GPs don’t need headlines and a truckload of statistics to tell them what they live with everyday of their working lives – general practice is in a parlous, and some says perilous, state.
Despite a string of health ministers paying the time-honoured lip service that primary care, with GPs at the heart of it, are the cornerstone of our health system, they have presided over an ever-expanding bureaucracy while watching real-term Medicare rebates plummet, workforce recruitment and retention dive and blunt-instrument policy pit health professionals against each other.
While Minister Butler has thrown down the gauntlet to the newly appointed Strengthening Medicare Taskforce to find $750 million worth of solutions, Medical Forum has asked some Western Australian GPs for their views on the challenges and solutions that will return general practice to the jewel in our health care crown. Read their views in the below.
We have also sent out a poll in our weekly digital newsletter. Some of those views are also published here.
There is no overnight solution to these systemic ills, but we want to continue to share your views that have been informed by experience and commitment.
Email your comments to the editor, Cathy O’Leary, editor@mforum.com.au
Too precious to lose
Emeritus Professor Geoff Riley has been clinician, academic and advocate for general practice for over five decades. He knows how much the system depends on primary care.
The estimable Professor Barbara Starfield, the former head of the Division of Health Policy at the Johns Hopkins University School of Hygiene and Public Health dedicated her career researching the impact of primary care on health services. She published three key findings:
- Primary care improves equity, or ‘health security’, through reasonably local ‘access to high-quality medical care’. But access is not just geographical – critically the access concept includes affordability.
- A health system with high quality medical primary care produces significantly better health outcomes for patients.
- It saves the nation enormous money.
Starfield makes these observations in the context of the US health system, which is regarded as the worst in the developed world. The US system costs nearly twice the average cost of the other 38 OECD nations and produces among the worst health outcomes measured by standard indices of population health, including maternal mortality, infant mortality, obesity, life expectancy and suicide rates.
Hospitals, medical insurance and ‘Big Pharma’ are largely privatised, and public health is a small rump. Of course, the corporate owners of the health system have no interest in a universal health care system and probably pay a lot to maintain the status quo.
US doctors are as well trained as anywhere, and this includes their family physicians. However, a major impediment to efficiency and effectiveness is the absence of gatekeeping. This means that the health system loses the ‘efficiency dividend’ provided by an excellent family physician service, and patients forgo the key health benefits of primary care – bespoke service, with continuity of care.
‘The Commonwealth Fund’ is a US health think tank. In 2021 it published its most recent version of the ‘Mirror Mirror’ report, which summarised its conclusions as follows:
“The top-performing countries overall are Norway, the Netherlands and Australia. The United States ranks last overall, despite spending far more of its gross domestic product on health care. The US ranks last on access to care, administrative efficiency, equity, and health care outcomes, but second on measures of care process.”
So, the care is good! The doctors are fine, but only if you are wealthy. The problem is the system.
By comparison, at least in the major centres, the Chinese health system has very high-quality tertiary hospitals staffed by doctors who for several generations have trained in Western medicine.
China also has universal medical insurance to the tune of 70% of fees, with a range of safety nets and other supports for patients with chronic disease, disabilities and the like. What China lacks is a modern general practice. It knows this, understands the urgent need, and is rapidly ramping up the training of Western-style general practitioners in the medical universities.
“When the dragon rises, it does so quickly,” but they know that it will take several generations before they can introduce universal gatekeeping. Meanwhile in its absence, hospitals in the more remote regions are assailed every morning by a crush of literally hundreds of patients, who arrive early at the ground floor and are eventually seen by very junior and poorly trained doctors.
Perhaps some of the bigger centres may have a few specialists, but in the absence of triage, an elderly woman seeking advice regarding her shoulder pain may be seen by the ophthalmologist, while a young woman seeking contraception advice might find herself talking to an excellent orthopaedic surgeon.
The Australian Health System is routinely rated as one of the best in the world. Our specialists and general practitioners are among the best.
Gatekeeping is an unfortunate term, but it results in substantial efficiencies. According to the Australian Bureau of Statistics, GPs see about 82% of all new contacts in the health system and they manage the great majority locally without referral to secondary or tertiary services.
