It might surprise many that Health Minister Mark Butler has signalled that the most important challenge facing the Australian health system is not the ongoing effects of the pandemic, or monkeypox, but rather the impending crisis in general practice.
Outside of public hospitals, access to family doctors is one of the most cherished parts of our “universal” healthcare system.
Concurrently, the industrial arms of general practice and the Australian Medical Association have launched a media campaign threatening imminent closures of practices, and withdrawal of services to those who can’t pay additional out-of-pocket costs. The demands are focused on a 10% increase in the Medicare rebate for time-based services. However, there’s no evidence that increasing Medicare rebates actually leads to lower costs for patients.
In truth, new solutions should be on the table. They include a much greater focus on redistributing the division of labour between health professionals; extensive use of new digital technologies for assessment, service delivery and care coordination; support for team-based rather than fee for service-based care. Rewarding the tracking of outcomes rather than paying for each service provided should be central. Clearly, using funding mechanisms to enhance services to those most disadvantaged by age, geography or socioeconomic status has to be a national priority.
Butler has established a “strengthening Medicare” taskforce to urgently review these options. He has stated that he has already had “frank discussions with the doctors” on the need for serious reform. Consistent with his statements, the terms of reference for the review are much broader than a simple focus on more money. But this is where things get really hard.
The truth is that Australian general practice, based largely on the 1950s British model of easy access to basic care, is in rapid decline. It was conceived at a time of relatively low use of specialised medicine and technologies; few very expensive pharmaceuticals; less illness burden due to chronic disease and ageing; an emphasis on home visits and after-hours care; non-recognition of the impacts of conditions like anxiety, depression and substance misuse; easy access to a medical workforce.
In the 21st century, young doctors — and their informed and cashed-up patients — have voted with their feet. Being really good at specific things and delivering more expert care are far more attractive to young doctors. It is also what more informed patients demand. This is a worldwide phenomenon and one where digital technology is increasingly relevant. There is a massive unmet demand for better care that is more convenient, readily available, price sensitive and directly available to the customer.
Consequently, new “supply” chains of health services are well advanced. Many doctors assume that the “Uberisation” of healthcare — particularly the more straightforward aspects of primary and chronic care (think illness screening, health information, repeat prescriptions, blood test monitoring, telehealth reviews) — can’t happen. They assume government regulation, professional obstruction and public resistance will prevent it. I’m sure taxi drivers, local bank staff and hotel managers made the same wrong assumption.
This process of diversification of care pathways is well underway. Despite the howls of protest from the industrial arms of Australian medicine, a whole range of direct-to-consumer services, backed by technology platforms and a mobile medial workforce, is thriving. You can get the assessment online, doctors write scripts or referrals to specialists, and the medicine you want gets delivered in the post. No lining up in a doctor’s surgery, paying additional costs or spending time and effort on things you don’t need.
Additionally, the movement of general practitioners to more specialised forms of practice — those more rewarding financially and personally — is well advanced. Have you ever visited a GP-run clinic for dermatology, sports medicine, paediatrics, women’s health, mental health or 24/7 emergency and got a far more expert, accessible and affordable service than from a generic family practice? My family members have done exactly that and the experience has been great. That’s not to mention the extent to which GPs have moved to other less essential but financially lucrative areas like cosmetic practice.
So there is no stemming the tide away from traditional family practice. As Butler has noted, only 15% of Australian medical graduates are planning to be GPs. We will shortly run out of Australian-trained GPs as the workforce ages and retires. We are also short of specialists in many key areas like mental health.
No matter what other structural, workforce or training reforms are implemented, we will still need many more doctors — and many other health professionals (think nurse practitioners, psychologists, physiotherapists) to take over the roles previously performed by GPs.
Another important option is opening our borders to international medical and other health professionals. An emphasis on attracting those who have worked in team-based care systems would be very attractive.
The “closed shop” approach of Australian medicine has largely resembled that previously expressed by Australian pilots, namely only “Australian pilots can fly in Australian skies”. When they withdrew their services, Bob Hawke took decisive action. As Prime Minister Anthony Albanese models himself on Hawke, we may now have another occasion where such decisive action is required.
This article was edited post-publication on August 30, 2022. An earlier version of this article incorrectly referred to the Australian Medical Professionals’ Society instead of the The Australian Medical Association.
I was pleased to read that Ian Hickie’s family had a great experience visiting the specialist clinics run by GPs, but that anecdote isn’t the outcomes data he says he wants. In fact there’s no-one with any expertise in health policy suggesting that a move away from community-based generalist care – general practice in Australia – is a sensible direction for the health system to take. The outcomes data is well known to everyone except Hickie. Barabra Starfield showed in 2005 that health systems based around primary care produce better health outcomes across the whole community, are fairer in enabling health care for underserved groups, and are cheaper than basing your system around specialist secondary care. The Paradox of Primary Care – that GPs follow strict guideline-based care less often than specialists, but get better health outcomes, as well as being cheaper and more fair – is only a paradox for those who don’t understand general practice.
