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 (part 4) ...and yet more Medical Schools...

"CURTIN, Charles Sturt and the University of South Australia will press ahead with their plans to create new medical schools."

In the midst of concerns about intern positions for medical graduates, 3 universities have announced their intent to move forward with plans for more medical schools (and more medical students). Australia is apparently not training enough doctors.

It is undeniable that there is a shortage in the medical workforce, especially in rural areas. However, the bottleneck in training is not at the medical school level. In order to produce doctors that are able to work independently and service areas of medical workforce disadvantage we need to create the supervised junior and training positions to provide vocational training.

Without adequate resourcing of junior medical positions, including indemnity (which is potentially a barrier for moving training into the private sector), and adequate resourcing of the time needed from senior doctors to provide the supervision that junior doctors require, bumping up the number of medical graduates does very little to improve workforce shortages. It makes absolutely no sense to increase the number of medical schools and thereby increase the number of medical students, until the issue of adequate supervised junior positions and vocational training is resolved.

Senior medical folk associated with the universities need to seriously consider wisdom of creating new medical schools at this point in time. If the unit you work in is unable to accommodate any more junior doctor positions (due to funding or availability of adequate supervision) then the rationale for increasing the number of medical graduates is probably difficult to justify.

not enough jobs for junior docs (part 3)

This week, The Australian again reported on the lack of intern places for medical graduates. It is encouraging to see that the various interested parties (students, deans of medical schools, professional organisations) are starting to reach some level of agreement about what needs to happen. Now if only the people who make the decisions will listen...

Creating intern positions involves more than just putting aside money to pay their salaries. Medical interns are just out of university - they have a fair amount of book learning but don't actually have the context with which to use this knowledge safely. They need a hell of a lot of supervision. In order to have interns working safely, there needs to be training and infrastructure to support the senior doctors providing supervision, money to pay for supervisors' time, and adequate senior staffing levels so that supervisors can provide adequate oversight. I haven't heard any murmurings of this happening any time soon.

The Problem With Acronyms

At some point, haven't we all stopped and looked at a clinical record or a discharge summary and been completely confused about the multitudes of abbreviations? Is "BSE" bovine spongiform encephalitis or is it breast self examination (getting that wrong could be a mite embarrassing)? "NFR" could mean not for resuscitation of no followup required... maybe not so different after all.

Here's a story I heard from a colleague recently... Once upon a time there was a hospital of reasonable size which had all the usual bits that hospitals do including A&E, critical care, orthopaedics, cardiology, renal medicine, etc. It also had an inpatient mental health unit that had an acute unit and an attached longer stay or chronic care mental health unit. Working in this hospital was a psychiatry registrar who was doing the psychiatry on call shift one particular evening.

The registrar was called by a cardiology colleague in relation to a consult request.There was a patient who was in recovery from bypass surgery with a history of depression, and the team was worried that it may take a turn for the worse following surgery. The psychiatry registrar obligingly offered to go and have a chat with the patient in the coronary care unit (CCU) - he informed the nurses in the inpatient acute mental health unit that he would be "in the CCU" if needed as he realised that his mobile phone would need to be turned off in the monitored area.

Unfortunately, in the world of mental health treatment, the term CCU refers to Chronic Care Unit. An incident occurred within the mental health unit that evening, and the nursing staff tried to ring the registrar... the phone was switched off. They contacted the Chronic Care Unit... the registrar hadn't been there the whole evening. The poor registrar had a complaint made against him for not being contactable whilst on call.

It is easy to rely on acronyms as they are much quicker to say and easier to write... but there are risks...

Midwives, Professional Indemnity and Homebirths

I have been reading a lot of comments in the media recently about how new requirements for professional indemnity for midwives will make homebirths illegal and drive them underground.

One of the key sources of angst voiced by midwives is that the federal government pays for the indemnity for obstetricians and GPs, but will not pay for midwives. This is either a clear lack of understanding of how indemnity works or a deliberate attempt to mislead the reading public.

Doctors who deliver babies in the private sector pay for their own indemnity insurance and the premiums that they pay are substantial. The government provides a guarantee for claims above 20 million dollars, they don't actually pay the indemnity insurance premium.

The reality is that, if people highly value the homebirth option, then they will pay the midwifery fees that are commensurate with what the insurance organisations charge the midwives as premiums.

Nobody is "picking on" the midwives, they are simply expecting them to operate under the same, responsible framework of practice as everybody else. The move to national registration for all health professionals (medical, nursing, physiotherapy, pharmacy...) will mean that all health professionals will need appropriate indemnity cover to be able to practice. Surely that is a good thing.