The collapse of Australian general practice has been rapid and brutal. We are expecting a shortage of over 11 000 full time GPs in the next eight years.
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The proportion of young doctors choosing general practice has also plummeted.
It used to be 50 per cert. Now it's 12 per cent.
I don't blame young doctors for choosing other specialties. They can earn up to five times what I earn for similar training in another specialty, and with a $100,000 HECS debt and the current cost of housing, you can't blame them.
But driving them away from general practice is disastrous for the vulnerable in our community.
The GPs who remain are becoming less accessible and affordable. Solid, popular and highly valued practices like Hobart Place General Practice, a practice that served the LGBTQIA+ community for decades, have closed, accepting that they cannot remain financially sustainable.
In a health system where every taxpayer-funded dollar matters, it seems short-sighted to bankrupt the most effective and efficient part of the health system.
When a person sees a GP for their healthcare, they use less taxpayer funds than the walk-in clinics, headspace, acute care centres and certainly accident and emergency. So why has there been such a sustained policy drive to remove GPs from the healthcare landscape?
Why do I have to pay to see a GP when I already pay a levy?
Many people would say that they choose to use services like accident and emergency because GPs charge too much for a consultation. Most Australians, including GPs, believe the cost of care should be low or non-existent for the people who need it most and can't afford to pay.
However, consultations have become much more expensive. The consultation fee has to cover everything in the practice, including rent, salaries for nurses and receptionists, consumables and insurance. Medicare rebates have been static for over a decade so there is an increasing gap between the cost of the consultation, and the rebate Medicare will pay.
When a patient is bulk-billed, the doctor accepts the Medicare rebate as full payment. This means a 50 per cent discount on the cost of their care. GPs have covered this gap for decades, especially when patients would otherwise be unable to see a doctor because of their financial situation, but the gap has increased so much that GPs are no longer able to do so.
Therefore, even patients who are financially struggling are being asked to pay.
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The more complex the consultation, the less Medicare pays. The best rate is for a six-minute consultation, where the rebate is about $6 per minute. If a doctor sees a patient for 50 minutes (for a very long consultation about complex problems) the rebate is only $2.50 per minute. If they see their doctor for mental health issues, the rebate is even lower, at $1.26 per minute.
That works out at about $50 per hour take home pay for the doctor before tax.
It is natural that some GPs have responded to this government pressure towards shorter consultations by pivoting to "six-minute medicine". I am mystified why we, as a community, would want to discourage better care but that is what Medicare is designed to achieve.
GPs have advocated for fairer Medicare fees for decades, with little success. Norway, with its primary care focused health system, has shown much better and cheaper outcomes when primary care is well supported. In Australia, however, it seems likely the Medicare reforms will continue to bankrupt general practice.
Where is healthcare headed?
Apart from becoming more expensive, there is no doubt that healthcare is becoming much more complicated.
Consumers have asked for more choice in the care they receive, and this means we have a broader range of services available. However, as a GP, I am increasingly faced with patients who cannot access any care at all.
We cannot say we provide choice if patients are unable to access any of the options that are supposed to be available to them.
Like most Australians, I am also a consumer of healthcare services, and I have spent a lot of time inside large hospitals. As a doctor, you would think I would know my way around a hospital.
However, if there is one thing I've learned as a doctor, patient and carer, when you are sick, tired and overwhelmed, it is hard to make complex decisions without help.
Anyone who has assisted an elderly relative to navigate the My Aged Care portal will recognise how difficult healthcare processes can be. My patients with cognitive slowing, poor digital literacy or cultural and linguistic diversity simply cannot navigate this portal.
Add in anxiety, dementia or intellectual disability, and My Aged Care provides a barrier to care, not a choice. NDIS has a similar issue, spawning an industry of advocates that are needed to manage the bewildering maze of options.
When we outsource care coordination onto the patient and their families, we increase inequity.
As a GP, I am the only health service which does not limit entry. You don't have to work out if you fulfil the criteria to access a GP. People who don't know what they need, we are a one-stop shop. For patients with multiple illnesses, I shudder to think of the time and energy it will take to consult multiple teams designed to focus on one illness at a time. We fill a gap, treating the most vulnerable patients with the least support.
But GPs are smart enough to take a hint. In the last few years, we have been subject to increasing government audits, accusations of fraud (which were proven to be completely wrong), public violence, appalling professional disrespect and chronic underfunding.
Clearly, general practice is no longer welcome in the healthcare landscape, no matter what the rhetoric says.
A British colleague of mine with a lifetime of service to the NHS wrote: "as an older person, I want to state that I'm now afraid. I'm scared of dying in pain, dehydrated and unattended, on a trolley in a hospital corridor. I'm frightened that I'll end my days on a ward where the staff, however hard they try, won't have the time or resources to give me the care I need, either to cure me or to relieve my passing." I agree with him. Who will be there for me when I am old and frail?
I believe we are past the point where general practice can survive. In its place we are facing a fragmented system with complex, overlapping services, and large healthcare gaps.
Without general practice, the system with be more expensive, harder to navigate and less accessible. How, in a rich and privileged society, did it come to this?
- Associate Professor Louise Stone is associate director of professionalism and performance with the social foundations of medicine group at the Australian National University school of medicine and psychology.
