A CONFIDENTIAL report into Portland District Health has criticised the practice of using expensive locums instead of salaried staff at the hospital and recommends completely overhauling the way doctors are recruited here.

After several specialists at the hospital, backed by local GPs, expressed their concerns with the PDH board and Health Department in the Observer last week, the state government said it had accepted every recommendation of the “Towards a sustainable medical healthcare workforce in Portland” report.

But what does that mean?

The Observer has obtained a copy of the report – which has not been publicly released – written by Associate Professor David Hillis in June 2020.

He was engaged by what is now the Health Department and PDH to review the medical workforce model and recommend improvements, to ensure locals could continue to enjoy “at least” the same level of services as at present.

Professor Hillis is blunt about the challenges facing PDH.

The 44-page document says the health service, along with many other outer regional hospitals, were becoming “locum-led outposts providing an inadequate service to the community” largely due to the failure of Victoria’s medical workforce strategy.

However the option of a “hub and spoke” model; where PDH would effectively be a branch of a larger service such as Warrnambool, Geelong or Ballarat, ran into a major problem even if it were to be properly funded.

“Although it does address issues of sustainability more fully, it does little to directly build effective relationships with the General Practitioners of Portland or the Portland community,” the report says.

“Hospitals in outer regional areas exist not only for the services they provide themselves but also for the strong relationships and integration of activities with other service providers.

“The hospital is part of the community, and the community’s health services, culture and educational opportunities.”

“The rural generalist model provides a more complete solution to safer clinical care and better health care in Portland… Portland could be a highly successful demonstration site.”

The report calls for a completely different model to staff the hospital over the next 5-10 years, using what are called “rural generalists”, or doctors specifically trained to work in rural or remote hospitals with a wide range of skills.

These doctors would be able to then work with more specialised services at larger hospitals as needed.

“The rural generalist model can comprehensively support a hospital like Portland providing an effective supervisory role to junior staff and sophisticated interface to regional services,” the report says.

“A well-respected training program would have substantial appeal.”

The model had been successfully implemented in other states, but while Victoria had committed to rural generalists, many PDH staff were concerned about the lack of effective training pathways and the inadequate recruitment of those wanting to follow the path.

It also sheets the blame at the authorities who had commissioned several reviews and appeared not to act on them.

“During this review frustration was frequently expressed that the clinical service issues have not been addressed appropriately,” the report says.

“To many it appears that the decision makers lack the courage to make the appropriate decisions to benefit the health services for the community.

“It is most strongly recommended that no further reviews be undertaken until the recommendations accepted by the (Health Department) and Portland District Health are implemented.”

 Other issues

Professor Hillis also examined the state (as of June 2020) of the hospital’s services.

The report says locums can cost $2500 a day – their hiring instead of permanent appointments has been a key criticism by the doctors who spoke out last week – “which may be multiples of the income of resident rural doctors”.

“In addition on call periods may require payment from $300 to $700,” it says.

“At a state wide, strategic level, it is disappointing that increasing budgets for hospital based locum staff across Victoria has appeared an easier outcome than having a substantially more effective workforce strategy.”

For example Portland had the full time equivalent of 0.6 of a physician, when there was an “established need” for another three, which were covered by locums.

When junior international medical graduates were recruited they needed to leave Portland to be able to progress into the Australian medical workforce – due to their lack of local knowledge and experience it had been necessary to recruit more locums as well.

“In the consultation stage of this review it was a common reflection that the (graduates) lack confidence in their clinical decision making because of their junior status, the unknowns of the health system, their provisional registration, their fear of making mistakes not only because of their duty of care but they also need to succeed to access their planned exit out of PDH,” the report says.

“At the core of this issue is that the junior staff are recruited with the required career path being to leave Portland.”

Professor Hillis also pointed to issues with a lack of senior medical staff to supervise those working in the Urgent Care Centre – which the report says could be run by appropriately trained and authorised nursing staff, with medical practitioners being available around the clock and appropriate supervision systems.

“The model of medical coverage at PDH is strained with a mixture of international medical graduate junior and senior medical staff with Fellows of the College of Emergency Medicine on some day shifts,” the report says.

“There is no General Practitioner support within Portland, and there is a lack of onsite senior medical staff to provide a higher level of supervision.”

Recruiting more Australian-trained staff to supervise junior doctors was “difficult if not impossible” and the supervision requirements of foreign-trained doctors limited the possibility of recruiting them – “these requirements will almost certainly not change substantially as they have been actively and repeatedly reviewed over the past 20 years”.

“The impact of the junior and inexperienced profile is substantial particularly in the variability of clinical care decision making and also in the capacity of PDH to provide expected levels of care 24 hours a day,” the report says.

“This has substantial effects not only in the perceived service profile of the hospital but also on the community and ambulance service.

“With this variability… the ambulance service does actively triage patients away from Portland or are required to undertake transfer of patients between hospitals.

“This is very consuming of resources particularly when it is for observation only purposes.”

A previous report had highlighted a new model of care and workforce structure was required to make the Urgent Care Centre sustainable – and “minimise the number of ambulance transfers to Warrnambool” – which the rural generalist model would do.

There was virtually no direct clinical involvement by general practices with the hospital, with no desire to provide on-call services due to work-life balance needs and the significant workload on existing GPs.