IN late May 2018, Dr Tony Bartone was elected President of the Australian Medical Association, the first GP in 4 years to take that position. Few GPs would contest the notion that the state of general practice has never been worse in Australia, with Dr Bartone himself indicating that urgent attention needs to be given to this medical specialty.

There are many areas in need of repair. In this article, I identify what I feel are the areas most in need of attention, while in my next article I shall offer some ways forward.

The RACGP training and assessment process

Let’s start at the top.

The Royal Australian College of GPs enjoys a massive membership, which brings in an enormous revenue. It has a quasi-monopoly on GP training and standards. Increasingly, the RACGP has taken on a more political industrial role.

I believe that instead of focusing on standards and education, the RACGP has been distracted by its expensive marketing campaign, “I’m your specialist in life”. The cost to members of multiple billboards and television and radio ads is unknown, but these don’t come cheap. So, on the one hand the RACGP complains to politicians that GPs are doing it tough financially, while on the other hand it’s spending millions of members’ dollars on ads. It doesn’t add up. GPs are trained to be … (hold your breath now) … GPs! We’re not life coaches as the advertising campaign seems to portray.

Instead of worrying about advertising campaigns, the RACGP would be better to spend time and money on improving registrar training. Many registrars feel the RACGP training and assessment process is inadequate and many supervisors feel that graduating Fellows are not ready for independent practice and that the exams remain too easy to pass. It is still possible to attain a fellowship of the RACGP without ever having done cervical screening, excisions of skin lesions and intravenous cannulation.

The RACGP continuing education program has also been mired in controversy and is in need of urgent review.

With a membership fee of close to $1000 per year, I often wonder what I am actually paying for.

Medicare reimbursement structure

As hard as GPs may try to improve the way primary care is delivered in this country, it is to no avail while we have to work within the current Medical Benefits Scheme (MBS) framework.

As they are currently structured, item numbers governing general practice only give financial security to GPs who do one or more of the following:

  • a high volume of short consults;
  • a large number of care plans of low clinical value;
  • focus on after hours urgent house calls;
  • several procedures; and
  • charge high out-of-pocket gaps to their patients.

Of the five points above, the first four create perverse incentives to practise low quality care. The last point is politically unpalatable, socially unpopular and risks excluding those most in need of a good GP.

The MBS review is unlikely to solve any of the problems above, as they are not within its remit and it would then rely on support from the Minister for Health.

Decline of small and medium private general practices

When I look around me, I see very few young GPs investing in their own practices; most are content to be employees or locums.

I also see that corporate clinics and government-backed clinics are gaining more market share at the expense of small private practices.

When I ask young doctors why they avoid starting their own practices, they always mention red tape, competition, stress and cost as the turn-offs.

The business case for opening a practice is weak, especially while the Medicare rebate for GP consultations remains pitifully low. Any marginal financial advantage in being a practice owner has to be weighed against all the stress that goes with managing a business, in particular employing staff.

Corporates get around this problem by having the ability to raise capital, create economies of scale and integrate other businesses. Government-sponsored clinics do not stress about profits and can also spread their expenses across different “cost centres”. Whenever there is a government clinic running inefficiently by bulk-billing Medicare, one can usually be sure that there is a state government running the clinic grateful to be shifting expenses from the state coffers to the federal purse.

Many owners of small and medium practices in metropolitan and regional areas fear corporate and government clinics pricing them out of the market. In smaller towns, these threats may not be present, but lack of workforce is at least as threatening, if not more so.

Establishing and managing a practice has all the problems faced by all Australian businesses: council approvals and rates, high personal and company tax rates, land taxes, payroll taxes, (the most stupid of all taxes – you get punished to employ others), workers compensation, high energy costs, high cost of labour, IT costs and technical difficulties.

Specific costs that relate to medical practice include equipment, sterile supply, waste disposal, Australian Health Practitioner Regulation Agency fees, College fees, high costs of education and credentialing, high costs of insurances.

Unlike the hospital-based specialties, GP registrars see these realities very clearly during their training. While it is excellent that GP training offers such insights, the flip-side is the avoidance of practice ownership.

I know of practices that are struggling to stay afloat financially; some principals working for less than their employees and seriously contemplating early exit from general practice.

Workforce

So many graduates, so many new GP Fellows, and yet if you ask most practice owners, most lament that they cannot find GPs willing to work. Contrary to what many may think, this is just as much a problem in urban areas as it is in rural areas.

Just have a look at any doctor magazine or website and you’ll see many ads looking for GPs. The locum agencies are offering small fortunes for short and long term placements, so desperate are so many areas.

