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We are at the top of the medical hierarchy. We coordinate care into every other medical specialty, and we are a medical specialty. We diagnose just about every condition and there needs to be a lot more respect for the complexity of what we deal with. We need to be resourced to be able to deliver on the promises that our training gave us
GENERAL practice is at a tipping point, and besides root-and-branch reform of models of funding, experts say attitudes to general practice need to change, and change now.
With rising costs of providing care (here, here and here), increasing burnout rates of doctors (here, here and here) and low numbers pursuing GP training, there are repeated calls across the industry to dump universal bulk billing and fund primary care in a different way.
But it’s not just about the money. GPs want wide-ranging changes for the sustainability of their profession.
“We’ve got to celebrate our profession, we’ve got to be respected,” said Dr David King, Senior Lecturer in General Practice at the University of Queensland.
“We need to be included in decisions that involve health care, and the nation needs to realise that we’re the foundation of health care in Australia, particularly primary health care.”
Dr Karen Price, President of the Royal Australian College of GPs (RACGP) went further.
“There needs to be whole attitude change towards general practice,” she said.
“We are at the top of the medical hierarchy. We coordinate care into every other medical specialty, and we are a medical specialty.
“We diagnose just about every condition and there needs to be a lot more respect for the complexity of what we deal with.
“We need to be resourced to be able to deliver on the promises that our training gave us,” she told InSight+.
Bulk billing is the tip of the iceberg, but it’s a tip getting a lot of attention.
“[The financial sustainability of general practice has] come to a tipping point. When interest rates got to 0.1%, you can’t go any lower and then once you go up, it’s going to cause a crisis. That’s what happened with bulk billing,” Dr King said.
How did the primary care funding crisis begin?
Many believe the primary care funding woes started in 2013, when Labor federal government introduced a Medicare freeze as part of a cost savings plan. The Coalition government extended it the following year.
However, Dr King said general practice has been struggling for decades.
“In the decade prior to that, there were a few years where GP rebates rose at half [Consumer Price Index (CPI)] while the specialist rebates rose the full CPI.
“And in the decade prior to that, under the Hawke and Keating government, they tried to bring in a copayment, but instead of adding it on top of the rebate, they were going to allow us to collect $5, which would have meant a pay cut because of the extra administration.
“General practice has been squeezed for decades,” he said.
The impact of universal bulk billing on doctors
GPs see the implications of these poor decisions daily.
“This morning, I saw a patient for telehealth, then I had to do a few things, but I can only charge for more than 6 minutes,” said Dr King. “For my 20–25 minutes work, I earn $39 minus the costs of the facility fee … For the half hour work, what did I earn? $25 or so.
“It’s not really sustainable. And that’s full costs, that’s not my wage … There’s no way that I can sustain the practice,” Dr King explained.
The implications of bulk billing are far reaching for both doctors and patients, said Dr Price.
“General practice is a private business. We can’t afford to build buildings that have, for example, spare rooms for infectious diseases. We can’t afford to put on all of the allied health staff that might be needed in managing the complex chronic diseases that we’re seeing more of.”
Funding is also impacting the number of GPs who want to enter the profession as they work for a lower income than other doctors.
The proportion of final-year students listing general practice as their first preference specialty fell to its lowest level since 2012 at 15.2%. At the same time, the GP workforce is ageing – the proportion of GPs over 65 years increased from 11.6% in 2015 to 13.3% in 2019.
Fewer GPs puts a strain on others who need to fill the gaps. Burnout and fatigue is a common concern for GPs, according to the RACGP general practice health of the nation report.
It’s particularly apparent in rural areas where there are even fewer GPs than in urban centres.
“Doctors need to have time off to recover, but they also need time off to upskill,” Dr Price said.
“Because of workforce issues, they can’t leave their practice. What happens is people after a while burn out and they leave that rural area, leaving the population without any access to general practice care at all,” Dr Price explained.
For many doctors, the only solution is to move to a mixed billing model, a model supported by the RACGP.
“We did a webinar (about moving to mixed billing) and then we had the practice owners conference. It was one of the most popular webinars we’ve had in a long time, and certainly the discussion is still alive on the forums.
“We’re not trying to abandon those who can’t pay. We’re trying to do a mixed billing approach so that we can still support them. But we have to keep the doors open. And if we’re going to keep the doors open, we’re going to have to charge some people the gap,” Dr Price explained.
The future of primary care
However, other experts want a more comprehensive solution.
“I do think we do need to look just beyond putting up Medicare rebates,” Dr King said.
Funding models such as capitation or blended capitation have been debated before and still are.
“Other funding models for general practice are moving away from total fee for service,” Dr King said.
“Even bringing back in the practice nurse incentive may allow us to deliver primary care more holistically with a team and still get paid for what we do.”