This process of filtration, local management and triage, ‘protects’ the expensive tertiary system from unnecessary Emergency Department presentations, preventable admissions and outpatient appointments, and saves money by reducing overdiagnosis, overinvestigation and overtreatment. Our tertiary hospitals reap huge benefit from general practice through ‘gatekeeping’.
So why is general practice so efficient and effective?
It’s all about the personal and continuing relationship. Research has confirmed that being remembered, known, listened to, heard, believed, respected and properly responded to, are critical to patients.
This is not unique to general practice, I hear you say. And that’s correct. What is characteristic of general practice is a long-term, continuing relationship, resulting from earned trust and reinforced over sometimes years of contact.
G. Gayle Stephens, a doyen of US family medicine said that this relationship is characterised by “intimacy, mutuality, durability and born of the human need for other”. And he, like Michael Balint and legions of others observed that the relationship itself is therapeutic. Indeed Stephens explicitly recommended to family physicians “the emphatic use of the self as a therapeutic agent.”
Beyond that, General practice is characterised by:
- Generalism: comprehensive coverage of all ages, genders, cultures, diseases, organ systems, acuity and so on
- Early presentations of undifferentiated illness
- Safety-oriented diagnostic reasoning, including a ‘rule out’ approach, probabilistic thinking and use of base rates and Bayes Theorem
- Particular awareness of the psychological and mind-body interaction, styles of help-seeking behaviour, illness and non-disease, and social determinants of suffering
- Holistic, (whole person), ‘known’, understood worldview and sources of meaning.
- Personalised, bespoke care
- A biographical approach. The remembered ‘backstory’ saves time and money
- Opportunistic and planned health maintenance and disease prevention
- Coordination of care, advocacy, (referral and return) and integration of care (multimorbidity) and chronic disease management
- Maintenance of the most comprehensive health record.
The list could go on.
So general practice is critical to successful health systems and works very well, but in Australia it is now in crisis. ‘Crisis’ has come to mean ‘pending catastrophe’, but its etymology is based in the simple idea of ‘decision point’. Both meanings are relevant here. It is time for proper funding of general practice.
It is simply unfathomable that successive Australian Governments, far from properly funding general practice have been stripping money out of it for decades at the same time as pushing our system towards the failed US model. And it’s also pertinent to note that the very existence of gatekeeping comes with a moral imperative to ensure that general practice services are viable and therefore accessible and affordable.
It’s useful here to observe the parallels between teachers and GPs. Both largely comprise vocationally committed individuals doing very demanding front-line work with long hours, increasingly overburdened by bureaucratic administration, which significantly interferes with their core roles and their family demands.
Meanwhile, they’re feeling chronically underappreciated, undervalued and underpaid.
Clearly the last straw was the pandemic. Both groups are exhausted and disillusioned and, not surprisingly, both are leaving the professions in droves, creating an entirely predictable crisis.
Trainee teachers are walking away before they even complete their degree because they start to see what the future holds, and young medical graduates are not choosing careers in general practice for the same reason. Why would they?
Medicare rebates for general practice must be substantially increased. Now.
Nothing that money won’t fix?
Dr Brenda Murrison is a regional GP who has developed a network of practices throughout the southern regions of the state and in Perth.
Everyone will have an opinion on the reasons we have a crisis and many factors contribute to the reasons why, but the short answer is money – Medicare funding specifically.
Everyone knows that Medicare funding has not kept up with health inflation.
From 2010-19 health inflation was about 5% a year. State health, pharmacy funding and private health insurance all increased by about 5%. Medicare general practice funding increased by 0.5% by comparison.
Unsurprisingly, with so little money going into primary care, it has had a flow-on effect to recruitment and retention of GPs, specifically the number of registrars coming into the profession, which has nosedived from in excess of 50% or graduates a decade ago to less than 15% now.
Hospital wages have kept better pace with inflation so registrars in many cases need to take a pay cut to come to general practice, clearly this is not acceptable. By the time most registrars are heading into general practice they have other responsibilities to think about – cars, mortgages, student debt, weddings, partner, children and then the exam itself, which is an enormous expense particularly if you supplement this with the many expensive training courses around.
Just as well that general practice is the best career in the world!
