Issue 6 / 27 February 2023

General practice and primary care are not an island; they are a significant feature in the complex integrated landscape of our health care system, writes Dr Will Cairns OAM …

The Strengthening Medicare Taskforce report was released a few weeks ago. I must say, I was disappointed, not by what it did address, but by what it did not. The report is more an aspirational concept plan – let’s call it an architect’s sketch – for the redesign of primary care, than a detailed plan for significant health care system reform.

Despite this confusion between the content and the title, the report correctly identifies that strong and effective primary care is essential.

In retrospect, the flaws of the funding model that were structured into Medicare at its inception are obvious to me and I have written about them before (here and here).

Since the introduction of the Medicare freeze, it was inevitable that our primary care system would find itself in the state that it is today: disrespected, demoralised, underfunded, and loss-making.

Given what we know about the behaviour of complex systems, we should then not be surprised by the unravelling of Australian primary care in “two ways. Gradually, then suddenly” (to quote Ernest Hemingway from The sun also rises).

Although the reforms proposed in the report are worthy and necessary, they are only the most urgent part of a much larger reform process.

It is hard to imagine how, given interconnectedness of its parts, strengthening the whole of Medicare is possible without addressing the full range of its shortcomings.

These are my core concerns:

  • The declining viability of primary care is founded in the imbalance in the perceived value of, and the resources distributed between, primary and secondary/tertiary care. Attempts to revive Medicare will not succeed if we do not create recognition and provide resources that prove that high quality primary care is accepted as vitally important for our health care system and the wellbeing of our community.

  • The progressive commercialisation of health care and the growing focus on profits has seen increasingly large quantities of money being extracted from patients, some health care workers, and taxpayers. The result is that less money is available for patient care and poses a threat to the viability of complex health care systems.

  • The report gives little consideration to the growing gap between the resources available and the promises that are being made across the full spectrum of health care. I believe there has been almost no purposeful discussion in Australia about how we might undertake ethical and equitable resource allocation of finite resources to meet this challenge.

GPs specialise as our community’s medical point of first contact with the health system, other than in emergencies.

GP training is designed to equip doctors to identify and prioritise the needs of patients who may present with any illness, to manage those illnesses for which they have the necessary knowledge and skills, and to recognise the boundaries of their knowledge and capabilities by referring on those patients whose illnesses are outside their personal scope of practice.

They are the coordinators of the complex multidimensional whole person care for which disease and organ-based specialists are seldom equipped and generally avoid.

As the complexity of health care has escalated over recent decades, the vital contribution of other health care workers who bring skills that complement those of GPs has increasingly been recognised and welcomed by most doctors.

The Strengthening Medicare Taskforce report appropriately identifies the benefits that derive from integrating these health care workers into the primary care team and remunerating them for some of the tasks that GPs have traditionally undertaken themselves.

All health care workers have exclusive sets of skills, or combinations of skills, but always there are overlaps, and some tasks can also be undertaken by health care workers other than GPs (eg, cervical cytology, some routine health checks, some repeat prescriptions and the management of some minor injuries and ailments).

GP training equips doctors with the knowledge and skills to take overall responsibility for assessment, diagnosis, treatment, and for ongoing care and oversight of multidimensional problems.

This role cannot be assumed by other health care workers (without training them as doctors) and cannot be removed from the responsibility of GPs.

Sadly, established GPs are quitting general practice and newly minted doctors deciding to pursue careers in other fields (here and here).

Why would a junior doctor choose general practice when they see their peers (who, as they know from their time studying and working together, are not cleverer, wiser, more dextrous or better doctors than them) become specialists who are well respected and have secure incomes that are often at least several multiples of what they could ever earn as GPs?

Unless we are careful, our system founded on primary care medical assessment and appropriate referral to (non-primary care) specialist practice will grind to a halt. Alternative means of referral will be necessary, or self-referral accepted with the result that non-GP specialists will be engaging in primary assessment, a task for which they are not equipped and do not want.

The most important victims of the collapse of general practice are patients. They are losing the opportunity for a long term, perhaps lifelong, relationship with the one doctor who can know them and their family.

Fragmentation of care (and medical records) compromises routine assessment of the progress of children, disease prevention, the management of chronic disease, disability care, and transitions across the lifespan including childhood and adolescence, sexuality, parenthood, ageing and aged care, advance care planning and end of life care. Not to mention the routine support for better mental health and dealing with the inevitable and normal stresses of relationships, study, careers, work, unemployment, illnesses and family bereavement.

Reversing the decline will require very loud signals that general practice is a vital and equally important component of health care as specialist and procedural medicine. Not just pronouncements, but a funding model, perhaps with salaries in line with hospital specialist rates, that remunerate careers in general practice that are as attractive as other fields of medicine. In the absence of a massive injection of new funding for GPs, this probably means a redistribution of Medicare funds from non-GP procedural specialist practice to primary care.

