In the second of this two-part series, Dr Aniello Iannuzzi offers some ways forward for general practice in Australia. Part 1 can be found here.

DONE well and pursued to its potential, general practice is rewarding and fulfilling. Moreover, it is unquestionably the medical specialty that has the maximum utility and benefit for the community.

My last article highlighted the major problems faced by Australian general practice. This time, I offer some solutions to the GP blues.

The Royal Australian College of General Practitioners (RACGP)

The College has a once-in-a-generation opportunity in the next few years. The planets have aligned to offer the RACGP:

  • a huge membership, with the buckets of treasure this brings;
  • resumption of direct control of GP training; and
  • a tsunami of applicants for GP training.

In simple terms, this equates to money, power and workforce. Consequently, there can be no alibis for not offering world-class training, with the highest of standards and assessments and selection of registrars.

The RACGP also has a major advantage over other Colleges in that it has negligible hindrance from the cumbersome state hospital systems, allowing it to be agile, flexible and innovative.

The College should unapologetically set learning objectives that are academically rigorous, thoroughly assessed, and objective. It should not cave in to complaints from those who are unwilling and unable to pass tough assessments and who refuse to attend minimum pre-requisite experiences.

Some simple measures that could be easily and rapidly introduced include:

  • a logbook of patient numbers, caseload and procedures;
  • written exams that demonstrate competence in writing reports, referrals and patient advice;
  • viva voce exams that also include long cases; and
  • a mini-thesis demonstrating an understanding of the Australian health system and primary care.

Naturally, there will be protests. The assessors will complain about cost and the time it takes to run such assessments. The registrars will complain that it is all too new and too hard.

However, if GPs are to shake the reputation of being the bottom of the medical food chain, they have to earn it, rather than buy it with an advertising campaign. Nothing short of a radical redirection of College energy and spending will achieve this goal.

Both Colleges

The government looks to the medical Colleges for expertise and advice in many areas. Most Colleges are assigned the role of advising government about whether doctors meet certain criteria to access Medicare and clinical privileges in hospitals.

While government funding can be helpful, the RACGP and the other general practice College, the Australian College of Rural and Remote Medicine, need to maintain independence in respect to how Colleges and their members practise as doctors. It is vital that both GP Colleges remain independent so that they can maintain standards and education without interference.

Medicare

The recent experience with after-hours item numbers has demonstrated that the item numbers themselves are often the problem and that redefining item numbers can have quick, efficacious results (and here).

While the Medicare Benefits Schedule remains founded on time-based attendance fees, volume overservicing will persist. However, capitation and fund-holding risk the opposite; the incentive to work hard is taken away.

Australia needs to conduct a mature discussion about the merits of a copayment. Labor in the Hawke era and Liberal in the current era both dipped their toes in the copayment pool only to find it too scary. Yet, in our society the idea of “user pays” appears licit when it comes to energy, education, roads and parking, and even pharmaceuticals.

By legislating to permit voluntary copayments in addition to the direct-billed scheduled fee, the federal government would allow a sensible middle ground to emerge between the high output bulk-billing clinics and expensive private clinics. In my opinion, this would also go a long way to solving any overservicing with respect to procedures and diagnostic services.

Such legislation would reduce the financial reliance on care plans we see in general practice. It is plainly obvious to those of us in general practice that care plans are being rorted, abused and distorted, sometimes naively by those who are not au fait with the regulations. However, once the financial necessity for care plans is relieved, the care plan item number mess can be tidied without lethal political and financial repercussions. It is worth keeping in mind that many good GPs were issuing care plans to patients long before the care plan item numbers came into existence.

Decline of small and medium private general practices

Above-mentioned reforms may also remove much angst for those in or thinking about small private practice. As things stand, practice owners have to choose either full fee, which many patients find out of reach, or bulk-billing, which means reliance on high volume and care plans. By allowing a middle ground for fees, the threat of corporate and government clinics is not as ominous.

It’s important to preserve small and medium practices, as they provide diverse and individualised services. Smaller practices offer flexibility, geographical penetration and agility that the larger models do not permit.

Political leadership is needed in addressing the challenges that apply to Australian small and medium businesses.

Thankfully in some areas of need (not all), local councils create incentives for doctors wanting to establish practices.