I have no doubt that this was the case when I graduated and still is! Cradle-to-grave care offers variety, flexibility and infinite opportunities – as wide as your imagination.
I think this is time of great hope and promise of change. Early 2023, for the first time in 20 years, RACGP will be taking training back in-house, not just for GP registrars but for the other training pathways that International Medical Graduates (IMGs) must travel to get their fellowship here.
What we need to do is not copy what has happened for the last 25 years. Registrars and IMGs must train where they feel comfortable and supported – they should not be forced by conscription to work in the most rural, regional and remote areas.
Asking people to give up all their support networks involuntarily to work remotely is not and has never been the answer. However, money is again the answer.
To ask registrars and IMGs to give up all the entitlements they have accumulated is not fair. I am referring to their annual leave, sick leave and long service leave.
A better system would be for the hospital to sub-contract the doctors-in-training to suitable general practices at the base rate that they were on in the hospital, much like the PGPPP worked in the past. The practices keep the money that was billed by the doctors, which will hopefully cover the cost of their wages, in most cases it would.
Solutions are not simple though, and the obvious flaw in this scenario is what would happen to all those rural, regional and remote towns if we were to implement this?
Again, money is the answer. Medicare incentive payments need to be tiered depending on how remote the location is. The bulk billing incentive needs to be massively increased for the most remote locations. To be frank, if GPs feel appreciated and their skills rewarded by fair and equitable pay, they will return to these remote locations.
GP Bashing!
It’s not just a branding issue. General practitioners take a roasting from our specialist colleagues – you know who you are! GPs are not your interns, we are specialists based in the community who deal with literally everything and not one niche area. We need the support of our specialist colleagues – if there aren’t enough of us out there, who is going to refer to you? Or who will keep the hoards away from hospital?
But it is not just specialists’ support we need right now. We need to protect ourselves from the insidious creep of other professionals into the general practice space.
There is some sense to the argument that other people can do parts of our job description. Pharmacists, physiotherapists, nurses, paramedics, dietitians, the list could go on but none of them has done the training that specialist GPs have done.
Let me be clear on this, I do think that everyone should work to the full ability of their scope, but it needs to be done in a coordinated way, ideally through multidisciplinary teams based in general practice.
But first we need to save general practice as a business and this is another complex issue.
General practice business viability has eroded as the rebates have stagnated to the point that many practices are not viable, particularly vulnerable are the smaller practices. The costs of running a business are so high that you really need six to seven GPs working together as a minimum to be viable or accept, that as an owner, you will likely take home a smaller percentage than the contract doctors who work for you.
The only exception to that is to become procedural, which is no doubt why so many GPs do so much skin or cosmetic work to supplement their revenues. On top of that, practice owners have to worry about pay roll tax (6% in WA) and the threat of our contractors being reclassified as employees with a tax debt going back seven years. We are dependent on pathology incomes to remain viable, yet this is also under attack by the so-called Red Book pathology.
But I do strongly feel that hope is on the horizon.
We again have an opportunity right now in the Strengthening Medicare Taskforce, which is reviewing everything. I hope that they come to the obvious conclusion, fee-for-service has given Australia the reputation of being one of the best health care systems in the world. Our system has been admired by everyone.
Investing in primary care by normalising the Medicare rebates to where they should be and augmenting with patient registration – continuity of care should not be fragmented any more than it already is – and tiering Medicare rebates for rural and regional Australia would fix our problems of recruitment and retention and would have the welcome side effect of reducing pressure on our already stretched, expensive tertiary care services.
Common sense solutions? Too simplistic? Maybe, but we need to start somewhere and too many people are far too happy to criticise without any giving solutions.
Invest in Primary Care! The obvious solution.
Med schools’ role
Associate Professor Nahal Mavaddat is UWA’s Head of Discipline of General Practice and offers a medical school perspective.
General practice is in a crisis in Australia.
We are suffering a major shortage of general practitioners, especially in outer urban and rural areas. Our emergency departments and hospitals are not coping, in part due to lack of access to timely community care for patients. Many Australian GPs are considering leaving clinical practice or retiring altogether. Many of those who remain report significant burnout. GPs feel overworked but under-recognised despite their recent herculean efforts in the face of the COVID-19 pandemic.