The Strengthening Medicare Taskforce report failed to address the potential threats posed by the escalating commercialisation of health care businesses, including the exploitative fees charged by some procedural doctors. The Australian Government has a duty to ensure that the regulation of Medicare supports the efficiency, invention and imaginative change that business-like processes can bring without patients being financially exploited.

Although there is not enough space here to discuss the evolutionary origins and nature of human behaviour and their impact on health care (perhaps the topic of my next opinion piece), it is worth thinking about how such matters have shaped the disaster that is the United States health care system.

Surely we do not want to go too far down the US road, which has them spending about twice as much per capita on health care (including profits) as most other affluent societies, and yet having a shorter life expectancy (the US is 66th in the world at 78.203 years, Australia is 13th with 83.579 years [here and here]).

It has been reported women have been charged for having skin contact with their newly delivered babies, and 41% of the US population is saddled with health care debt. I recommend an article from JAMA, Salve lucrum: the existential threat of greed in US health care.

Even though Australia is not yet subject to the eyewatering greed of some US health care businesses, Australians should not feel too complacent – a US study found that 30% of women of reproductive age in Australia have problems paying medical bills (US 52%), and 32% of women of reproductive age in Australia skipped or delayed health care because of the cost, second only to the US on 49%.

In dealing with this issue, it is most important to consider carefully what we should expect of our health care system – designed to take advantage of the benefits of being run in an efficient business-like manner while maintaining its predominant focus on health care as a service to the community that offers high quality care for patients and proportionate benefits for those who work in it. Perhaps in doing so we would be applying the rumination in Australia’s Treasurer Jim Chalmers’ summer essay to the design of the marketplace of health care.

Finally, human curiosity and inventiveness have prolonged our lives by improving the quality of care, creating therapeutic possibilities and designing best practice standards, all of which the Australian community are told that we have the right to receive. However, applied across the board, they would cost far more than we could ever afford to provide, either as expensive technology or the health care workers required to deliver them. We are already struggling with the high charges for some patented medications, face the extraordinary long term expense of novel and effective treatments for rare inherited diseases and personalised therapies, and are daunted by the costs of providing care for those whose lives have been prolonged or enhanced by our successes.

I recently wrote that the immediate challenges for health care in Australia should be prompting careful consideration of the outcomes we are trying to achieve with our health system – Perfect as the enemy of good. While it is appropriate to set high standards for health care, it is important for the community and the wellbeing of health care workers that they are not set so high as to be unattainable. As discussed recently in The New York Times, our community should not be led to expect that we will receive health care that we cannot afford, and that clinicians should not feel that they are failing because their efforts are spread thinly across too many patients.

If we accept that there is not enough money to do everything that we would like to do, and remembering that when we allow considerable, sometimes excessive, profits to be extracted from health care, less is available to provide such care, then we must adjust our expectations and decide which goals we will pursue and how we can share the benefits and the shortfalls in an equitable manner.

Dealing with the complex ethical issues of resource allocation will require government and community leadership of a candid and broad community consultation if we are to agree on compromises that minimise ongoing conflict.

I had expected far more of the Strengthening Medicare Taskforce report. I hoped that it would have at least identified the broader threats to Medicare, and that it would have reassessed and reasserted Medicare’s values and goals. By identifying the voids in the report, we can engage with our community to agree a plan that strengthens the whole of Medicare.

Dr Will Cairns OAM is Consultant Emeritus at Townsville University Hospital and an Associate Professor, James Cook 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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13 thoughts on “Decline in status of general practice ‘a disaster’ for healthcare

  1. Anonymous says:

    Wrong priorities poor understanding and lack of courage to fix the GP funding by politicians seems to be the problem.
    Pulling wool over patients or voters is what they are attempting. There is no reason for Australia to depend on overseas Drs to service a greying population.
    Cannot blame GPs for Pvt billing. It is a free market economy. Why are we looking for charity.

  2. ken cameron says:

    Will this is the most concise clear articulate and pragmatic article on the current state of australian general practice I have had the pleasure to read
    I have spent 40 yrs in general practice and you have absolutely nailed the difficult issues we face
    I am both envious of your depth of vision and writing skills and in awe at the same time.
    Well done
    Lets hope decision makers at federal level actually read , reflect and act on some of your ideas

  3. Glen says:

    While i can only agree that the funding model has left no real financial benefit to work as a GP. I believe the reduction in status likely has other sources not discussed. Of concern to me is that I would not return a second time to about 60%-70% of the GP I have attended. This low return rate has little to do with time or money, but sheer competence. I have shown a GP a photograph of the test I required. He failed to prescribe that test but prescribed other needless tests. If this had been life threatening I would now be dead. I provided this information in the most timely manner possible. This is not an isolated case. One has to address all of the reasons for loss of status. When I have raised concerns like this at the GP practice I have been treated with contempt, rudeness and usually combined with a total failure of the practice, practice manager and GP to address the issue at hand. There are a number of reasons for a loss of status…. If these GP practices need to be run as a profitable business customers service and accountable is somewhere in there, I liken this process to take away pizza would I order another???? not likely. Anyone know a good GP??

