Most people usually only see a final policy announcement, but the advocacy that leads to that moment is often slower than you may think. Some of the most important work happens behind closed doors, in stages, and frequently over long periods of time.
As GPs, we become expert at and comfortable with solving complex medical problems by using time, patience, iterative interventions, patient education and the synthesis of multiple influencing factors that impact patient outcomes. Think diabetes care, any mental health condition, heart failure.
Interestingly, these are the same skills that good advocacy requires: listening to members, understanding different perspectives, gathering evidence, building relationships, staying engaged over time and working through competing priorities.
Effective advocacy requires a sense of curiosity to genuinely understand an issue, the perspectives of each stakeholder and the patience to invest generously in each one’s understanding and commitment to addressing the problem at hand.
Supporting the Next Generation of GPs
Prior to 2023, recruitment of doctors into general practice training was below target. Hospital doctors cited a stark drop in income from their hospital salaries to first-year GP training earnings as the single biggest barrier to choosing general practice as a career. At the time, the Victorian Government was also seeking ways to boost medical workforce, having recognised limitations in available services during the pandemic.
Advocacy to better support GPs in training was not new at that time. It had been a topic of discussion in state and federal arenas for some years. But as the Victorian Government started examining workforce capacity, the opportunity to address the known barriers and collaborate on designing solutions emerged. This opportunity was realised because the conversation had already been started and the concept was not new to government. Familiarity with the situation enabled policy makers to incorporate the GP training issue into the wider suite of solutions for boosting workforce in Victoria at the time.
Those years of conversation prior had developed trust with government that acted as the foundation for collaboration. We had worked together solving myriad other pandemic challenges and a respect for genuine intention to improve the Victorian health system was well established.
We suggested a forty-thousand-dollar grants program to support doctors entering GP training in Victoria: a 30k payment to address the drop in income and 10k to help cover the costs of fellowship exams.
The government agreed and committed to a 2-year program.
We had listened to trainees about their barriers. We had spoken to the government about its workforce needs. We had suggested an intervention that addressed both.
The program was so successful, other states sought to set up similar grants programs to retain and train GPs in their own locations, causing iterative changes to unfold around the country.
With multiple states boosting GP training numbers with the simple yet hugely impactful action that addressed lost trainee income, we then had a compelling, evidence-based and success driven story to take to the federal government to advocate for a permanent first-year trainee payment program.
The federal government, similarly committed to increasing GP workforce agreed, and the result has been more GP trainee applicants than ever before in the history of GP training.
For patients, practices and communities, that outcome matters.
Lessons From Successful Advocacy
Why does this story matter?
It matters because Australia needs more GPs and doctors were unable to enter GP training because of the intense financial pressure the drop in income put them under.
But more than that, it matters because it paints a picture about what is required to do advocacy well.
Advocacy is recognising that change does not happen overnight.
It takes genuine curiosity about an issue and preparedness to do invisible work. It requires relationships and trust. It needs solid, credible evidence and a good deal of persistence. It demands strong representation and a commitment to collaborate.
Finally, it requires an acceptance that you are there to produce practical, tangible results, many of which are obvious to your stakeholders, some of which may remain largely behind the scenes.
“In this world, nothing can be said to be certain except death and taxes,” said Benjamin Franklin in a letter to his friend Jean-Baptiste Le Roy in 1789.
He wasn’t the first to say it. He pinched it from Defoe’s The Political History of the Devil (but let’s not go there.)
It’s since become a catch cry for modern life, its myriad uncertainties and the two great swords of Damocles – death and taxation.
As an optimist, I read into it that almost anything else can be fought for, saved, rescued or advocated for.
As a realist I read into it that everything else will need to be fought for, saved, rescued, advocated for.
Rural general practice sits firmly in that category. Many speak about its decline as though its death is inevitable. I don’t believe it is.
Why Rural GPs are Worried
In six years as Chair of Victoria at the RACGP, I have spoken to hundreds of GPs, practice managers and registrars; concern about the viability of rural practice is real and needs to be treated with respect.
Yet despite these challenges, I remain optimistic. Not because the problems are small—but because we already know many of the solutions.
Rural GPs face enormous workloads and relentless on-call demands, have fewer opportunities for leave, can be professionally isolated, and are at high risk of burnout.
The Funding Model is No Longer Sustainable
We have said it repeatedly and we’ll say it again now: Medicare rebates have been so poorly indexed over 25 years that many rural practices now lose money performing procedures. The cost of equipment, consumables and staff has risen well beyond the rebates paid to provide care.
Some GPs are effectively subsidising essential healthcare from their own businesses.
When I ask them why they do not charge a fee to at least cover the equipment costs, they just state flatly that patients now believe gap fees are outlawed and many become angry or simply refuse to pay.
When we turn the discourse to funding, the immediate riposte is the “greedy doctor” narrative that generates resentment from the public who now expect everything in general practice to be done for free. The fact is, expert generalists deserve to be remunerated for their lifetime of training, the extraordinary levels of responsibility they shoulder, the long hours of on call, their skills and knowledge and the risks they take in operating businesses in difficult circumstances. I have never read an article or political commentary that derides greedy pharmacy owners. That particular stiletto seems only to get lodged in the backs of doctors. And while self-sacrifice still seems to be synonymous with virtue in medicine, a GP can’t put their kids through school only banking virtue.
Red Tape is Taking Doctors Away from Patients
Rural GPs are also spending disproportionate amounts of time on administration, compliance and regulation requirements. Australia has a very proud history of high standards in medicine, but every hour spent on paperwork is an hour not seeing patients and not generating an income.
The system urgently needs to ask which administrative requirements improve quality—and which simply consume time without improving patient care.