What is a worrying prospect for the future of health care, though, is not only that GPs are leaving but that they are not being replaced, with only 15% of medical students across Australia currently choosing general practice as a specialty.
Discussions about bulk billing and remuneration for GPs are important. As an example, for the same time spent with a patient, mental health care provided by a GP is remunerated by Medicare at only one third of the fee for a psychiatrist.
While choice of specialty by a medical student may not be based solely on potential future salary, financial remuneration does play a role in student decisions about specialty training. Disparity of income between specialists and general practitioners, who typically spend a similar time in discipline-specific training, strongly signals a disparity in professional status, with the assumption that higher pay equates to greater knowledge and value of contribution.
It is frequently assumed that specialisation requires greater intellectual skill and academic prowess and that medical students who are not smart enough to enter the specialties choose general practice. This is a fallacy not supported by assessment of academic or junior medical officer work-based performance.
General practice attracts some of the smartest and most well-rounded students. Nevertheless, some of the best may reject general practice due to seeing it as a less competitive and intellectually stimulating career choice. (Manski-Nankervis et al. 2020).
The Australian Medical Schools Outcomes Database (MSOD) 2021 is often quoted as reporting intellectual content as one of the most important to medical student speciality choice.
In a UK study published earlier this year in BMC Medical Education, (Misky, et al.), studying perspectives of medical students, found they associated specialists with ‘broader influence’ and ‘academic work’, while generalists were assigned ‘lower prestige’, as ‘gatekeepers’ with a ‘lack of academic opportunities’ and if conducting research only doing so “if they had the time” and “without remuneration”.
Such perspectives are frequently reinforced within our own health care system. Many specialists reflect that they could never do the challenging daily work of a GP, yet the medical contribution of GPs is often minimised, with errors or omissions by GPs frequently being the only times medical students hear about GPs during their hospital rotations.
The low ratio of professors and higher-level academics within general practice compared to specialist departments at Australian universities is also telling. The academic GP workforce is ageing in Australia with a number of professors of general practice across the country having recently retired or taken redundancy without being replaced.
A loss of research-informed GP leadership within strong GP academic departments conveys to medical students that general practice “lacks rigour” (HODS Report 2021) and is not one to be chosen by those looking for an intellectually stimulating career.
So, what can medical schools do in this crisis to raise the status of general practice in the eyes of students?
Firstly, all medical schools must recognise their role in moderating health care workforce issues through perspectives acquired by students during their undergraduate medical training and act to address these.
In the case of promoting general practice, active steps to include GP teaching early in the curriculum, improving the quality of this teaching and role-modelling of good practice have all been identified as important to student choice of general practice as a future career and should be supported.
Thankfully, through the efforts of excellent teachers and GP preceptors at UWA, GP teaching comes early in the curriculum, includes opportunities for mentorship and pre-internship experience, and is highly valued by students.
Further, medical schools should take steps to value the discipline of general practice and demonstrate this through example. A “zero-tolerance approach to denigration of any specialty” by those involved in teaching medical students has been espoused. (Carlin 2021).
This should not only be enforced in all teaching settings – formal or informal – but the merits of general practice highlighted whenever opportunities arise. Attempts should also be made by medical schools to strengthen GP academic departments, bringing these in line with larger specialist research departments, thus allowing medical students to view general practice no differently to any other specialty in terms of intellectual content and opportunities for academic progression.
Specialist medical knowledge and skills have meant that our sickest receive the best medical care that scientific advancements and technology can offer. However, this achievement is not reflected in the overall health of our population. Chronic diseases, including obesity-related illnesses, and an ageing population with multiple comorbidities continue to ravage the Australian population.
Solutions to these pervasive healthcare problems require new models of care. Item and fee-for-procedure-based remuneration, with an overreliance on sub-speciality treatments, have contributed to the US becoming the most expensive health care system in the world without evidence of world-leading outcomes.
Analysis of cost-effectiveness and value in health care suggests the essential role primary care must serve, highlighting it as the best place to invest financially to produce better and more equitable health outcomes.
Proposed models must also support a radically different approach to the management of chronic disease. This cannot be achieved by six-minute “one appointment, one problem” medicine. Universities and medical schools have a role in proposing such models and evaluating them.
