The "complete reliance" on visiting medical officers (VMOs) in regional hospitals can mean malpractice can go unchecked for "decades", as demonstrated by the now-banned gynaecologist Emil Gayed at Manning Hospital, a submission to a NSW parliamentary inquiry says. Gayed was found guilty of professional misconduct and had his medical licence suspended by the NSW Civil and Administrative Tribunal in 2018 following allegations of the unnecessary removal of reproductive organs, unnecessary or wrong procedures, perforations of organs and a reluctance to transfer to tertiary facilities. In a submission to an inquiry into rural and regional health care, Dr Nigel Roberts - the director of obstetrics and gynaecology at Manning Hospital - said due to a lack of rural staff specialists, the hospital had become overly reliant on a few VMOs - particularly Gayed. Related reading: Dr Roberts believes that with appropriate governance and oversight, Gayed's malpractice would have been picked up years earlier, and prevented the suffering of hundreds of women. "Gayed worked in the hospital for 16 years, and within nine months of me being there, he was not able to operate in Australia again," Dr Roberts said. "It wasn't an accident that there was a staff specialist appointed as a director there, and then these events were discovered." He is calling for an "appropriate balance" between staff specialists and VMOs in regional areas, and for the NSW government to incentivise working as a staff specialist in regional hospitals. "Without VMOs, the system wouldn't work," he said. "But when there is a complete reliance on VMOs, when adverse events happen, there is often no one who has the time or is appointed to provide that governance and oversight that a department within a hospital needs." Dr Roberts said within the VMO model, women would be referred to Gayed who would see them in his private rooms but perform their surgeries in the public system. "Then she would go back to see him in his private rooms for follow up," Dr Roberts said. "There was no oversight within the hospital system as to whether that patient actually needed that surgery he booked, whether it was the appropriate operation, whether the appropriate investigations were performed, and whether those investigations supported the operation." Gayed also worked in Grafton and Kempsey. "We can't ignore these problems. We have got to put in the mechanisms to stop it happening again," Dr Roberts said. "What happened with Gayed in obstetrics and gynaecology, it could be happening with other specialties right now in other hospitals because of the complete reliance on VMOs and the lack of directors, who are staff specialists, to oversee the governance of safety issues." Dr Roberts said it was difficult to recruit staff specialists to regional areas. "They might start as a staff specialist and then change to a VMO because it is potentially more financially rewarding," he said. "If I was a staff specialist in a big tertiary hospital, where there are 30 other doctors in my specialty, you might have to be on call once a month, maybe twice. "In a regional area, because there are fewer doctors, you have to be on call twice a week, and you're not paid for on call as part of the state award. "Whereas if you are a VMO, you are paid for on call, you are paid when you get called in." Dr Roberts said in addition to that, staff specialists would have "almost certainly" been training in a city. "So they have to move house, their spouse probably has to change jobs, the kids have to change schools - it's a big deal to get someone to move from somewhere they have set up and lived as a trainee to move to a regional area," he said. "To do that for more on call but the same amount of pay is not working in NSW, and that's why I believe NSW is having more problems with it than Queensland. "The government has to incentivise working as a staff specialist in regional hospitals so we get more of a balance." Dr Roberts said he hoped the inquiry into rural and regional healthcare in NSW would provide the impetus for the changes needed.