Dr Price agreed that there needs to be a funding model that integrates other services.
“We need to look at different models like the ACCHOs (Aboriginal Community Controlled Health Organisations) have done. They’ve got a great model for Aboriginal medical services. We need to look at centres like that in some of the lower socio-economic areas where they can’t afford a gap. We need to look at how that might work with access to physiotherapy and social work and occupational therapy and psychologists in a way that is equitable and supported.
“Currently, patients are going to hospital, which costs thousands of dollars, because that’s the only place that a public patient who can’t afford gaps can really access allied health care. They can’t access it in the community,” Dr Price explained.
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Society , its structure and values have all changed over time: the problem is that general practice hasn’t evolved at a similar pace and what we now see today is the result. The public feel that they’re entitled to be bulk billed at a gp level, but readily accept a substantial fee gap if referred to a specialist. The govt now can’t make any serious inroads now as the gap has become too large to fund. New solutions are required, all of which , will be to the detriment of general practice as a viable career. The future will be one of nurse practitioners, working independently and a whole host of para medical s probably in a corporate style setting, of which the gp is just one of a team. Very flat income structure , but as team leader, when things go wrong or there’s a complaint, guess who’ll carry the can. Solution for some GPs -need to plan to .move on, as remuneration and conditions won’t change . If you’re smart enough to have done medicine, then the world of law, finance etc awaits
Good bye General Practice:
I have been a GP for over 12 years, the specialty has never been in worse shape. Many of the comments above I agree with however, I fear some of our worse opposition are our very own non GP specialist colleagues and sit on boards advising Politicians. The lack of respect from patients and peers behind closed doors is shocking. A restructure is needed and maybe we need to tear it all down and start again. I still believe change has to start with our change of name as truly no one can respect our generality of practice nor can they even understand it! Primary Care Physicians are who we are.
For now, I can only try and save those doctors thinking of doing General Practice and advise them do not! Choose another specialty… I know I am and have never been happier transitioning into another field of medicine.
Why do people expect free medical treatment from a GP – they wouldn’t expect this from Woolies, the car dealer or a hairdresser. And why do subsidise pensioners so much? We’re already paying huge percentage of our taxes to support them. They should pay the same price as anyone else who walks in the door, just like the would at Woolies. Then we could reduce the cost for working people, the backbone of our nation. If pensioners can’t pay, then clog up the hospital. If you haven’t got a job you’ve got plenty of time to wait.
As another new GP Registrar, I share much of the sentiment of Tim above, with respect to how the government underfunds and therefore undervalues a crucial part of our health system.
I also have to add, valuing colleagues in our words is so important.
I entered medicine from another field, with the intention of becoming the well-rounded family doctor, health promoter and master of diagnosing the undifferentiated (as I viewed the requirements of the job!). Since then, I have spent a lot of time in the hospital system, preparing for the broad skill set needed. During this time I been disgusted at the attitudes towards GPs throughout medical school and beyond, from a whole range of our colleagues and the general public. The juniors/students seeming to parrot the words of senior doctors, despite the fact that a large proportion of them will go into GP.
The amazing, hard-working GPs I’ve met have shown me how their approach rises above that and doesn’t at all reflect the negative perception.
Spend a few weeks doing the job, experiencing its challenges and there would be a very different herd mentality.
Sigh! I’m exhausted. I feel wrung out everyday trying to do so much for so little (not just little money). General practice as a comprehensive health service properly caring for people over their lifespan and trying to keep them out of hospital seems doomed to me. I’ve resigned and am looking forward to my second gap year next year when I’ll be able to breathe and not have to count every minute and dollar of each day.
PS I’m under 50 but I feel 65 some days
AMA and the GP colleges have to take aome of the blame here. While RACGP had a nebulous “your specialist in life” advertising campaign some years back, it is evident that the general public have a preconceived notion othat GPs earn a lot of money, are not specialists, and are entitled to ‘free healthcare’. Neither do they seem to understand whether they are seeing a VR GP, Non-VR, or GP registrar. While AMA and the colleges unsuccessfully lobby the successive goverments, the pubic is not being educated as to the root cayse of the problem and GPs unjustifiably become the bad cop once they turn off routine bulk bulling. In addition, older GPs who may not be carrying a HELP debt or as large a mortgage undermine other younger GPs in a practice by being more amenable to routine bulk billing for their patients. I think the AMA and colleges fiddle around the edges but lack any new ideas to convince the general public to get behind them.
(Disclosure: married to a GP)
GP’s need realtime access to pathology company test results fro their patients both in public hospital, private hospital and community based pathology test settings. THis avoids needless duplication of pathology testing.
