Suzanne Davey: General Practice: A bleak future for quality and quantityAug 27, 2022
As a retired GP, I would like to fully endorse the excellent suggestions of Dr Katrina Watson, expressed in her recent article in Pearls and Irritations, to improve the current parlous state of General Practice in Australia.
To summarise, Katrina suggested that GP fees should be increased without any increase in out-of-pocket expenses to patients and these fees should be more aligned with specialist fees, given that GPs and specialist shoulder similar levels of responsibility. She suggested financial support for GPs for their Continuing Professional Development requirements and subsidised childcare. She thought that GPs should work as part of a team with extra administrative support provided, consultation times should be lengthened and there should be regulation of working conditions for GPs working in corporate practices. She also had some great ideas as to how the education of GPs from the very beginning of their medical degree could be improved.
I recently retired after a deeply satisfying career in General Practice, in which I developed long-standing relationships with my patients. I always spent enough time with them to ensure that all their issues were addressed. To this end, I worked long hours and often ran late, but my patients rarely complained as they knew that I would spend time with them when their turn came. About one third of my consultations were “long” consultations. As a practice owner, I made a reasonable living and was able to bulk bill about 40% of consultations. Those who could afford to pay subsidised those who could not. I experienced great camaraderie with, and support from my colleagues and my workplace was a happy one.
This style of practice is no longer viable. The Medicare system of rebates rewards quick consultations rather than the long ones needed to address complex issues and mental health concerns. Unfortunately, there are strong incentives to write a script for an antibiotic rather than give a long explanation of why an antibiotic may not be necessary, and to write a script for a cholesterol-lowering medication without detailed dietary advice.
Since the late 1990’s there has been increasing corporatisation of General Practices in Australia. This certainly reduces the administrative burden of running a general practice, and there is no concrete evidence that outcomes for patients are any worse in corporatised practices. However, the corporate structure tends to result in patients identifying with a practice rather than with an individual GP. This tends to foster “episodic” consultations where patients are seen for one condition by a doctor whom they may not have seen before, and therefore who is not familiar with their family circumstances or detailed medical history. This contrasts with the concept of “continuity of care” where the doctor who knows the patient can put their complaint in context socially and historically and treat accordingly, whilst considering and advising the patient on their future preventative health care needs. There is also some evidence that in corporatised practices doctors are more likely to refer patients for pathology and radiology where these services are co-located and commercially related, in comparison to the rate of ordering of these tests by doctors in non corporatised practices.
The current General Practice “in surgery” Medicare rebates are $39.75 for a consultation up to 20 minutes long, $76.95 for a consultation 20 to 40 minutes long and $113.30 for a consultation longer than 40 minutes. Since the inception of Medicare, these rates have been slowly eroded relative to increases in the costs of running a practice.
These rates should be compared with the prices charged by hairdressers, vets, dentists, and other allied health professionals. I contend that is impossible to run a viable practice providing a quality standard of service and still bulk bill all patients. There is strong evidence for this contention. Because so few doctors in Canberra bulk bill, the ACT government has embarked on a programme of setting up a series of Walk-in Clinics where the patient is seen by a nurse practitioner at no cost to the patient. This has proved to be a very popular service with patients. However, there is no such thing as a free lunch. This service costs the ACT Government about $200 per consultation to run, paid for by the ACT taxpayer of course!!
When I graduated in 1977, about 20% of medical students were women. This figure is now 50%. There has been great feminisation of the GP workforce. General Practice appeals to women because of the flexible hours and the ability for it to fit in with family responsibilities. However, as with their colleagues in the other altruistic, majority female professions of Nursing and Teaching, both male and female GPs are leaving their profession due to inadequate remuneration for very arduous work. Only 10 to 15% of medical graduates now want to go into General Practice, simply a totally inadequate number to sustain let alone increase the General Practice workforce to serve an ever-increasing ageing population with chronic health care needs. This will of course only exacerbate the current critical rural doctor shortage as the total GP workforce contracts.
Things will never improve whilst we have politicians talking of lower bulk billing rates as a disaster and an indication of doctors’ greed, rather than addressing the simple fact that the current Medicare system is broken. A broken Primary Health care system just puts increasing pressure on an already severely squeezed Public Hospital System!
Australia spent 9.91% of its Gross Domestic Product on Health in 2019 according to World Bank figures, in comparison to USA (16.77%), United Kingdom (12.00%), Germany (11.70%), Switzerland (11.29%), France (11.06%) and Canada (10.84%). Maybe we need to increase our health care budget and the percentage of this budget spent on Primary Health Care (33.1% in 2019-2020), or else risk a continuing decline in Primary Health care standards in Australia, and consequently the overall health, well-being, and longevity of all Australians.
Dr Suzanne Davey BSc (Hons) MBBS, DCH, DRCOG graduated from University of Melbourne in 1977. She then worked in the public hospital system in Far North Queensland and in the United Kingdom. She settled in Canberra in 1986 and worked in General Practice there until her retirement in early 2022. She has been a long-term active member of AMA ACT, was on the AMA Council for General practice for 6 years and in 2021 she was made a Fellow of the AMA.