General Practice in the headlines... again...

I'm inspired to write my first post in years on this blog by multiple news reports over the last couple of months about the state of General Practice. To paraphrase Shakespeare, something is rotten in the state of General Practice in Australia and it is nothing to do with the efforts and skill of the local GPs on the coal face of healthcare.

Concerns over the ongoing financial viability of General Practice were raised again recently, culminating in a summit on the future of General Practice held a month ago in Canberra. The dire straits of General Practice funding come as no surprise to those working in healthcare, as the impact of years of indexation freeze and partial indexation of Medicare item numbers comes home to roost. 

Unlike other areas of healthcare in Australia, General Practice is almost completely run as private businesses that utilise Medicare funding, with no equivalent service provided in the public, state government funded system. This means that there is more pressure on GPs to bulk bill their patients as there is no public funded service to provide care for folk unable to pay private fees. This leaves General Practice particularly vulnerable to the vagaries of Medicare funding. This has resulted in a direct impact on our GP workforce - the proportion of medical graduates choosing to go into general practice has reached an all time low; GPs near retirement age are bringing forward their retirement; experienced GPs are quitting or reducing their hours and picking up other work. These workforce pressures are felt the most in rural and regional areas which have always struggled to find GPs, but even General Practices in metropolitan areas are struggling to find doctors now.

In a recent news report, a small country town in Queensland (Julia Creek) was offering a $500K package for a GP to work there without luck. Dr Michael Mrozinski, a GP that does rural work, has summed up well the reasons why recruitment is such a challenge on his TikTok. Spoiler - it's not about the money.

And talking money... What about those ABC reports on the 8 billion dollars leaking from Medicare due to poor billing practices by doctors? First a quick fact check - the figure of 8 billion dollars is dubious according to the ex head of Medicare's PSR and the MJA. Undoubtedly there are some doctors intentionally billing Medicare poorly, and even fraudulently, but the actual cases are miniscule compared to the errors in billing related to the ever increasing complexity of the Medicare schedule. The myriad of separate item numbers with specific clinical and administrative requirements, which have little relevance to actual clinical care, increases the likelihood of billing errors. So complex, in fact, that if you contact Medicare for advice because you have difficulty interpreting the clauses in the schedule the person you speak to is equally as unlikely to know the answer and will basically read back to you the same passage that you have just been struggling with. Rhetorically - how much simpler would it be if  item numbers were simply time based? How much easier and cheaper would it be to audit a time based schedule? Does a Medicare bureaucrat really need to know if I have mental health issues or was late for a PAP smear? My GP's time is as valuable whether they are checking my blood pressure or treating a sinus infection; and none of the clinical details need to be visible to non clinical folk who sort out the billing.

The simple solution would be for GPs to stop bulk billing and start setting the fees that would make their practices viable. This would probably help maintain the viability of General Practices, but would also leave less well off patients at higher risks of falling through the cracks

not enough jobs for junior docs

Unsurprisingly, the media is reporting on a shortage of junior doctor jobs for the 3000 or so medical students about to graduate from Australian medical schools.

Lets go back in time to the '90s... all the rhetoric in the early '90s was about the oversupply of doctors. The Medicare budget was blowing out, and the clever bean counter types looking at the supply and demand equation were convinced that this was due to too many doctors spruiking for business. There were 10 medical schools in Australia and there was a rumour that there were plans to decomission one of them bringing the number back to 9; the government of the time put caps on vocational training places (particularly in general practice). This, of course, was a bit of a surprise to the doctors out in the commuity who were having diffculty recruiting other doctors to work with them and hadn't had a holiday for years because of lack of cover.

It didn't take long for the real truth to emerge in the numbers. Far from an over supply of doctors, there was actually a shortage. This was brought to a head by the limitations in training places. All over the country, communities were reporting difficulties accessing medical care (general practice and specialist). Demographers started to pay attention to the aging medical worrkforce.

Lets fast forward a little - a decision was made to open up medical school training places. This would supposedly produce all the doctors we need to fix the shortage... The universities were more than happy to put their hands up to run medical training; after all medical schools are prestigious things for universities to have. More and more universities started announcing medical schools, and the number of medical graduates has more than doubled.

Somebody forgot to consider that, for doctors to be able to work in unsupervised in the community where they are needed, a they need a period of vocational training in supervised jobs. So here we are in the ludicrous position of simultaneously having ongoing medical shortages in the community and a shortage of supervised junior medical jobs.

The sad thing is that this was not unexpected. For several years there have been senior doctors expressing concerns about the rapid expansion of medical schools in Australia and the capacity of the system to take on junior doctors.

What's the best way forward?

The government is keen on expanding training outside of the major public hospitals. As a concept this is laudable - the test will be putting it into operation and ensuring that the quality of supervision and the adequate safety measures are not compromised. Will smaller private hospitals (the bigger ones already take junior docs) and nursing homes have sufficient numbers of medical staf around to ensure adequate supervision? Will the breadth of clinical presentations and scope of practice provide enough valuable experience for junior docs? Will there be enough support for training within the infrastructure of these organisation?

Time will tell.

It is a difficult time to be a new graduate. My thoughts and sympathies are with all my junior colleagues out there about to take on the big adventure of meidcal practice.