  4. DrPhil says:

    Who remembers the Relative Value Study way back in the 90s? It was quietly shelved by the govt after the shock of the findings put the wind up the treasury. It’s a great pity that a once noble profession has been reduced to just another small business.

  5. Anonymous says:

    Watching my own excellent General Practitioner struggle with time available being less than my own complex medical needs require has been like watching the sun set close to the equator. The noticeable morale decline, the need to bill every moment and action in what was once a service that was costed as a whole is also quite depressing.
    The premise of government funded healthcare and disability care as uncapped systems is false. GP’s and patients need to be funded in a way that keeps the hearts of both beating strongly.

  6. Anonymous says:

    Excellent points, Will, but they’ll probably fall on deaf ears where it matters. Fellow doctors get it, but those in power have other agendas. I also agree with Bob House’s comments above about doctors’ good will being exploited and it makes me feel sad. (I’m a non-GP specialist)

  7. Anonymous says:

    That’s a well written article. Clear and concise. As a rural locum GP, it hits the nail right on the head. It would be a wish that Mark Butler reads this…

  8. Anonymous says:

    Fantastic piece (and I’m a non GP specialist!). Thanks

  9. Gerard Gill says:

    Will has addressed many matters and his solutions are sensible and pragmatic.

    What he has not addressed is the malign policies of the Universities particularly the Group of Eight and the NHMRC.

    Medical Student selection actively discriminates against students from a non-selective state high school, the students most likely to enter general practice from British studies but also more likely to require increased teaching support. The lack of investment in general practice academia from Universities is evident. Perhaps our parliamentarians might like to reduce Vice Chancellor’s salaries and use the money to fund GP academics.
    Australian GPs have written 9% of all GP doctorates written in English in the last 23 years but the research support offered to general practice is abysmal.

    Good general practice care adds two years to your life expectancy and reduces the chance of a hospital admission by 10%. These outcomes have been found across the world.
    Perhaps we should not fund skin cancer clinics, botox or fillers or cannabis oil prescriptions under Medicare. These activities which do not improve health outcomes (the incidence of metastatic melanoma has not decreased in Australia or the USA in spite of screening) seem to be where GPs are investing their time.

  10. Phillip De Ronchi says:

    There must be a realisation that Medicare funding funds the patient – it is not a doctors allowance / salary / income.
    Most GP practices are privately owned and operated businesses that need to be financially robust and sustainable.
    This necessitates private billing. A practice that is profitable, sustainable and successful is the best vehicle for offering sound primary care – Bulk Bulling (BB) in contrast pushes one to poor outcomes through time poor management. BB may give the illusion of a cheap solution but largely means multiple presentations for the same issue / inappropriate investigations / premature referral to other services which have an upstream effect.
    It is time private billing became the norm and the patients seek improved rebates. The demise of GP will not do the patients any good.

  11. Bill Thompson says:

    Well said ,
    There is some urgency to increasing dramatically the medicare rebate for GP Services .
    Although we private bill for those that can afford to pay (gap greater than the medicare rebate ) there is over half the practice who can’t afford private fees and we subsidise this group ,mostly ” bulk billing” .so that they have access to proper care .This group include low income ,indigenous ,nursing homes etc .
    This situation is rapidly becoming untenable and is not sustainable in the medium term ,let alone the longer term .
    I am nearing the end of my over 40 years GP career and have accepted this rapid decline in GP income ,but the next generation will not ,as is already become obvious by the failure to fill the positions of GP Registrars in the national training programme as the Registrars can earn more working in the hospital system as RMOs and CMOs

  12. Sally Manuell says:

    Excellent, articulate and pragmatic assessment of the current state and positioning of general practice within our current Medicare set up. Thankyou Will, I wish I could work with you!
    As a long term practising GP I also felt somewhat let down by the outcome of the Strengthening Medicare Taskforce report. It had the sense of limited pragmatic understanding of real life GP practice.
    It seemed once again to be based on the ideas of theorists as much as those who know day to day practice realities.
    I hold to my firm opinion that good quality general practice is key to the health care of most people in our country. We as GPs get to know the person in many facets of their life including their health issues. Of course the time taken to develop this understanding is not regarded highly in our Medicare system. Woe betide you as a doctor if you spend significant time at present with a person who is need of detailed care.
    I really do hope the system of GP is strengthened as described in the article. It would be such a gain for our country.

  13. Bob House says:

    As always a reasoned and informative article from Will. The sad facts are that General Practice has been the victim of a confidence trick; the formation of the College and the rigorous training regime were a device to suggest the status of specialist medical care with none of the financial benefits. Will does not mention the sad reality, that the current system is held toeather by good will and the efforts of many, most notably women, who are unable to change their career path and for whom the only alternative is quitting the profession, which is becoming far too common. It is indeed a crisis and we all know that the only way change will occur is if the crisis is allowed to reach its conclusion. Sadly the victims will be the patients not the politicians.

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