Doctors need more say in fixing GP crisis 

Our health care system is sick.

No doubt you can list signs and symptoms that confirm this:

• fragmented care;
• lack of equitable access;
• poor mental health (in both patients and doctors);
• mounting bureaucracy; and
• inadequate resources for complex patients … the list goes on.

The coronavirus disease 2019 (COVID-19) pandemic unmasked what many have been saying for years: our health care system needs radical change.

I suggest that the health care system is not just sick: it is in septic shock. Multi-organ failure is imminent unless we act swiftly.

Future shortage of GPs

Extending this metaphor, general practice is the cardiovascular system.

As is shuts down, other organs (other specialties) start to suffer too. Is that overly dramatic?

Let’s examine the facts:

• patients are waiting longer to get in to see a GP;

• preventive health checks and chronic disease management have fallen behind; and

• many GPs are reducing working hours or planning early retirement; some are simply closing their doors.

If predictions by Deloitte are realised, in ten years there will be a shortfall of 11 392 GPs — almost a third of the GP workforce.

That is sobering, but predictions for the next 12 months are more concerning: in late 2022, 28% of 750 respondents surveyed by AusDoc said they had “already quit general practice, had plans to find a new career or planned to retire completely within 12 months”.

The costs of running a practice

Why is this happening? Exhaustion from the COVID-19 pandemic is one reason often cited, but do not be fooled into believing that is the only reason.

A major driver is quite simply that GPs cannot afford to do our jobs anymore.

GPs have long struggled to cover costs when charging just what the federal government, via Medicare, will rebate their patients (ie, “bulk-billing”).

Politicians often quote high Medicare bulk-billing rates as a sign of “success”.

This is naïvely short-sighted: by pushing this as a marker, politicians are telling the community they can access quality health care at a dangerously cheap price.

The irony is that because of this, some GPs have had to close their books or even their doors and the net result is less access for patients.

Something the general public often doesn’t understand is that the Medicare rebate is not a doctor’s pay. It’s a rebate to the patient, not the doctor.

Additionally, only a portion of what is paid for a GP consultation goes to the GP. The rest covers administration staff, nurses, IT software and hardware, security, licences, the premises, consumables etc.

The Medicare rebate for a short consultation (up to 20 minutes) has barely budged in ten years, rising $4.15 (from $35.60 to $39.75).

To think that reasonable care can be delivered to a patient and cost less than $40 is naïve.

Yet that is what GPs who bulk bill are trying to do, and that’s the worrying part. What are they cutting back on to be able to provide care at this price? Often, it’s their own wages. The evidence is here: GPs are not receiving a higher proportion of their billings, and Medicare has barely increased, so overall wages have stagnated. That’s hardly healthy, not for the doctor, not for the practice, and not for the future of the specialty.

Nonetheless, simply increasing the rebate won’t be a long term solution. Like a fluid bolus in sepsis, it may delay complete shut-down, but definitive treatment is still essential.

Where is the funding going?

An “end-of-the-bed” analysis of our health care system funding is revealing.

Politicians love to quote Australia’s comparatively low gross domestic product spending on health care.

Less cited is that 40% of total health expenditure goes to hospitals, 34% of total health expenditure goes to primary care, and between 4.2% and 6.8% of total health expenditure is spent on general practice services.

This is despite the fact GPs provide most of the clinical care.

For example, about 90% of Australians saw a GP in 2021–22, compared with 15% presenting to an emergency department (ED). [EZ1] 

Of course, hospital-based care is more expensive than general practice, but surely the rational, fiscally responsible thing to do is invest heavily in keeping patients out of hospital?

If a patient attends an ED because they cannot get into their GP, the cost of them just walking in the door is about $530. How many GP visits could have been paid for with that same money?

The case for primary care

Primary health care is health care people seek first in their community, such as GPs, pharmacists, and allied health professionals.

Measuring the impact of GPs is difficult; how do you quantify the patients whose early intervention prevented future problems such as heart attacks, mental health crises, or surgeries? At a structural level, however, there is overwhelming evidence that a strong primary health care system provides the cheapest and most sustainable health care (here and here).

This is even recognised in principle in recent federal government discussion papers, where a ten-year plan is outlined to strengthen primary care.

However, as someone currently working on the ground, I don’t believe we can wait for a ten-year roll-out. We need to value and invest in GPs right now.

Assume a fluid/funding bolus keeps general practice (and therefore the health care system) alive.

We still need to stop the infection. What would the equivalent of empirical intravenous antibiotics be?

Solution

To manage sepsis, you must address the source of infection. The reason we are so sick right now, in my opinion, is because general practice is not understood, valued or respected.

Fragmented and inadequate funding is just one consequence of this.

The complexity of existing funding models enable politicians to blame someone else — another branch of government, or even GPs.

Federalising funding would be a major step in reducing political sidestepping and scapegoating, helping get money to where it’s needed.

However, it is not just about funding. Other evidence of GPs being undervalued includes:

• not being considered frontline workers during the COVID-19 pandemic, thereby having to source our own personal protective equipment, cover our own costs if exposed to the virus, and waiting months before being allowed to be vaccinated;
• being accused of systemic fraud while in truth GPs tend to undercharge rather than overcharge; and
• having inappropriate Medicare audits that often penalise those doing the hardest work.

Fixing funding is important but not sufficient. Respect and recognition for how general practice sustains the health care system is essential for long term solutions.

If we miss sepsis and diagnose something less life-threatening, what happens?

We cannot risk that mistake here. As doctors, we did not create this crisis, but we must be part of the solution. Regardless our specialty.

All of us need to step up. If we unite, politicians will take us seriously.

They cannot afford to ignore us, and we cannot afford to let them.

Dr Natasha Yates is a Brisbane GP and PhD candidate at Bond University

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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