Workforce Shortages are About More than Recruitment
Rural practices are also perennially challenged by attracting and retaining adequate workforce. We often read about doctors not being willing to go rural, but in fact the issues that hamper them are often structural and systemic. A rural town may not have adequate housing, childcare, schools, employment for non-medical spouses and opportunities for non-medical pursuits. It can also be very difficult for rural GPs to take leave and to access ongoing professional education. And even the most self-sacrificing GP will think twice before committing to a roster of endless on call because no adequate back up is available. What we need is to attract, train and retain rural GPs and to do that we need to retain the entire medical family.
The Old Model of Rural Medicine is No Longer Sustainable
And while we often hear nostalgic and misty-eyed praise of the rural GP of the past who worked 6 days a week, saw 60 patients a day, was on call for months at a time, and required a full-time stay-at-home spouse in order to survive, we have to be brave and recognise that that model of medicine is not sustainable, reasonable or safe. It’s an anachronism.
Meet Henry. He’s part of the team at my practice. Lately he’s been demonstrating exactly how many rural GPs are feeling…
Rural Practice Remains One of the Most Rewarding Careers in Medicine
Despite these challenges, most rural GPs love their work, love their communities and espouse the satisfaction and value of their profession.
The Broadest Scope of Practice is Medicine
For many doctors, the appeal of rural practice lies in the clinical autonomy, enormous variety and scope of practice and deep connection to their patients. Rural GPs deliver the full continuum of care—treating generations of families and whole communities, performing myriad procedures, often with admitting rights at local hospitals. They often have advanced skills in obstetrics, anaesthetics, general surgery, palliative care, emergency medicine, paediatrics. These people are the Swiss Army Knives of the medical world and can deploy their skills in a variety of settings.
When things go wrong, there are few doctors with broader skills than a rural GP.
If you find yourself in a survival situation the best thing you could ask for is an Australian rural GP. Any doctor whose emergency skills include liaising with the local vet to keep the supply of atropine flowing is no ordinary clinician.
Why Burnout Remains the Greatest Threat
But while rural GPs report high satisfaction and love of their work, they are also the most likely of all the medical professionals to experience burnout. It is the huge and relentless workload followed by administrative and systems barriers they cite as the leading problems.
The Solutions Already Exist
The encouraging news is that none of these problems are beyond our capacity to solve. We already know what works. The challenge is having the leadership and the courage to implement those solutions consistently.
Listen to those Working on the Frontline
Over the past six years, I’ve spent a great deal of time visiting rural practices and listening to GPs, practice teams, supervisors, registrars and the communities they serve. One lesson has become abundantly clear: the best rural health policy is not designed in isolation. It is built by bringing frontline experience into every advocacy conversation and turning it into practical, evidence-based reform. That is how lasting change is achieved.
We can’t make rural GPs immortal, and we can’t stop their requisite yearly homage to the Tax Man, but we absolutely can prevent their profession from decline.
Strengthen Rural Generalism
Rural generalism is now a recognised specialty of medicine which is bringing recognition, respect and a protected title to the profession. More trainees than ever are enrolling in RG pathways and taking up advanced skills. To consolidate on that trend, we need rural health services to create positions for RGs to use and retain their skills. Country hospitals need to welcome RGs with open arms so that the vision of the Collingrove Agreement can be realised: highly trained GPs working in local general practice and utilising advanced skills in local hospitals and community settings, thereby bridging the gap between the two. The Single Employer Model seeks to realise that opportunity but applies only to some trainees. Its intent must be replicated in permanent positions post fellowship. We must also remunerate a GP’s advanced skills in recognition of their value and the huge relief those skills bring to the health system at large fiscally, logistically and geographically.
Support the Supervisors Training the Next Generation
Rural training and workforce pipelines can only flourish, however, if there are adequate supervisors available to support incoming trainees. Alongside RACGP’s huge success in recruiting more registrars into rural practice is the repeated call to properly remunerate supervisors for the time, effort and commitment they make to teaching the GPs of the future.
You can’t do everything for the love of it, and we can’t keep rewarding people who do more by giving them less.
We also have a precious opportunity to make the trainees of today into the supervisors of tomorrow if we get that model right.
Protect Professional Autonomy
Significant positives in the world of rural health include the many grant opportunities, RG support, government focus on rural medicine, financial incentives loadings and local workforce solutions that GPs can consolidate on to meet the needs of their communities. But remember what brings GPs the greatest satisfaction and protection from burnout: autonomy and relief from unnecessary red tape. Rural GPs must be left with the autonomy to bill and to practice medicine independently. Handcuff them to funding restrictions, limit their ability to innovate and build bespoke multidisciplinary teams, or preclude them from using their skills and capacity independently and their communities will suffer and they may walk away.
Recognise the Contribution of International Medical Graduates
One group deserves far greater recognition in this conversation. More than 50% of GPs in Australia are international medical graduates. Many IMGs have committed their lives to the service of rural communities. In fact, Australia’s health system would have collapsed decades ago were it not for our IMG community working in general practice and every other specialty. Their story has been woefully overlooked in the story of our health system. Many of our own systems make entering our country and flourishing in medicine orders of magnitude more difficult than it needs to be for IMGs. We have also an urgent need to create attitudes of celebration and gratitude for their service to replace darker narratives that have long existed.
Rural Practice is Worth Saving
When I think about rural GPs I think resilient, intelligent, resourceful and deeply committed. I don’t think they are inexhaustible. They are human.
I know that the future should not be designed from Canberra alone, but our federal funders are key stakeholders in our vision for a robust, equitable and sustainable rural general practice. In the modern age of co-design, the very best thing we can do is ask our rural GPs and their patients what is needed to secure their collective futures and to act on that advice.
Rural practice doesn’t need sympathy. It needs sensible policy, genuine respect, and leaders willing to back the doctors who have been holding rural Australia together for generations.