However, the real contribution of medical schools in addressing the current health-care crises at a fundamental level may not lie in endorsing any particular model of care, but rather in promoting generalism within medical school curricula as an engaging and intellectually stimulating academic discipline in its own right, with its own methodologies and applications.
The world outside medicine has already acknowledged that we may have swung too far in the direction of specialisation and reductionist approaches to the solution of complex problems and is supporting a return to generalist knowledge, looking at the wider picture and of systems thinking – that is understanding the relationships between parts.
In the context of health, this means more than simply knowing the factors that impact on health and disease, but rather knowing how they interact. Medical sciences though “remain largely taught according to a specialist-based, compartmentalised approach”. (Fleming et al. 2017).
When generalism is valued and taught during training, and matched in the clinical environment with appropriate remuneration for the significant intellectual contribution made to patient welfare, we may see more choosing general practice.
References on request
The system needs us
GPs are lynchpins of the health system. Dr Sean Stevens says no government can afford to see general practice go under.
I’ve been in general practice for 25 years. Throughout that time, we have repeatedly been “at the crossroads” and “in crisis”, yet somehow we always seem to pull through.
In the 1970 and ’80s, the Labor party was going to nationalise medicine with this draconian beast called Medicare. Vocational registration was introduced enforcing “unreasonable and unpaid” requirements on the profession. In the ’90s, accreditation of practices was another “unnecessary layer of bureaucracy”, and compulsory GP training was “unnecessary and unreasonable”, the rapid corporatisation in the late ’90s and early 2000s was going to “destroy the fabric of general practice forever”, and I could go on.
Today we face increased sub-specialisation of our medical colleagues; scope creep from allied health, inadequate indexation of Medicare rebates, increasing chronic disease, the COVID pandemic and dwindling numbers of doctors entering our profession.
I am, however, supremely confident we are up to the task, just as we were in the past.
We are the cornerstone of the medical system, ensuring that our patients are seen, treated and appropriately triaged. Unlike America, patients can’t refer themselves off to an ENT for tonsillitis and end up with an MRI, serum rhubarb and a tonsillectomy!
General practice is the most efficient part of the health system, and, despite taking us for granted, the Federal Government knows it, and we shouldn’t forget that.
So, how would I suggest that we save general practice?
I think the first thing we need to do is break the reliance on bulk billing. There’s one thing I can guarantee – the Government will NEVER re-index the lost Medicare Freeze, and it will continue to index Medicare well below inflation.
I think of it like counselling our patients. You can’t make the other person change, you can only change your own behaviour. The RACGP and AMA will not get traction on these issues while the rates of bulk billing are so high.
Next, I would encourage more junior doctors into a career in general practice.
I think GP is the best job in the world, and we just sell it poorly. If we look at the determinates of a happy life, general practice has them in spades – family relationships, work fulfilment, community and friends, leisure time.
Yes, our procedural colleagues will earn more, but they suffer much higher rates of divorce and burnout and have much less time for community, friends and leisure time.
I don’t think another advertising program is going to solve this issue. The key is providing exposure in the pre-vocational years to high-quality mentors and practices who have a positive outlook on the profession. These attachments will show junior doctors what we do before they get polluted by the jaundiced view that pervades some areas of the tertiary system.
Concerning scope creep, I think having more GPs will help provide the services that allied health are seeking to take from us. I also believe we must stick to our argument of patient safety first.
The view that treating a UTI, for example, is a simple intervention that doesn’t need a GP is erroneous. Only GPs can screen for other illnesses, conduct preventative health, order the appropriate investigations and follow the patient up.
I completely agree with my colleagues that we are facing some strong headwinds, but I do not believe they are any worse than they have been in past times.
We, in general practice, remain the cornerstone of the health system, and while we do have some work to do, I still believe we have the best job in the world.
The clock is ticking
It’s now or never for Medicare reform, says WA Primary Health Alliance CEO and Strengthening Medicare Taskforce member Learne Durrington.
Recent media headlines reflect increasing concern over the vulnerable state of primary care, causing too many patients to either fall through the cracks or inappropriately present at emergency departments. These patients have chronic and complex care needs which can be well managed in a thriving primary care setting.