The e-health record needs to be more than a collection of pdf files, it is unwieldy and an unsuitable clinical tool, not good value for the amount it cost the taxpayer..
The Medicare rebates for GP services are insuffieint to keep their small businesses aflot- if they can’t stay in the black, but go into the red, they must needs go out of business.
The covid pandemic has caused many GPs and their ancillary staff to catch covid repeatedly with additive morbiditiy with each accumulated infection and they have had to stop working in patient-facing roles as their health is broken too.
Respect is earned not awarded. I was horrified to see GPs advertising themselves in Sydney airport. Didn’t see any other medical specialists doing the same! If we don’t believe in ourselves why on earth would we expect the community to believe in us. Let’s just do our job not the least of which is to look our patients in the eye. In the pandemic there has not been one day when my partner and I have not seen patients in the office. We have a very elderly practice and not one has died from Covid.
But others have died from other rotten diseases, Are their deaths less valuable because they didn’t die with Covid,. We as doctors should support our patients and give them confidence if not we are in the wrong job.. I have been an ICU specialist and now GP.
“Me thinks we doth protest too loud “ it’s our job.
Ok, as I’ve been saying for years, but nobody seems to listen, even though they keep coming out with statements like this…”The patients may wait hours in a hospital to be seen, but I can guarantee that the consult takes more than 20 minutes when they are seen, and the Doctor in the hospital is salaried on a reasonable fixed hourly rate. Certainly the cost of materials, the nurses wages and the rent of the building DON’T come out of his pay”.
Y’all need to fight to get on a decent salary. It’s so much the bleedin’ obvious, the refusal to confront this option still irritates and gob-smacks me to the point I think people deserve what they get – or don’t get – and I’ve lost sympathy for you all.
You’ve got people like Dr King, and the RACGP President, Karen Price, saying things like…”“I do think we do need to look just beyond putting up Medicare rebates, funding models such as capitation or blended capitation have been debated before and still are. Other funding models for general practice are moving away from total fee for service…”
Dr Price agreed that there needs to be a funding model that integrates other services.
Yet you all still dodge the logical extrapolation from what you now have – to what you need to address all the above gripes. Beats me…and I won’t hide behind anonymity either…
If patient’s don’t want to pay for their wound dressings-and the GP clinic cant afford to stock them- they should go to the ED where the cost is included. GP practices cannot run at a loss.
If it costs too much to run an autoclave, hire staff to sterilize equipment, purchase sutures for a GP as well as cover the cost for bookings, IT, new computers, fund computer programs etc ( that hospital ED doctors don’t have to to cover) -then of course patients need to be referred to the ED for treatment of their small lacerations.
The Government in their wisdom even cut the remuneration of doing an ECG – it is not even worth the cost to the clinic to assess pts with any sort of chest pain just on principle for this ghastly mistake- then of course they should be referred to the ED. If the patient doesn’t want to pay the 15 dollar gap for seeing a GP-then they can seek treatment at an ED where they are guarentted that they don’t have to pay a thing. That is their option and perogative.
GP’s have overhead costs that are rising and ongoing.
Currently GPs divert a huge number of patients from the ED-guess what , you only know the names of the frequent referrers. If GPs stopped working the hospital system would be over-run in an hour.
Respect, appreciation and admiration for the family doctor was the norm a few decades back. They were in control of their practice and their values. Now GPs are a pale shadow of that status, being dictated to by government on the one side and corporates on the other. Until GPs find a way to throw off the chains that enslave them and recover the professional freedom to be their best, they will be disrespected for the conduct so often foisted upon them by third parties.
It is noteworthy that the majority of responses are anonymous. The unwillingness to provide names must reflect the widely pervasive fear within the profession which probably ties in with the issues that so many doctors have with AHPRA . Secondly, GP remuneration is utterly pathetic and shows no respect for the exceptional skills GP requires across the whole of gamut of medicine.
Another critical factor is the loss the principle of the doctor-patient alliance that has come with the designation of patients as “consumers”. This implies that doctors are responsible for patient heath outcomes rather than being partners in the journey of restoration and maintenance of health and wellbeing. Doctors have 100% responsibility to apply their professional skills in diagnosis, recommending and implementing appropriate treatments. Patients are responsible for what they do with that professional advice. Patients must be able to trust doctors to be professional. In return, doctors must be able to trust their patients and the systems within which they work to build and maintain the alliance. As this diminishes, doctors become more fearful, defensive, dependent on excessive testing and imaging, disillusioned and burned out. Added to this, each health care episode is a process, not an event. Often the process needs time to play out. Increasing demands for instant answers and ideal outcomes make for unnecessarily expensive bad medicine.
