General practice: where the problems lie

IN late May 2018, Dr Tony Bartone was elected President of the Australian Medical Association, the first GP in 4 years to take that position. Few GPs would contest the notion that the state of general practice has never been worse in Australia, with Dr Bartone himself indicating that urgent attention needs to be given to this medical specialty.

There are many areas in need of repair. In this article, I identify what I feel are the areas most in need of attention, while in my next article I shall offer some ways forward.

The RACGP training and assessment process

Let’s start at the top.

The Royal Australian College of GPs enjoys a massive membership, which brings in an enormous revenue. It has a quasi-monopoly on GP training and standards. Increasingly, the RACGP has taken on a more political industrial role.

I believe that instead of focusing on standards and education, the RACGP has been distracted by its expensive marketing campaign, “I’m your specialist in life”. The cost to members of multiple billboards and television and radio ads is unknown, but these don’t come cheap. So, on the one hand the RACGP complains to politicians that GPs are doing it tough financially, while on the other hand it’s spending millions of members’ dollars on ads. It doesn’t add up. GPs are trained to be … (hold your breath now) … GPs! We’re not life coaches as the advertising campaign seems to portray.

Instead of worrying about advertising campaigns, the RACGP would be better to spend time and money on improving registrar training. Many registrars feel the RACGP training and assessment process is inadequate and many supervisors feel that graduating Fellows are not ready for independent practice and that the exams remain too easy to pass. It is still possible to attain a fellowship of the RACGP without ever having done cervical screening, excisions of skin lesions and intravenous cannulation.

The RACGP continuing education program has also been mired in controversy and is in need of urgent review.

With a membership fee of close to $1000 per year, I often wonder what I am actually paying for.

Medicare reimbursement structure

As hard as GPs may try to improve the way primary care is delivered in this country, it is to no avail while we have to work within the current Medical Benefits Scheme (MBS) framework.

As they are currently structured, item numbers governing general practice only give financial security to GPs who do one or more of the following:

• a high volume of short consults;
• a large number of care plans of low clinical value;
• focus on after hours urgent house calls;
• several procedures; and
• charge high out-of-pocket gaps to their patients.

Of the five points above, the first four create perverse incentives to practise low quality care. The last point is politically unpalatable, socially unpopular and risks excluding those most in need of a good GP.

The MBS review is unlikely to solve any of the problems above, as they are not within its remit and it would then rely on support from the Minister for Health.

Decline of small and medium private general practices

When I look around me, I see very few young GPs investing in their own practices; most are content to be employees or locums.

I also see that corporate clinics and government-backed clinics are gaining more market share at the expense of small private practices.

When I ask young doctors why they avoid starting their own practices, they always mention red tape, competition, stress and cost as the turn-offs.

The business case for opening a practice is weak, especially while the Medicare rebate for GP consultations remains pitifully low. Any marginal financial advantage in being a practice owner has to be weighed against all the stress that goes with managing a business, in particular employing staff.

Corporates get around this problem by having the ability to raise capital, create economies of scale and integrate other businesses. Government-sponsored clinics do not stress about profits and can also spread their expenses across different “cost centres”. Whenever there is a government clinic running inefficiently by bulk-billing Medicare, one can usually be sure that there is a state government running the clinic grateful to be shifting expenses from the state coffers to the federal purse.

Many owners of small and medium practices in metropolitan and regional areas fear corporate and government clinics pricing them out of the market. In smaller towns, these threats may not be present, but lack of workforce is at least as threatening, if not more so.

Establishing and managing a practice has all the problems faced by all Australian businesses: council approvals and rates, high personal and company tax rates, land taxes, payroll taxes, (the most stupid of all taxes – you get punished to employ others), workers compensation, high energy costs, high cost of labour, IT costs and technical difficulties.

Specific costs that relate to medical practice include equipment, sterile supply, waste disposal, Australian Health Practitioner Regulation Agency fees, College fees, high costs of education and credentialing, high costs of insurances.

Unlike the hospital-based specialties, GP registrars see these realities very clearly during their training. While it is excellent that GP training offers such insights, the flip-side is the avoidance of practice ownership.

I know of practices that are struggling to stay afloat financially; some principals working for less than their employees and seriously contemplating early exit from general practice.

Workforce

So many graduates, so many new GP Fellows, and yet if you ask most practice owners, most lament that they cannot find GPs willing to work. Contrary to what many may think, this is just as much a problem in urban areas as it is in rural areas.

Just have a look at any doctor magazine or website and you’ll see many ads looking for GPs. The locum agencies are offering small fortunes for short and long term placements, so desperate are so many areas.

Millions have been spent by state and federal governments on workforce agencies; it appears to no avail when it comes to general practice.

Accreditation

In my opinion, practices do accreditation for one reason and one reason only – to access the Practice Incentives Program (PIP), which can represent up to 40% of practice revenue.

Any other excuses and reasons given by the Colleges, government and accreditation companies themselves are not realistic. If the PIP was not essential to financial viability, practices simply would not bother with accreditation.

With every iteration of the RACGP standards that govern accreditation, the demands on practices become more demanding and sadly more absurd.

Accreditation is a very expensive exercise, both in terms of the fees charged to practices and huge number of hours staff need to spend preparing for accreditation.

As individuals, doctors already have high demands on them in terms of professional development. Practice accreditation is like another layer on top of this.

As a profession and also as a society, we need to ask about the utility of all this money and time spent, which ultimately is time away from treating patients.

To make matters worse, practices wanting to teach registrars and students have to do what is virtually another two accreditation processes for the Colleges and the universities. Calls for one accreditation to cover all these things have fallen on deaf ears … why have one empire when you can have three?

Low value care

We often hear this term used but it has many meanings to many parties.

Some things that it can mean include:

• the $37.05 schedule fee being hardly enough to justify a proper patient assessment;
• bulk-billing encourages patients to present for petty problems;
• consultations solely for filling in forms and certificates;
• care plans only for accessing allied health rather than improving patient care;
• encounters that could have been handled just as well by a practice nurse under the purview of a doctor; and
• prescriptions and procedures without evidence base.

Low value care is generally unsatisfying for both doctors and patients. While it remains so prevalent, it leads to a double-edged sword: the government shall find it hard to justify raising the rebates and GPs find it hard to charge what they are worth.

For example, when a 90-year-old patient with arthritis comes in to have a GP sign a disability parking form – a purely bureaucratic demand – it is hard for most GPs to charge.

Or the parent with a 4-year-old with autism, who has been sent by the paediatrician to the GP to “get a care plan so you can get free access to a speech pathologist”. For a start, such a scenario may not even qualify for a care plan and, more importantly, how is a care plan going to help that child?

The deluge of National Disability Insurance Scheme forms has taken GP low value care to new depths.

Leadership and unity

In my view, representation of general practice has lacked leadership and unity for too long.

There have been many voices with different agendas. Many of the voices have been distracted by political and vested interests.

There has also been a lack of authenticity, evidenced by the many experts, who are not GPs, offering their knowledge and expertise that, while well intentioned, is not accurate or realistic.

Dr Bartone has a big task in front of him. I wish him every success.

Dr Aniello Iannuzzi, FACRRM, FRACGP, FARGP, FAICD, is a GP practising in Coonabarabran, NSW, and a clinical associate professor at the University of Sydney.

 

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