Halting the slow demise of general practice in Australia

OVER the past few weeks, there has been a flurry of reports on the decline of bulk billing, the shortage of GPs, and the small proportion of medical students and junior doctors who see GP training as their career path of first choice.

One might be forgiven for thinking that these problems emerged only recently. Rather, they are the inevitable consequences of decisions made at and since the creation of Medicare that have been allowed to fester over half a century of ineffectual governance with little regard for, or understanding of, the long-term hazards.

As background, I have worked on both sides of the GP/specialist divide, including a significant period with a foot in both camps.

In 1982, I started in general practice after 4.5 years as a junior hospital doctor. In the late 1980s, I became interested in the care of dying people and began a very slow transition into specialist palliative medicine, initially to half-time hospital palliative medicine with the balance of my time in general practice. In 2000, I was able to move into full-time hospital palliative medicine when funding became available to pay me as a salaried non-specialist until our new specialty was recognised in 2006.

I was quite naïve when, in 1983, I bought my GP practice and built a new surgery in 1986. I thought that simply providing good quality care to my patients and bulk billing pensioners and health care card holders would support the business of my practice and provide a reasonable income. Although the sequence of events is blurred by the mists of time, I experienced some of the challenges that have progressively undermined the appeal and viability of general practice as a business and a career option – in particular, the differential between specialist and GP Medicare rebates, the intermittent freezing of GP Medicare rebates, and the emergence of exploitative high turnover bulk-billing general practice as a business opportunity rather than a service for patients.

The latter caused our patient numbers to drop off when such a practice opened just down the road – several patients said that they went there to be bulk-billed and only came to us when it was something serious. The revenue from those shorter, less complex consultations had balanced the longer time required for more complex problems and their associated discussions. More importantly for the patient’s outcomes, their care and their medical records had become fragmented.

Each consultation we had with our practice’s long-term patients enhanced our relationship with them and provided another piece in the jigsaw of our understanding of them and their circumstances.

For many in the community (including some GPs themselves), one inevitable consequence of the creation of high turnover medicine was a transition in the perception of GPs from valued collaborators in health care to piece-work employees paid on throughput, and generators of wealth for investors. It had morphed to a paradigm wherein primary care is an opportunity for the exploitation of both vulnerable patients and health care funders.

From the outset, our health care system has had primary care at its core. GPs are the first point of contact and the generalist managers for a great diversity of problems, ranging from minor one-off ailments to highly specialised and complex whole-person care of patients with the multidimensional bio/psycho/social challenges of ageing, disability and mental health. GPs refer to specialists those patients who have more complex, usually single-organ system diseases that require specialist care beyond their skill range.

The importance of the primary care role has only increased as the complexity of health care and patients’ morbidities have multiplied in our ageing population (here, here, and here). Many patients have their individual diseases managed well, but with no one coordinating the whole-person care necessary to manage the totality of their illnesses. GPs and specialists are not trained or tasked for one another’s roles.

To quote either Yogi Berra (player and then manager of the New York Yankees baseball team) or computer scientist Jan van de Snepscheut,

“In theory there is no difference between theory and practice. In practice there is.”

In theory, the doctors who fulfil the diversity of challenging and essential medical roles are equal but different. In practice, they have not been treated as equals by one another, by the community at large or by governments.

Nobody seems to have paid much attention to the embedded flaw of Medicare that made the slow financial decay of general practice inevitable. From the outset, a differential between GP and specialist revenue was built into the system based on the Australian Medical Association’s (AMA) scale of fees that, at the time, valued specialists more highly than GPs, and procedural skills more than consultation-based medicine and cognitive skills. Even when the Medicare rebate for GP services increased by the same percentage as specialists, “the miracle of compound interest” means that with specialist rates starting from a higher base, specialist revenue increased at a faster rate, further widening the GP–specialist gap, and cementing the belief that since the government pays them more, specialists must be worth more.

For example, in my experience elderly patients with cataracts generally expected to be bulk-billed for a standard consultation for their pre-operation assessment while being happy to pay their ophthalmologist for one 15-minute procedure (not including any facility fee) approximately the revenue that my practice generated in a day.

One proceduralist asked me to undertake the difficult discussion with a patient and their family about the outcome of an investigation. This intense discussion took more than one hour in a room with the patient and half a dozen anxious relatives, and during that period the proceduralist could complete about four of their investigations for more than ten times my revenue for that hour.

Understandably, I was very pleased to hear in the early 1990s that the federal government and the profession had recognised the inequities of, and perhaps the threats posed by, the situation and launched the Relative Value Study. This project had the aim of measuring the effort and difficulty of the various roles and tasks of doctors to redress the imbalance between the remuneration for cognitive and practical/procedural/technical tasks.

To cut a long story short, it failed because it was doomed from the outset – the participants had not agreed on a number of central issues. Perhaps most importantly, the government did not accept that there should be any increase in the cost of Medicare billing as consequence of an agreement (the funding pool would not be increased), while the AMA did not accept that any of its members should be disadvantaged (that the redistribution of a fixed pool was not acceptable). From my perspective as a GP, at the time, I felt that the federal government had ducked a confrontation with the AMA, which, rather than accept the need for compromise, seemed to favour the interests of one group of its constituent doctors over those of another. To my great disappointment, the process eventually ground to a halt and has gone nowhere since.