Millions have been spent by state and federal governments on workforce agencies; it appears to no avail when it comes to general practice.

Accreditation

In my opinion, practices do accreditation for one reason and one reason only – to access the Practice Incentives Program (PIP), which can represent up to 40% of practice revenue.

Any other excuses and reasons given by the Colleges, government and accreditation companies themselves are not realistic. If the PIP was not essential to financial viability, practices simply would not bother with accreditation.

With every iteration of the RACGP standards that govern accreditation, the demands on practices become more demanding and sadly more absurd.

Accreditation is a very expensive exercise, both in terms of the fees charged to practices and huge number of hours staff need to spend preparing for accreditation.

As individuals, doctors already have high demands on them in terms of professional development. Practice accreditation is like another layer on top of this.

As a profession and also as a society, we need to ask about the utility of all this money and time spent, which ultimately is time away from treating patients.

To make matters worse, practices wanting to teach registrars and students have to do what is virtually another two accreditation processes for the Colleges and the universities. Calls for one accreditation to cover all these things have fallen on deaf ears … why have one empire when you can have three?

Low value care

We often hear this term used but it has many meanings to many parties.

Some things that it can mean include:

  • the $37.05 schedule fee being hardly enough to justify a proper patient assessment;
  • bulk-billing encourages patients to present for petty problems;
  • consultations solely for filling in forms and certificates;
  • care plans only for accessing allied health rather than improving patient care;
  • encounters that could have been handled just as well by a practice nurse under the purview of a doctor; and
  • prescriptions and procedures without evidence base.

Low value care is generally unsatisfying for both doctors and patients. While it remains so prevalent, it leads to a double-edged sword: the government shall find it hard to justify raising the rebates and GPs find it hard to charge what they are worth.

For example, when a 90-year-old patient with arthritis comes in to have a GP sign a disability parking form – a purely bureaucratic demand – it is hard for most GPs to charge.

Or the parent with a 4-year-old with autism, who has been sent by the paediatrician to the GP to “get a care plan so you can get free access to a speech pathologist”. For a start, such a scenario may not even qualify for a care plan and, more importantly, how is a care plan going to help that child?

The deluge of National Disability Insurance Scheme forms has taken GP low value care to new depths.

Leadership and unity

In my view, representation of general practice has lacked leadership and unity for too long.

There have been many voices with different agendas. Many of the voices have been distracted by political and vested interests.

There has also been a lack of authenticity, evidenced by the many experts, who are not GPs, offering their knowledge and expertise that, while well intentioned, is not accurate or realistic.

Dr Bartone has a big task in front of him. I wish him every success.

Dr Aniello Iannuzzi, FACRRM, FRACGP, FARGP, FAICD, is a GP practising in Coonabarabran, NSW, and a clinical associate professor at the University of Sydney.

 

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20 thoughts on “General practice: where the problems lie

  1. David Cilento says:

    Congratulations, Dr Iannuzzi !

    This is the most accurate & straightforward assessment & summary of the current condition of “GPworld” anyone has dared to set down … admittedly just in this professional magazine & not in the national press … of both persuasions.

    It should be required reading [that shouldn’t be too hard ! ] for the myriad “researchers” & highly paid advisers & journalists attempting to solve the puzzle of what’s happened to good doctoring in this special & beautiful Country of ours…. blessed & muddied in so many ways, but still shining with the dedicated.

  2. Dr Stephen Barnett, GP and Clinical A/Prof University of Wollongong says:

    Thank you Aniello for your insightful summary of the many stressors facing the general practice sector. With 2/3 of graduates now going into specialties, a ballooning healthcare budget and with the data showing that primary care not only saves lives but saves money, we need the co-ordinated leadership and unified ‘voice’ for the profession that you advocate. Let’s hope the incoming RACGP president, Dr Bartone and the Prof Ruth Stewart at ACCRM can build this voice together.

  3. Dr Rosanna Capolingua says:

    Once again, Dr Iannuzzi clearly describes the reality of General Practice and identifies a number of areas where small changes would release money back into Medicare rebates for patients and deliver real care with better outcomes, rather than paperwork and “tick box” medicine which has permeated Australian Primary Care.
    Such sensible commentary should be heard and acted upon.

  4. Neil Beaton says:

    Thanks Aniello

    Your article sums the plight of private general practice well.

    I am aware that rural doctors have ongoing deep concerns regarding viability of general practice overall and they are actively involved in the reform of Medicare through RDAA.