** Cue the all the complaints about GP by those that have no experience or insight into working in general practice and/or count their experience with a few GPs to that of 30 000 **
I would also love a reciprocal MJA InSight article to comment on the all the instances of half baked patients being discharged from hospital inpatient wards and ED’s that we are left to deal with
Anonymous is obviously not impressed, feels GPs don’t deserve a living wage.
Solo General Practice is now essentially not cost effective.
Throughout Covid, now 2 1/2 years, I have averaged 14 hour days with the Telehealth an added burden, and income after expenses, ~ $120,000. We have had to bulk bill because we have had a number of Bulk-bill clinics open up in our are over the last few years, and despite expectations to the contrary, whenever we charge a fee, ~ 50% of our patients will go elsewhere “for the small stuff” but “come back for the important or complex stuff” which they happily tell you, as if they are doing you a favor. There are four essentials in life, food, clean water, shelter and health care.
People understand that they will need to pay something for 3 out of 4!
It costs more for a Macca’s meal for 2 than the gap fee we ask, but we risk losing patients for such a small amount.
The answer seems simple, pay more for longer, more complex consultations, and that would change the funding model for brief “sorry, one consult one problem” consultations and diagnoses would not be missed and the $20.00 skin glue cost would be covered for that simple cut, leaving the Doc with more than $19.00 for practice expenses and Dressing pack etc, for his 20 minutes or more work.
The patients may wait hours in a hospital to be seen, but I can guarantee that the consult takes more than 20 minutes when they are seen, and the Doctor in the hospital is salaried on a reasonable fixed hourly rate.
Certainly the cost of materials, the nurses wages and the rent of the building DON’T come out of his “pay”.
The reason that 13% of GPs are over 65 is most of them can’t afford to retire.
I think it’s interesting the first comment is critiquing general practitioners in article talking about how structural issues are causing burnout, churn and burn medicine and furthermore a lack of ability to stay up skilled due to work pressures.
As a new GP registrar who has worked as a medical registrar and then ED I have been surprised to genuinely struggled at times with the pace of general practice and it’s scope.
I’m going to list some of the shockingly low mbs rebates I’ve encountered that non-GP doctors might not be aware of that I’ve encountered the last 6 months
1. When we drain abscesses; the item number is 30219 – this pays us $27.35
2. I took a foreign body from underneath a tradies eyelid last week: the mbs item number is 30061 – $23.50
3 I sutures a hand that had been (fortunately superficially!) lacerated by their hedge trimmer along the thenar eminence. 7 sutures and a thorough cleaning with n/saline flush. Mbs item: 30026 – $52.50
4. I sutured a lovely 4 year old boys small wrist laceration after he fell at daycare. Topical anaesthetic applied, local then applied, cleaned. Sutured with 3 sutures while he watched bluey: again item 30026 for 52.50
To me these rebates are an absolute joke. We get paid a percentage of this and, 40-35% to the practice, and then after we have been taxed we need to account for super and put some aside for Rec leave and sick leave! (Which we obviously don’t get!)
I do my best to support effective primary healthcare and keep people out of ED, but to be paid so little means I have little motivation at times to have my day run behind seeing urgent walk ins for a pittance of pay. Not to mention it feels like being taken for a joke – can we imagine another specialist field accepting these amounts? Not to mention we are absolutely drowning in covid like other areas of health – and the nursing home takes up a significant amount of time with this too.
As a new GP registrar, it’s sad to see how the government has backed general practice into a corner. Our remuneration method shouldn’t have so much influence on our practice (or our own and patient outcomes)
A 6 minute consultation that leads to an annoying referral to an Emergency department ( 6 hour wait ) for a problem that does not and should not need an Emergency department does not lead to much respect.
Hi, The article itself seems confused, it is about respect and then talks about money/finding. Yes I agree that being paid appropriately is perfectly logical and ‘could be linked’ as a financial indicator of respect.
From my own perspective the face to face respect from patients/clients is my perception. Personally I would not go back to 80%+ of the GPs I have attended. They have left me disappointed with there ability to diagnosis, complete notes, respond to basic concerns, address privacy matters, write a pathology request following being shown a photo of the required test and advised of the test required ect, etc, (they failed) basically to treat the patient/client with dignity, respect and integrity. There is an element here of doctor treat thyself first. Yes GPs need respect, which is earnt. Cheers
We definitely need a funding model that encourages GPs to fulfill their potential, and prevent unnecessary diversion of patients to hospital EDs. Telehealth use in metropolitan areas, poor compensation for performing minor procedures, little collaboration between practices etc lead to patients being sent to hospital for “someone to look in their ears”, “glue that small cut”, and a “second opinion on a rash”.
Our communities need general practice to perform its full role in primary care, and EDs to perform their true role in emergency care.
Of course it should, the statistics speak for themselves.