Monthly Archives: March 2012

Open Letter to the Minister

Well, it’s finally happened. I’ve succumbed to the urge to fire off Victor Meldrew-like letters of indignant fury to the Health Minister over the recent exchange of press releases between Liberal and Labor Health Ministers regarding the issue of country patients being charged fees for A&E services.

Grumpy old doctor aside, I really believe this is an issue that is important. Rural Australians are disadvantaged enough, without having to face fees for A&E services.

I should note that this is not an issue of self interest – as a rural doctor, I derive part of my income from charging fees to attend a patient at 3am. And I am comfortable with charging a fee where it is fair. But when the same patient would get the same service for free in a metro ED, I have to question the process. And when patients are afraid to attend the A&E because they fear a fee, something is very very wrong.

It is true that a private fee can be charged as part of a continuing care episode or by prior arrangement for a patient to see a particular doctor privately. Fair enough.

But the people who attend EDs usually have urgent issues that cannot be dealt with in GP private rooms. They often require services that cannot be delivered in rooms (X-rays, anaesthetic, plaster etc). They haven’t asked for a particular private doctor to see them – they have correctly self-presented to the emergency department and the hospital has in turn decided to call in the doctor.

Rural health outcomes are already bad – to charge people just makes this worse.

So – I’d be a lot happier if I was paid by the hospital for attending patients who the hospital feels need to see a doctor urgently, through my contract to provide A&E services. I may be poorer if paid by the hospital, but it would be a fairer system

I am pretty sure patients would prefer it!

Anyway, here’s my latest missive.


Dear Minister

I read your latest Press Release re: country hospitals charging fees in response to the Press Release of Martin Hamilton-Smith. Regardless of whichever party is in power, I remain perplexed.

The fact remains, country people are charged fees for non-admitted A&E attendances in rural hospitals,  for services that are provided for free in metropolitan areas.

These are not, as you suggest, charges for routine GP services – your 2010 contract with rural doctors is very clear – non-admitted patients in the ED are considered to be private patients of the GP

Examples of non-admitted A&E attendances include

– forensic medical examination of a rape victim
– assessment including X-ray, reduction & plastering of a fractured limb
– repair of a complex laceration
– assessment of victims of a vehicle rollover
– urgent assessment of a complex mental health crisis
– administration of a neuroleptic agent for reduction of a dislocated shoulder

These are not routine GP services. These services are appropriately provided through an Emergency Department and are provided for free everyday in metro EDs.

When the Hospital calls the oncall doctor, it is through his/her contract with CHSA to provide A&E services, not as a private arrangement betwixt GP and patient. 

Many patients are rightly fed up with being charged fees for services in an emergency. Sadly some patients do not seek medical attention with urgent problems that SHOULD be seen in an ED, for fear of cost. I have recently been told of a patient who delayed seeking medical attention for fear of fees…then presented in extremis several days later and died.

Your press release intimates that the only alternatives are for either GPs not to charge patients their gap fees, or for CHSA to put in salaried medical officers and ‘put rural doctors out of business’

You neglect to mention the third option – simply to pay the oncall doctor for the work he or she does, regardless of admission status. Existing fee-for-service arrangements would be more than adequate and would be in line with conditions interstate.

Surely it’s not that hard to grasp? If a patient presents to a CHSA hospital with a problem that is deemed urgent, the hospital needs to call a doctor as part of the A&E roster, and the service cannot be provided in routine GP rooms….then the patient should receive the service for free and the doctor be paid by CHSA.

The matter has been needless obfuscated by lack of confusion over what is and what isn’t an admitted service..and a continuing reference to provision for private patients to be treated by their own doctor when they request as part of a prior arrangement or as part of continuing care. None of these apply for the patients I am called to see when on your A&E roster.

I rang Medicare last week. They reckoned it was illegal for me to be charging patients for services provided in the A&E department and referred me to the National Healthcare Agreement which states that:

States and Territories will provide health and emergency services through the public hospital system, based on the following Medicare principles:

(a) eligible persons are to be given the choice to receive, free of charge as public patients, health and emergency services of a kind or kinds that are currently, or were historically provided by hospitals;
(b) access to such services by public patients free of charge is to be on the basis of clinical
need and within a clinically appropriate period; and
(c) arrangements are to be in place to ensure equitable access to such services for all eligible
persons, regardless of their geographic location.