    A key issue seems to be that the community does not understand that the Medicare fee is actually their patient rebate and not a doctor fee. It has to cover all the on costs which are steadily mounting as you point out and unsubsidised practices are being non viable.

    This lack of community understanding means that it is difficult for GPs to lobby strongly without sounding “greedy” when the government promotes free care at the expense of GP viability and never explains the arithmetic to the general public. The realisation may come too late as access to a regular GP drops

    One other issue which is now an increasing problem in Queensland is that the option of finding hospital work for advanced and standard GP skills in the state system as a VMO in the public sector is hampered by:

    a) a VMO award and contract agreement being out of date and inadequate with a huge and increasing inequity between the SMO award and GP awards which is attracting GP VT graduates away from private practice and
    b) reducing opportunities for GPs to use their skills in hospital care through the complexity of credentialing and related administration problems when applying for work with HHSs and
    c) the decrease and lack of access to inpatient privileges (available beds) for GPs to use advanced skills or procedural skills and allow patients to access private insurance for inpatient and procedural care in country hospitals.

    Hence, although it is a major problem, it is not just the Medicare freeze and relative low value of fees as set by govt that has stalled GP income and placed the business framework at risk but it is also reduced access to alternative part time hospital work which is also being denied – a problem which will only get worse as the RG program extends.

    Finally, and sadly, it seems that private GPs are gradually being actively squeezed out of this more lucrative rural hospital work while specialists cream skim the best opportunities in rural and regional towns in favour of their new graduates particularly in emergency obstetrics and anaesthetics.

    Thanks for your article – I agree that the leadership needs to establish a strong front and I look forward to reading your solutions

    Dr Neil Beaton
    Atherton

  5. Peter (Melbourne GP) says:

    Thank you Dr. Iannuzzi.

    You have perfectly expressed what every RACGP member feels, many of the GPs I work with express the same sentiments. I really wish the RACGP stopped trying to be a political and advertising organisation.

    I am a recently fellowed GP with RACGP, and am already contemplating making the switch to ACRRM, if not to save money, then at least to protest the current nature of RACGP.

  6. Dr Richard Roffe says:

    Dear Aniello,
    Thank you for such a wonderfully accurate article.Finally we have a doctor who understands the complex difficulties faced by GP`s and who can express those difficulties so well.Kind Regards Richard.

  7. Dr Scott says:

    A good read for the most part, especially regarding the bizare, condescending and complete waste of money ad campaign for the RACGP.

    I do wish to point out one error that I have seen on this website several times: “It is still possible to attain a fellowship of the RACGP without ever having done cervical screening, excisions of skin lesions and intravenous cannulation.”
    This is false. As part of RACGP fellowship you have to complete a logbook which includes the above skills and be signed off by your supervisors as capable of performing them without supervision. At least this is the case with WAGPET (the WA training provider) but I’m sure it is part of the national RACGP curriculum.

  8. Anonymous says:

    I have been a supervisor for over 30 yeas and have never “signed off on a logbook” for cervical screening, excisions of skin lesions and intravenous cannulation for a registrar! (Training provider now GMT previously TMT) I HAVE signed off for medical students on these procedures. Having said that NO registrar has ever left our practice incapable of all these basic tasks!! And most of our medical students become reasonably competent during their time with us!

  9. Anonymous says:

    Years ago, when doing a year as an anaesthetic registrar, as preparation for GP, the director of Anaesthetics and Intensive Care advised me, “P—-, I’d drop the idea of going general practice if I was you, as you’re a natural anaesthetist, and I do feel GP is ultimately doomed”. I should have listened. That was 1977..! This article explains why he was right.

  10. Anonymous says:

    Congratulations on a beautiful succinct analysis. This type of article needs to reach the general press, but the risk is that GPs will be branded greedy and/or incompetent. There are many who need to seek out bulk billing GPs, the working poor ( people on low incomes for whom gap fee on top of full costs for PBS medicines is prohibitive) as well as people on government benefits. It is nigh on impossible to provide a quality service via a bulk billed environment. Patients aka consumers in the newspeak, need to be mobilised somehow to help address the problem. RACGP has been derelict in its duty to facilitate quality care. Escalating CPD requirements do nothing to improve patient care in the face of economic imperatives that reward fast throughput and tick box formulaic medicine.

