ageing.

Senator the Hon. Jan McLucas,
Parliamentary Secretary to the Minister for Health and Ageing.

The Hon. Anna Bligh,
Member for South Brisbane

The Hon Stephen Robertson,
Minister for Health,

The Hon. Gary Fenlon,
Member for Greenslopes

AMA Federal Secretariat

AMAQ

RACGP College House

National Seniors

Comments from Patients.

2008-03-17T06:58:00.000+10:00

As a long-standing patient I was horrified to learn that the Logan Road General Practice is in danger of closing due to a shortage of doctors. Janet Clarkson has been my GP for 15 years and has seen me through a number of quite complicated medical procedures and conditions. Should the practice close I wonder what will happen to my medical records.

My concerns are replicated by hundreds of the practice’s patients and I for one have decided to join the campaign to save the practice.

Beverley Miller
Coorparoo

I read the article in the SouthEast Advertiser about the GP situation in the electorate of Griffith. At my next appointment with Dr. Janet Clarkson we talked about the situation and how dire it is not only for the Logan Road General Practice but for GPs generally. I offered to write to Kevin Rudd, member for Griffith and Prime Minister. So this campaign got underway.

I have sat in the waiting room of the Logan Road General Practice often and have watched the diversity of people who are cared for in this practice, including immigrants and the elderly. These doctors serve the community around Greenslopes as well as a wider demographic.

Barbara Reynolds-Hutchinson
Coorparoo

The Story Begins.

2008-03-17T06:18:00.000+10:00

This story began for me on the day that my staff showed me the above article in the local community newspaper. I am ashamed to admit that my first reaction was purely selfish – I did not want to cope with the overflow of patients from this adjacent clinic, particularly in view of the fact that we are going to lose a doctor from our own practice in the first week of April. The anxiety was sufficient to put me firmly into denial mode.

I have just celebrated my 60^th birthday. I do not have a succession plan for my practice. I have found some fine doctors over the years, but all have been overseas-trained, and are therefore unemployable by us as we are not classified as a District of Workforce Shortage. I admit to having completely given up on the problem.

A few years ago there were four practices within a few hundred metres of each other in this inner suburban shopping precinct, representing about eight full time practitioners. We are the only practice left, and when we lose one of our doctors, we will be down to slightly less than 2 FTEs. We service the local community, including a significant number of refugees, as well as a large number of commuters from the outer metropolitan area. I truly do not know where these patients will go if we close.

I was humbled out of my denial by the response of patients of the practice when they read the follow-up article which explained our own plight. One of those patients has started a petition, and the first batch of signatures has been handed in to the office of our local member – Mr. Kevin Rudd.

All of us working at the coal-face in general practice are tired of the same assurances and promises. We are certainly tired of the workforce issue being analysed. There have been at least four large workforce studies since 1996. Every time the figures are done the sitution is worse. Any further data-collecting exercises must be seen as an excuse for real action on the part of the Government.

I have always felt that General Practice is the most creative form of medicine: so many of our patients do not fit any mould, and so many are sent back to us when all specialist solutions are exhausted, yet we must keep coming up with ideas and assistance. I do not believe that this problem is insoluble, if we generate a true spirit of discussion.

Mr. Rudd wants to fix the Health System.
We want to fix the Health System.
Our patients definitely want us to fix the Health System.

At the risk of sounding like an old cynic, it seems that our joint adversary is the Bureaucracy.

We must find some solutions that do not frighten the bureaucrats.
We must find some solutions that do not worsen the bottom line.
We must simultaneously address the Rural Health problem.