From that point on, in the absence of radical change, the fate of Australia’s general practice/primary care model was sealed. The federal government and our own profession’s leading organisation had just walked away from a clearly identified threat to the system as a whole, and left the inevitable to roll on as an exercise in survival of the fittest.

Soon after I had sold my general practice, corporates started to buy up general practices and amalgamated them in to large centres. I can understand why buyouts were attractive to GPs. Many hoped that they would now be able to focus on the care of their patients and leave the growing bureaucratic burden of management to the new owners.

Although many corporate managers may have intended to continue to provide personalised care, their primary responsibility (and their raison d’être) is to make money for their shareholders. They might not have understood the whole-system role of GPs, and are not bound by the ethics of medicine or our codes of conduct.

Doctors and their patients soon faced the reality that the long-term doctor–patient relationships that are so important to effective primary care were fading. Many patients came to see GPs as a source of prescriptions or certificates, rather than as a partner in wise health decision making. Governments, content to measure success by the politically expedient bulk-billing rate, expressed little concern for the change.

Over many years, the federal government has continued to thoughtlessly and sporadically save money by casually squeezing the soft target of GP Medicare rebates. When a practice’s Medicare bulk-billing revenue growth does not match the growth in practice costs, doctors are faced with the choice of either introducing or increasing co-payments, or increasing their throughput with shorter consultations. I saw several colleagues abandon their principles, disengage from their patients’ health care lives, and switch to a low commitment, impersonal, high throughput style of practice.

Of course, many GPs and their practices have maintained their traditional role, but this has now become virtually impossible in less affluent areas where many patients cannot afford to pay for the time necessary to fulfil the primary care role. However, unlike those who cannot afford expensive private specialist practice and whose specialised care needs may eventually be met at public hospitals, there are no alternative providers of primary care for those who cannot afford the GP gap payments that keep general practices afloat.

Complex medical treatments managed by specialists often separate patients from their GPs, sometimes for years, and, when disease-centred care is not sufficient for a patient’s needs (eg, for palliative care), patients may find that that their specialist does not have the breadth of skills (or is unwilling) to manage care across multiple comorbidities. I and others have observed that some specialists engage their deep but narrow knowledge and skill base to treat disease with great competence but have shrunk their professional identity to that of a disease-treater (perhaps forgetting the expectations of Good Medical Practice and the guidance of the professional qualities curriculum of their specialty training). Patients may also discover that they no longer have a working relationship with a GP that can be revived. The broad role of GPs knows no disease boundaries and carries enduring responsibilities.

As a palliative care specialist, I have noticed a progressive decline in the proportion of GPs willing or able to make the time to visit dying patients, either at home or in residential aged- care facilities (RACFs). Few provide care at night or on weekends, when many crises arise, or whenever someone quietly and peacefully dies.

Many jurisdictional palliative care service plans will fail because they are predicated on the unrealistic premise that, particularly in rural areas, GPs will be available to provide non-specialist palliative care. For me, this is all particularly sad as the privilege of caring well for a patient as they die, and supporting their family, is among the most important and personally rewarding roles of primary care physicians.

Unsurprisingly, and as in other areas of our economy, we are discovering how the viability of complex systems such as health care is threatened when the interests, status and incomes of those who deliver vital components of the system are not recognised as being essential (eg, RACF staff and airline baggage handlers). This is playing out in the massive disruption of diversion to other venues of health care: emergency, bed blockage, RACF transfers to hospital, and the massive waiting times for primary care appointments.

Like most journeys for which we have not agreed upon a destination, we have ended up with a health system shaped not by design, but with all the flaws and vulnerabilities that may have been expected from the vagaries of chance, short term perspectives, self-interest, market forces and, sometimes, a sense of entitlement.

Complex human social systems evolve over time. Although we may think that we control our destiny, we often display little regard for the long-term consequences of our actions. By our ill-considered choices, we have allowed our health care system to drift into an organisational dead-end (here and here). There is no easy way out that does not require assertive disruption.

Health care system design is a responsibility of the governments who pay for most of it with the community’s funds.

The success of our health system depends on a valued, respected, efficient and financially secure system of primary care.

The essential first step in the journey of repair is to strongly affirm that primary care is of at least equal importance to specialist care for the success of Australia’s health care system. This could start with eliminating the two-class, GP–specialist divide that is built into the Medicare schedule and creating a system (perhaps derived from the Relative Values Study) that values and remunerates all doctors equally.

Only then, perhaps, will the community again understand the importance and true value of the role of GPs, and doctors be lured back to general practice because it is an attractive career.

Finally, in the words of Nobel Prize winning economist Angus Deaton and his Princeton co-author Anne Case, in their book Deaths of despair and the future of capitalism:

“Free-market competition does not and cannot deliver socially acceptable healthcare.”

While respecting the benefits of competition, the profitability of corporate medicine should be founded on its efficiency, not on its ability to extract profits by compromising the quality of care and/or exploiting the taxpayer, the commitment of staff, and vulnerable patients.

Failure to act urgently in the face of this inevitable crisis risks offering an example of how complex systems collapse slowly at first, and then suddenly.

Dr Will Cairns is a generally cheerful Consultant Emeritus in Palliative Medicine, an Associate Professor at James Cook University, and has recently retired from clinical practice.

The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.

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