This page briefly outlines some of the more prominent practice models in use in regional Australia. It also covers some innovative models designed to operate in those environments subject to chronic workforce shortages.

The Traditional Rural Practice
The main feature of this model is that the GPs are “owner- operators” with a long-term commitment to the practice and the community. The GPs carry the principal management responsibilities and in group practices would use partnerships or associateship arrangements to disburse revenue and costs.  Often the GPs own the practice premises and may have invested significant capital in equipment and other facilities. This model has served rural Australia well for many decades but its viability is at question for the following reasons:

• Return on business investment is often less than other investment options
• The market value for rural practices appears to be decreasing. In the case of solo practices the market value may only equate to the value of the physical assets.
• The cost of doing business in rural areas is considered to be higher than urban areas- freight, communications, petrol, etc.
• The financial returns for services are often less than urban practice. Many rural practice bulk-bill in recognition of the depressed economic status of rural towns.
• GP workforce shortages undermine the stability and financial viability of the service.
• There are often intractable difficulties in securing cost-effective locum cover to allow planned recreation leave.
• The complexity, demands and risks of clinical practice are higher in rural areas. e.g. after hours work, procedural work such as obstetrics, etc.

In response to these pressures the Federal Government and some State Governments have enacted a host of financial subsidies and other support measures for rural practices. However, the future of the model remains questionable.

The Walk-In /Walk-Out Practice
This model is also known in some States as the Easy Access- Gracious Exit model. This approach allows a GP to join a practice with no capital outlay and no obligation to undertake practice management responsibilities.  The incoming GP has no employment or practice management responsibilities. In some cases the practice is owned and operated by the LGA. As a variation the LGA owns the facility and leases it to a private practice management company. GPs may elect to act as independent contractors, or alternatively, are employed by the practice operator. The approach operates on the premise that GPs will be more likely to stay if they can avoid business risks and are more likely to experience work satisfaction if they can avoid the tedium of business management responsibilities. The model serves to allow GPs to establish a good work/ private life balance. The principles of the WIWO model can be used with a number of the following approaches.

Out-sourcing Practice Management Model
This approach allows the practice owner to “out-source” its business management needs. Some GP principals in Tasmania have opted for this approach. Under this model the practice owner contracts with a practice management company (e.g. TASPRAC) to provide specified business management services. Contracted services may include a mix of the following: GP recruitment, practice reception services, patient billing services, credit management, staff rostering, etc. In this case the practice owner retains the overall business risk but allows busy GP principals to purchase a desired package of business support services.

Serviced Medical Suites
Under this paradigm the practice owner pays a facility charge for the receipt of practice support services.  A component of the payment would cover the rent on the surgery with the balance covering reception services and utilities. The practice owner would remain the operating agent and be responsible for all other practice and business management responsibilities including clinical consumables. Some GP practices operating in Tasmanian DHHS facilities function on this arrangement. The attraction of this model is that the incoming GP does not need to purchase a practice and gives them the option of avoiding staff employment responsibilities. In some instances practice nurse services can be built into the GP’s facility charge. 

The Fly-in/ Fly-Out model
In the most remote areas of Australia GP staffing can be extremely problematical. With small populations and vast distances a visiting GP service may be the only option available to these remotest of communities.  In general these arrangements are unviable under existing revenue arrangements and as such require ongoing subsidization by government.

The District Hospital  with a collocated GP Clinic e.g. St. Marys Hospital
In this case the rural District Hospital and the GP surgery are collocated.  Often staff, clinical infrastructure and equipment are shared. This approach produces economies of scale and is perhaps most appropriate in small communities where the population does not support a standalone GP practice. In some States the doctors are primarily remunerated through their hospital work but may have rights to private general practice to enhance earnings. In situations where maintaining the critical mass of clinical expertise is problematic then this approach may be indicated. Collocating health professionals allows for mutual support and helps resolve the fragmentation that hinders service delivery.

In some settings GPs operate a private general practice on the Hospital campus. The practice effectively leases rooms in the hospital but may utilize hospital facilities such as treatment rooms. When the private practice is “embedded” within the hospital a range of issues need to be resolved including the mechanism for apportioning costs for clinical consumables and practice support staff time.

