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Australian society cannot afford for general practice to collapse, writes Queensland GP Natasha Yates.
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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“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?” Unfortunately, that cost is notional and not transferable. ED costs are almost all set-up costs – plant and staffing – with very little variability day-to-day despite fluctuations in attendances. ED budgets are fixed – they are not fee-for-service. Those attendances that are so-called “GP substitutable” are generally the less complex in terms of staff time and consumables. So, if a person with back pain decides to wait to see their GP rather than attend ED, no cost is saved.
The real cost of the paucity of places for worried people to receive urgent non-risk-averse advice is that even-more-worried people line up in ED, causing ED overcrowding, long waits, anxiety and frustration for patients and a terrible workplace for staff – who are both at greater risk of error and tightly audited (what a perfect storm!).
From my current position in Emergency Telemedicine, I provide assessment and reassurance – as well as treatment and referral – for a large number of people who straddle the ED-community medical service divide. Most would otherwise have no choice but to call and ambulance or present to ED because they don’t know whether their symptoms are dangerous or not.
Most current “advice lines” are too risk-averse – directing people to ED if they tick any “risk” boxes.
Much of the currently unmet need could be managed by a combination of telehealth (real clinical telehealth – not just prescription factories), forward planning (having enough medication on-hand at home for exacerbations of known conditions) and realistic escalation plans (teaching patients and families what to look out for and when urgent attention is needed for a range of conditions such as fever in children).
A very good critique of the current system problems
I suggest on the solution side a severe curtailment of the money wasted on Medicare locals care plans and other bureaucratic systems including expensive private consulting agencies instead of medical practitioners working in the area.
The problem with healthcare in Australia goes back to the 1970’s. The health system was run by people who had a professional understanding of the requirements of the health service. Once this was taken over by health uneducated managers, bureaucrats and politicians the rot set in. The primary focus which used to be the quality of healthcare delivery became the budget bottom line.
This shift in healthcare quality meant that when rebuilding or replacing hospitals the bed numbers were either kept the same, despite a growing population, or were reduced. The pen pushers had no understanding of the need for some redundancy in the system. The end result is that patients come to hospitals who have no beds available for them. Those brought in by ambulance are then stuck in a suspended animation, ramped, outside of Accident and Emergency.
For some time now anyone brought into A&E are assessed with the question, “Is this patient’s life potentially at risk in the short term?” If the answer is yes, then they have to find a bed they don’t have. If the answer is no, then give them some analgesia, or whatever relieves their immediate symptoms, and discharge them back to their GP.
This is an absolute disgrace in a first world country in the 21st century.
Well argued, but without real solutions unfortunately – and the basics are what need to change. The silos must go, the intraprofessional communication must be enhanced, and a patient-held medical record, accessible to every team member caring for that person has to be built. The opportunities lost with myHR must be addressed, and the eHR standards need to be structured to support these changes. In the interim, a time-based (per 5 minute block ad a minimum!) realistic rebate structure needs to be implemented, with proper recognition of the input from team members – the recent nonsense “nudge” letters about nurse input into health assessments and reviews, and CP prep, need to be withdrawn, because they actually seek to undermine good team-based care.
Australian health reform needs to take the best options in supporting primary care from places like Denmark and Estonia and mould them into a user-friendly framework so that every person benefits – never easy to do with CALD communities, indigenes and the homeless, but we must make an all-encompassing system that benefits everyone.
Candide by Voltaire should be compulsory reading for doctors, Voltaire’s message is that if something is bad and you do nolthing about it the situatrion will get worse.
General Practice is a complex specialty. Funding shoiuld reflect GPs who have particular expertise, Group Practices should be encouraged to reflect the problem. Psychiatric consultations shoujld be appropriately rewarded as being as valuable as minor surgery. Woman doctors should be rewarded for the role in looking after tbe so called “heart sink patients’. Targets should be abandoned . Patinets are individuals and not one taget fits all. Care Plans are insulting and benefit Practices who have sophiticated computer skills and not nessarily the patients. Doctors should have the knowledgeto select what is the most approprioate care for their patints,
Excellent clear description of the crisis and causation. How best to fund GP needs to be elucidated and explained so politicians can understand and work with us.
This is all so true.
We need a Code Red call but no one seems to be responding , I think a cardiopulmonary arrest (planned or unplanned ) might be the only action that will trigger a response. I still remember the effect of the Doctor’s strike during the indemnity crisis. Yet this would just be another symptom of an unhealthy health system. GPs will work out their individual solutions but the “universal health “ that we , in principle strive for comes at a cost , and this needs to have “ universal solutions “ .
Perhaps a write in competition with a great prizes for best suggestions /solutions from GPs (only ) would yield some of the best , most insightful , intelligent, resourceful and practical pathways to care for this very sick patient! However as per your article, GPs are not directing this resuscitation and there seems to be very inadequate resuscitation staff and resources provided even if we attended this foreseeable Code Red . The sad thing is that the GP’s staying in the system who even care , will have only despair left in their little black bags.