Obtaining first-line medical attention at night, especially if the patient is house-bound, has become increasingly difficult. Proposals to improve affordable access to such services need to take account of changing urban structures, medical culture and community expectations.
The Medical Benefits Schedule Taskforce has announced its findings on the funding of “urgent after-hours primary care”. This is not before time. Its recommendations are aimed at appropriate reimbursement to patients. The review has been prompted by the vast sums paid annually to doctors, or to their employing organisations, for providing these services.
The taskforce wishes to appropriately reimburse “GPs who provide after-hours care to their patients in addition to seeing their patients during their normal working day”. The taskforce “was of the strong view that a patient is best treated by their regular doctor as this facilitates continuity of care”.
That pious aspiration would be endorsed by any sensible observer. But such doctors, at least in our large cities, are as rare as diamonds. Indeed, they have not existed, other than in smaller towns and rural areas, for decades.
When I commenced work in a general practice in an affluent Sydney suburb in 1966, my colleagues and I were rostered on every third night for after-hours and weekends, in addition to our daily darg. Our practice maintained this service until some years after I retired in 1990. The burden of after-hours, in the mid-’60s and ’70s, was such that I would be called out of bed, on average, four times each night I was rostered on!
By the time I retired in 1990, improvements in medications meant that it had become once in six weeks. But such service no longer exists in urban areas. Why has it disappeared?
- Poor rebates for out-of-hours work – Most suburban practitioners felt, rightly, that the Medibank/Medicare rebate for out-of-hours consultations was so paltry that it was not worth the disturbance, lack of sleep and consequent effect on the next day’s darg. Commercial after-hours services found their market. A doctor doing a night shift could be directed, profitably, to many patients in several suburbs each night. We maintained our own service, but charged more than double the Medibank/Medicare rebates. GPs in less affluent suburbs stopped offering such service.
- The feminisation of the GP workforce – With more young women gaining entry to Medicine, women became 60% of our graduates. To become a ‘vocationally registered’ GP (see below) requires several years of post-graduate training. With the average age of Australian women having their first baby being around 29, I leave it to you, dear reader, to imagine what that does to most women doctors’ careers. Despite being the father of two doctors-daughters, I have been lambasted aplenty over the decades for such truthful, but non-PC, comments. I have written previously, in my years as Chair of the AMA’s Federal Council, urging female medical students not to become cannon-fodder in urban commercial (corporate) general practices, none of which, to my knowledge, provides after-hours service. But that is where many women doctors have ended up. The office-hours, often 0900 – 1500, combine conveniently with mothering duties.
- Parking – During my years in practice, local councils recognised how much more they could gather in rates by allowing houses to be demolished and replaced with blocks (often tower blocks) of apartments. Where a quiet, narrow street-block might once have been home to a dozen or so families, each with one car, the plethora of apartment buildings, with minimal on-site parking for residents, soon led to these same narrow streets being choked with residents’ cars. By 1990, I would almost always have to park illegally at night, leaving a sign on the outside of the driver’s window and on the dashboard ‘Doctor on urgent house call’ – and hope for the best. And also hope not to be mugged when returning to my car. This change in urban culture was hard enough for men, but for women practitioners, questions of personal safety at night became serious. So which of the few female GPs in a traditional practice would venture out alone at night, carrying a doctor’s bag, known to contain morphine and other opioids?
Quality of Care – Doctors who qualify as fellows of the Royal Australian College of General Practitioners are ‘vocationally registered’ (VRGPs). Medicare provides higher rebates paid for all their services. These doctors sign an agreement that they provide after-hours services for their patients. The RACGP and those overseeing Medicare have known for more than 30 years that this requirement is almost universally observed in the breach.
The late Adjunct Prof Amanda McBride, who sat up night after night on weekends, phoning practices around Sydney and checking on their recorded messages, found that almost all referred callers to the local hospital or to a deputising service.
When I or one of my partners was called, out-of-hours, to a patient of the practice, but not someone we knew personally, we would call by the surgery, collect the records, make notes that night or weekend, and report to their doctor the next working day. Friday lunches were briefing sessions about sick patents for the doctor on weekend call. Nowadays an unknown doctor from a deputising service attends the patient with no information other than that which the patient can tell him – assuming that the patient is well enough to do so!
While I applaud the Medical Benefits Schedule Taskforce for seeking to save taxpayers’ money, I caution that any hope of patients “being treated by their regular doctor” is a pipe-dream. We are about to emulate the United States – anyone sick at night will simply go to the nearest hospital with an accident and emergency department. I tried, in 1978, to buy a doctor’s bag in Houston, Texas. No such item was available for purchase anywhere!
Peter Arnold is a retired general practitioner. He was a prominent office bearer of the AMA from 1987 to 2000, having been active in medical politics since 1968. He has served on several committees and boards relating to quality of care, medical registration and discipline.