Hickie pretends that GPs don’t want health system reform, but GPs are the ones who stay with their patients when they can’t afford the higher out of pocket costs for psychologists and psychiatrists, the long waiting times in the public mental health system and the apps and websites that require levels of literacy and technical ability that are beyond them. Underfunded and undersupported, GPs would love reforms that benefit our patients. Hickie’s suggestions are not these reforms. His suggestions would lead to worse inequity, less access to the human interactions essential for mental illness care and mental health protection. That Hickie thinks that all GPs do could be replaced by an online assessment, a prescription and a referral, or that “Being really good at specific things and delivering more expert care” is not what GPs are doing is surprising, and frankly insulting from a medical colleague. GPs are really good at many specific things, including the specific things of primary care specialism that improves the health of populations. GPs provide expert care in multimorbidity, in preventive health care, in behaviour change, in co-ordination of teams, in early diagnosis, in the management of uncertainty. It would at least be entertaining to see him sit the FRACGP or FACRRM high level exams for qualification as a GP in Australia.
Hickie sets up our own medical profession as a “closed shop” and an “industrial arm” – straw man arguments if ever there were two – to suggest that any suggestion of reform that includes increased funding for primary care can only ever be self-serving and wrong.
Curiously, the same arguments could be levelled against Hickie’s proposals. There is no evidence yet that widespread use of mental health apps and scoring has any effect on outcomes. But should this approach be funded by the government it would be quite possible that Hickie would personally benefit from his stake in Innowell, an interest that wasn’t declared in his article.
A good GP will navigate and “Project Manage” a patient through complex and potentially multi specialist needs.
This article doesn’t match what I saw with some relatives where a good GP made a larger difference to their overall health than narrow focus (and broadly deskilled specialists).
Same experience in enterprise critical very large scale complex IT projects, technical specialists needed to be utilised with care and in context – often they were quite oblivious and dangerous outside their deep but narrow skills and often they could not see the broader picture when considering a course of action.
Perhaps I have misunderstood the thrust of this article – but it doesn’t match what I have seen both in a complex and advanced IT career and some family members complex multi specialist health needs.
I will always want a good GP across all my medical needs, just like a good IT Project/Program Lead to adequately understand all IT specialist proposals/designs.
Totally agree. That’s been my experience too – both with GP’s AND IT professionals.
While some good points are made here, especially about coordinated team care, you have failed to address the underlying issues and greatly underestimate the value of the generalist. The article has a distinct flavour of having been written by one with little or no general practice experience, although I am also guilty on this front, as a subspecialist paediatrician.
The GP has been at the core of British /Australian medicine for many years and there are good reasons for this. It is also one of the hardest and most demanding jobs in medicine – I have the luxury of being able to take a “test everything, do everything” approach without much fear of criticism ( although such criticism would be warranted ). The GP, on the other hand, must pick out a) who really needs to have the book thrown at them and b) who needs a lot more listening and exploration, while filtering out the less serious/urgent stuff, always with the knowledge that sooner or later some smart-arse medicolegal doc will, two years after the event and with the wisdom of 20/20 hindsight, tear them to shreds.
The other critical rôle is as the generalist who will pull together the various strands of subspecialist communication/miscommunication and help the patient to make some sense of it all, greatly helped by a prior relationship with the patient. This after having tried to filter out which specialist is most appropriate.
As medicine becomes increasingly subspecialised this function is even more critical – not all chest pain is cardiac and not all abdominal pain is intestinal, some psychiatric presentations are truly psychiatric, others reflect organic pathology ( setting aside the argument about genetic/organic basis of psychiatric illness ). The patient may well not know which specialty is needed, nor which particular specialist ( horses for courses)
The US model, in which the patient has a cardiologist, a gastroenterologist a thoracic physician etc etc and often no generalist is a recipe for bad medicine at vast expense, as we have seen for years ( 17% of GDP on healthcare and stats which would get the health minister of many middle ranking developing countries either sacked, jailed or shot, depending on the country )
The GP must do all this while trying to feed their family and run a business on a pathetic government rebate, a rebate which has not changed for almost a decade. It is the most under-valued specialty in medicine, while being generally the most important. We need to look seriously at a) significantly increased funding for the GP, this to happen NOW and b) the development of models which reward taking time with families, coordination of care and provision of long-term prevention and follow up.
The existing FFS mechanisms mean that the only way to run a viable practice is to practice “6 minute medicine” , which meets nobody’s needs, so a short term “once off ” increase in rebate to buy political time is never going to cut it on its own..
Thanks for your comments and explanations.
The answer to this is simple. Pay GPs what they are worth. I have been on both sides of the fence, I once was a GP but I then specialised. I chose to specialise after a time in general practice, not for the cash, but for the intellectual stimulation.
But as they say, money talks. A comfortable lifestyle would be a great attraction to not try and get yourself on the specialist college merry go round, competing for training places, exams, and all the rest.
And what’s a medical practitioner worth? I’d say about the same as a top barrister, top end public servant, or a Minister of the Crown. Somewhere in the mid 300k range. You want the person who has your balls in their hands (figuratively and literally) to know what they are doing, and that costs.
Maybe the pathways other than general practice are too lucrative. Nobody ever asks the question, what is a reasonable income for a medical practitioner? The only answer we get is the same as other specialists. My thought is medicine in all it forms should generate lifetime earnings the same as other professionals, e.g. engineers, lawyers etc. We are paying specialists as if they are the best in the world, which if their salaries matched their worth we would be constantly flying them across the country and internationally to best use their expertise. Mind you the argument with the cataract surgeons who were reaping huge profits as techniques improved did not end well for the government.
Those exaggerated incomes in the high 6 and even 7 figure range are enjoyed by very few. Most specialists would be lucky to earn, after expenses, much over 350k.
And our specialists are in fact the best in the world. For the most part. Our training standards are among the highest, and our outcomes among the best worldwide.