As far as I am aware there is no section 19 exemption between SA and the Commonwealth.

How then can CHSA continue insist that doctors on the A&E roster charge patients for A&E services in CHSA EDs for conditions that are certainly serious but may not require admission for the requisite four hours to satisfy admission criteria?

I look forward to your response. These questions have been asked by me previously to CHSA CEO’s George Beltchev and Clare Douglas without response.

I hope you can finally answer this, not with political spin, but in the interests of rural patients who deserve a better deal.

Kind regards

tim leeuwenburg (dr)
kangaroo island
south australia

Loving the Job

I reckon the work as a rural doctor is the best that medicine offers. Just heard from a colleague with whom I did anaesthetics last year in NSW.

“Mate I love this job! In the past 7 days I’ve thrombolysed a 44 year old with a STEMI, resuscitated a 5 year old who had a fit in the local pool, drained a 2L pleural effusion off an ol’ fellas chest, gassed 5 people on a gen surg list, managed a snake bite, released two carpal tunnels, resuscitated a floppy neonate after a ventouse and seen a whole load of people in general practise. I LOVE MY JOB! Hope you’re having fun mate. This job just keeps getting better!”

No, he hasn’t been at the drugs cupboard. He is expressing the simple joy of being a rural doctor with the skills to do your work. As I’ve stated before, I reckon that being a rural doc is one of the best jobs around – especially for those with procedural skills.

Sadly skills aren’t all you need – you need the equipment to do your work well and you need structures behind you to ensure that your work is sustainable in what is, ultimately, a high-pressure job. For most of us, that means adequate locum relief or being paid for the work you do.

With regard to equipment, I’ve just submitted my paper on the availability of difficult airway equipment for rural doctors. Of the estimated 448 rural GP-anaesthetists out there, I’ve got responses from 293 – a 65% response rate, which is apparently quite good for an internet-based survey. So paper has gone in for submission…

I won’t give the game away (wait for the paper, if it survives the review process) – suffice it to say that there are common themes amongst the rural GP-anaesthetist cohort – lack of funding for basic and advanced airway equipment predominating amongst respondents. 

I’ve tried to outline in my paper some suggestions for affordable equipment to help advance the cause – for under $4K a small hospital can purchase some of the intubating LMA AirQ-II blockers, plus a fibreoptic device to allow intubation through the iLMA (something like the flexible AmbuAscope 2 or the Levitan malleable intubating stylet). There’ll still be change leftover to buy a KingVision videolaryngoscope – all of this gives a fairly robust kit for the ‘occasional intubator’ or GP-anaesthetist.

A&E Services & Contract Negotiations

Meanwhile, the State opposition Minister for Health has finally twigged to the inequity of country patients being charged for non-admitted A&E services that their metropolitan counterparts receive for free through Emergency Departments. Minister Hill is now on record saying that the ‘only solution’ would involve putting in salaried medical officers which would ‘send GPs in rural towns broke’ (The Advertiser, p15 9/3/12). He neglects to consider the alternative option – pay the oncall rural GP for A&E under existing fee-for-service arrangements, regardless of whether patient is admitted or not.

This solution would ensure patients attending the A&E with problems deemed inappropriate for routine GP would not face fees. It would mean the doctor is paid by the Health Dept without having to chase fees. Everyone is happy…

And it would be fairer to rural patients who already face significant health inequalities due to rurality.

This issue is all the more relevant as the existing contract between rural doctors and CHSA expired on 30/11/11 and has been postponed not once, but twice. I dunno about other rural docs, but I’m a little fed up of CHSA failing to come to the negotiating table and sending missives advising of a 90 day ‘contract extension’ on the last day of the existing contract.

It’s not a good way to do business and seems symptomatic of a relationship whereby CHSA treats rural docs and patients as a hinderance to their bureaucracy, rather than a vital component of the health service.