A perfect storm is brewing, with more medical graduates rejecting general practice as a career option – for every new GP there are 10 new non-GP medical specialists – and a projected GP workforce shortfall of 11,000 by 2032, representing almost 30% of the GP workforce.
Equally concerning is the rapidly declining bulk billing rate in general practice, as more and more practices find this financial model untenable against a backdrop of increasing chronic disease and relentless cost of living pressures, which are hitting those who need access to primary care the hardest.
The skills of many health professionals are not being used, funding models do not encourage general practice outreach and nor do they reward multidisciplinary care.
During a recent conversation I had with health economist Dr Stephen Duckett, he reflected that while the world has changed since Medicare was introduced in 1984, primary care funding, governance arrangements, and systems have not.
The Australian Government’s recently established Strengthening Medicare Taskforce clearly has its work cut out to identify the highest priority reforms, referencing the Primary Health Care 10 Year Plan by the year end.
A strong signal of the government’s commitment is the leadership of Minister for Health and Aged Care Mark Butler at each meeting, and, reading the room of health leaders representing a cross section of primary care perspectives, there is a spirit of optimism, partnership and collaboration.
Taskforce members recognise and respect the challenges of demarcated spaces and have a genuine intent to work through these in the interests of improving equity and access, and better supporting people with chronic and complex health conditions.
While my appointment to the taskforce is as an individual, I will represent the national Primary Health Network program. I also have an ear to the ground within WA thanks to a GP advisory panel, a joint initiative of WAPHA, Rural Health West and the RACGP WA, and various community reference groups.
Prior to the first taskforce meeting, members were asked to articulate their vision for the primary care system in the future. I am hopeful that we can continue to strive towards an integrated, co-ordinated primary health care system that delivers high quality patient-centred care with leaders across the health system united in the pursuit of the Quintuple Aim – best possible health outcomes, best use of resources, workforce experience, patient experience, equity and accessibility.
We cannot take a one-size-fits-all approach to general practice funding, business models and models of care. It is equally important to have variety and status for GPs (working to top of scope) to redefine it as a profession of choice.
New business models shouldn’t result in over or underservicing and data must be used to demonstrate the value of primary care against the Quintuple Aim.
Taskforce recommendations for changes to primary care must be actionable and sustainable, with $750 million on the table to turn the proposals into concrete actions for a person-centred primary care system.
We conducted a poll in our weekly newsletter.
Here is some of what doctors had to say:
Q. What are the two most urgent issues that governments need to address to alleviate the immediate threat to the viability of general practice?
- Workforce maldistribution
- Decrease administrative burden
- Patients need to change their attitude towards doctors
- Stop giving pharmacists/nurse practitioners our work
- Stop corporate clinics ripping off Medicare
- Fund us and you won’t need as much expensive tertiary care
- Get more medical students interested in a GP career
- It is impossible to run GP in remote rural and poverty- stricken areas.
* All respondents cited vastly improved MBS rebates needed
Q. If you are considering leaving general practice, what would make you stay?
- Nothing that I can see happening. I’m off soon
- Anything to make the job easier – as my patients have aged, my
work has become increasingly complex, and every day is a slog - Love for medicine and helping patients
- Access to salaried employment with paid leave benefits and super
- I am a solo GP and have not had a holiday longer than two weeks in 38 years. This year I have only been able to take a three-day holiday
- I earn more money as a hospital registrar than I do as a specialist GP. Start there.
Q. What is a key long-term solution for the health system’s current woes?
- Increased rebates for GP urgent care and better funding for coordinating care
- Halve the bulk-billing rate BUT double it for patients who are registered with a practice
- Start by engaging GPs in government policy decision making. We know how to make the system work better for patients, providers and government. Ask us how
- Show that GPs are really valued for their skills and not treat them like referral makers and sickness certificate fillers. Encourage our specialist colleagues to see their own GPs to understand what we do instead of self-referral after a corridor consultation with another specialist
- Combining state and federal health to create a national service.
Q. Are you confident that the new Federal Government will make any meaningful changes?
- 88% of respondents answered an emphatic no
- 12% were maybes
- 0% said yes.