DHHS may choose to contract an independent Practice Management company to recruit GPs and operate the practice.

The Multipurpose Centre (MPC)  with a collocated GP Clinic e.g. Nubeena
The principles outlined in the previous model apply equally in the case of Multipurpose Centres (MPCs). The MPC concept involves the collocation of a range of rural health services including a small A&E annex, aged care beds and a small number of acute beds. In some cases the MPC operator may contract an independent Practice Management company to recruit GPs and operate the practice (e.g. Gemini Medical Services).  The practice manager could be local or alternatively may adopt the remote practice management model explained next.

The Remote Practice Management Model  e.g. Nubeena and Gemini Medical Services
Under this paradigm a company (Gemini) delivers practice management services to a range of dispersed sites from a central location. An agency such as an LGA or a Rural Hospital contracts the company to recruit GPs and supply medical services. This approach may run in conjunction with the aforementioned models. For example, a company based in Hobart could contract with a number of rural LGAs to operate practices in Council-operated MPCs.

The Rural GP Super Clinic Model
This model is an extension of the Australian Government's GP Super Clinic Model.

This approach has application in those regions where it is considered essential to maintain comprehensive health services but workforce shortages will put the resident providers under unmanageable stress. In these circumstances an innovative approach might see services redesigned to ensure continuity of  the desired suite of services; -community general practice, hospital inpatients, residential aged care, etc.

Note that the "sphere of concern" for this model extends beyond traditional community general practice. It seeks to undergrid the sustainability of all associated rural health services.

With deficient "resident" healthcare professionals service provision may need to involve new modalities provided from an urban-based GP Super Clinic . The premise is that an urban-based clinic will be more successful in attracting and retaining healthcare professionals willing to support rural communities. This "Rural GP Super Clinic " would be tasked to support services in a specific regional area as follows:

• Telehealth medical consultations for rural inpatients in the catchment area
• Telehealth medical consultations for rural residential aged care in the catchment area
• Face to face GP services (on referral from Primary Health Nurses working in the catchment region)
• Limited visiting GP services (to treat high-need rural patients considered unable to travel)
• Limited visiting specialist medical services (to treat high-need rural patients considered unable to travel)
• Allied Heath services (on referral from Primary Health Nurses working in the catchment region)
• Day-stay procedures (lesion removal, biopsy, point of care testing, etc)

To render this model workable there would need to be:

• Patient transport options to ensure that referred patients had access to the urban-based Super Clinic
• Re-delineation of services within the catchment as consistent with the new model of provision
• Repurposing (and retraining) of the regional workforce to allow them to assume the new roles
• Remodelling of service infrastructure (e.g. installation of video-consultation suites at the rural hospital)
• Development of the technical infrastructure (e.g. telecommunications, computerisation, health information systems, etc.)
• Introduction of new workforce roles, if required (e.g. Rural Nurse Practitioners, Physician Assistants,Cert 4 Medical Assistants, etc.)
• Integration with the other arms of the regional healthcare system;  ambulance, teaching hospitals, after hours care providers, etc,
• An appropriate system of triaging to ensure that the "right patient is treated by the right healthcare provider, at the right time, to optimise patient outcomes and ensure cost efficent service provision".
• Due consideration of the non-clinical "products" of a rural health delivery system such as undergraduate multidisciplinary training or research.

Each of these models presents opportunities for customisation to suit local preferences and circumstances. Careful consideration is required to ensure that an optimal mix of the following is identified:

• Workforce options: (General Practitioners, Nurses, Nurse Practitioners, Ambulance Paramedics, Allied Health; Pharmacists; Cert 4 Medical/ Therapy Assistants, etc.)
• Service modalities:  (face to face, telehealth, selfcare, clinic-style)
• Service mix; (GP services, A&E, hospital care, aged care, palliative care, mental health, etc)
• Level of interventions:  (primary health, hospital outpatient, hospital admission) 
• Technologies: (videoconferencing)
• Patient transport options (ambulance, regional health shuttle, etc)
• Funding mechanisms (fee for service, casemix, capitation)
• Employment arrangements  (award-based, private contractors)
• Management options (on-site, remote, integrated, sector-specific)