State governments could offer payroll tax relief to general practices who take registrars and students. Interestingly, some state governments already offer payroll tax relief to businesses who take trainees; sadly, this does not apply to medical trainees. Because the other medical disciplines are trained in the state hospital systems, no payroll tax applies to those registrars. Therefore it appears that those who train medical students and GP registrars are getting a raw deal.

State governments could also do a lot to enhance general practice by making their hospitals more “GP-friendly”. Things that should be improved immediately include communicating better with GPs, allowing GPs access to inpatients and creating GP-training terms within the hospitals..

Workforce

Federal incentives need to be more targeted, especially in areas of workforce shortage.

Rules need to be tightened so that incentives to work in a coastal or island resort towns are no longer the same as those in less affluent inland towns. An inland indexation would be an improvement as inland towns find recruitment and retention harder than coastal towns.

Certain commercial interests and structures need to be excluded from relocation and retention grants, allowing money to be better directed to doctors who are willing to invest and reside in areas of need. As things stand, locums and fly in/fly out doctors can get the same incentives as genuine resident doctors; hence, this promotes cherry-picking and rorting, not relocation and retention.

Accreditation

Ideally, the next iteration of standards that govern accreditation should be half the number of words of the current tome.

Accreditation need only focus on important areas of safety and quality. It should not be about micromanaging practices. Meaningless and statistically invalid patient surveys, questionnaires and checklists that drive much of the accreditation process should be tossed out the window without further delay.

We are enamoured with evidence nowadays – let’s see some randomised trials comparing practices that accredit versus those that do not!

Low value care

There is a perception among some members of the public and other medical specialists that GPs are simply paper-shufflers and blood pressure checkers. Better trained and less financially stressed GPs may be more confident to push back against this low value care plague. Consultations could become more professional if GPs were able to spend more time looking at the patient, rather than watching a computer screen and scribbling on forms.

Leadership and unity

At this point we again turn to Dr Tony Bartone, the new President of the Australian Medical Association. We look to him to usher these important discussions not only within the profession but also in the arena of policy makers.

Carpe diem.

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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3 thoughts on “General practice: some ways forward

  1. Peter Bradley says:

    Aniello, I’m delighted you specifically mentioned this…

    “By legislating to permit voluntary copayments in addition to the direct-billed scheduled fee, the federal government would allow a sensible middle ground to emerge between the high output bulk-billing clinics and expensive private clinics. In my opinion, this would also go a long way to solving any overservicing with respect to procedures and diagnostic services.”

    Especially in the light of this part below, (part of my comment posted to your first part). As it looks like you are going to have support for this proposal, for the first time spelled out, by the new incoming president of the RACGP.

    “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.”

  2. Gerard Gill says:

    Aniello,

    You have been very good at pointing out the problems and opportunities for general practice. What you have left out needs some addressing. The AMA has failed general practice because it represents the practice owners, not the workforce. It has also unlike the college of surgeons been prepared to say to the robber baron segments of the profession that the predominantly taxpayer subsidised income discrepancies in the profession and if the truth be known between those dominated by women and those by men based are immoral.
    You have also let the university medical schools off lightly. While we have not got the around 10% attraction to general practice that some UK medical schools get, no Australian medical school has the 45% conversion to general practice needed to sustain general practice. UK evidence suggests that poor choice of students (UK students from the average public funded school are more likely to become GPs rather than the selective or private school students who form the majority of Australian medical students), bad mouthing and limited exposure to general practice all contribute to this low recruitment.
    We also need to hold the university rural clinical schools to account for the poor conversion of their Australian Graduates to rural general practice.
    Nostalgia is good when life seems tough but the Key Feature component of the RACGP exam is a written exam and sorts out bad candidates in my experience fairly well. Show me evidence that your concept of a stricter written exam does better.

    I look forward to a cordial face to face discussion with you sometime.

  3. Chris Briggs says:

    How is this chap not RACGP president?! I absolutely agree with everything said in both articles.

    It is difficult to gain the respect of patients and colleagues whilst providing low-value care in a mostly bulk-billing, time based environment. However, it is equally difficult to charge patients the full cost of what our time as specialist trained doctors is worth. Care plans are definitely not the answer, a low-yield use of tax-payer dollars, whilst college advertising is the RACGP’s version of wasted resources.

    I would love to set up my own small-medium practice, but am completely put off by both the financial risk given the lack of medicare funding for the profession, and the red-tape involved. I agree that the march towards large corporate practice needs addressing.

    I wish I had the answers, but thanks Dr Iannuzzi for articulating the issues so well.

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