  11. david nelmes says:

    a breath of fresh air in a world of political correctness and painfully accurate. I am a semi rural GP of 35 yrs standing and could not agree more as i come to the end of my practicing career

  12. Philip Dawson says:

    A great article with some good insights. I wonder about being able to get a fellowship without doing cervical screening, IV cannulation or excision of skin lesions though, none of our registrars leave here without being able to do those, we have been a training practice from when it started! Yes there are lots of administrative and bureaucratic hurdles. But in our 10 doctor practice we have enough staff to do most of that. We employ enough nurses so we manage to get most of our diabetics onto care plans, do all the over 75 medicals, etc. We even manage to do the over 75 health checks and drivers licence checks at the same consult to avoid two examinations per year! With a mix of bulkbilling card holders, private fees for everyone else and a reasonable industry base with lots of workers injuries we are doing ok, but I expect a purely bulk billing practice in a big city competing with free government clinics and the big corporates would struggle. Interesting that the governments so far have not introduced significant competition in any of the specialities. re useless paperwork, I think the quick computer generated forms required are not often a waste of time as they present an opportunity to review the health , medication, management etc of the chronic complex often confused patients who don’t always come for regular checks but will come when they need the paperwork filled in! Agree about the multiple different accreditation schemes and the ever increasing demands. We have to do QA and accreditations for RACGP, Medical Defense, Radiology licence, VMO status in local public hospital, practice accreditation, accreditation as medical Student teachers but thankfully Tasmanian workers compensation scheme no longer requires separate accreditation for that. Which means those specialists which refused to be accredited are now able to fill in the workers compensation certificates rather than flick them back to the GP just to fill in a form!

  13. MD says:

    The more medical specialist trained in Australia, the more expensive for the Australian government to maintain in the long run.
    Make all GP’s in Australia a fellowed specialist, likely less GP’s will be attracted to work in the rural and remote areas
    and there is chronic shortage of medicos in these areas will be ongoing.
    Appropriate medical Australian experience with government support and supervision is the Gold Standard of an effective and confident GP work in these area of needs, not taking too many qualifying exams that cost a fortune nowadays.

  14. Brian Morton says:

    Hi Aniello,
    A great article. It’s easy to identify with your comments. Good quality care takes time to communicate with patients. It’s a false economy propagated by Federal finance and health departments to squeeze remuneration for the most efficient sector of the health system.

  15. Paul Jenkinson says:

    Does anyone really believe GP will (is) a medical “specialty” that will exist in 20 years time?
    That young doctors will choose to be “your specialist in life” for a pittance?
    That young doctors will choose to be endentured to corporates for all of their career.
    Young doctors are smarter than that.

  16. Kylie Fardell says:

    Thank-you for such a concise and well written summary of the problems that face general practice. Your articles are always thoughtful but you’ve really outdone yourself with this one; I look forward to the next.

  17. Toff Beifong says:

    Just another +1/thumbs-up for a well-written article that resonates with me, especially for calling out RACGP for wasting their members’ money on their TV and movie theatre ads. It is bordering patronizing to both GPs and patients, and has the strong odor of insecurity. The Australian public is already well-aware that GPs are the front-line of medicine and can recognize a good GP when they see one. I have yet to meet a doctor or non-medical person who has said these ads were useful or eye-opening. I hope they stop this senseless campaign soon.

  18. John Deery says:

    Good roundup of problems.
    Solutions?
    I can’t get past patients making a co-payment to address the ‘low-value care’ problem.
    Yes, it will be difficult to wean patients from ‘free’ healthcare. However, what is the alternative?

    Leadership is lacking in General Practice (actually most of medicine).

  19. Peter Bradley says:

    We have just had (finally), a GP elected as President of the RACGP, who does not have his head in the clouds re GP, and where we are going, and worse, not going. So, let’s hope he can do some good. Dr Harry Nespolin is the first person to get into an office with some clout, who spells out what I have been banging on about for decades and getting no real hearing. Which is the need to get the direct bill of rebate and an up front gap fee de-linked, so one can offer the patient the convenience of both being direct billed, and pay a modest (as just paying the gap it would for once be able to be seen as modest) at the desk, and be done with refunds, etc. At the same time it would level the competition playing field, and as the value of Medicare has slipped so low, I doubt there would be a surgery in the whole country not charging some level of gap, at least to the so-called non-eligible patients, if we could just get this one Medicare rule amended. Go for it Dr Nespolin..!

  20. Raymond Yeow, BA MBBS says:

    I agree with Dr Peter Bradley, this is the number 1 benefit / issue that can transform GP landscape
    “Which is the need to get the direct bill of rebate and an up front gap fee de-linked, so one can offer the patient the convenience of both being direct billed, and pay a modest (as just paying the gap it would for once be able to be seen as modest) at the desk, and be done with refunds, etc….”

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