The case of the vanishing GP

I took my grandchildren to the museum recently where they looked with curiosity at a relic that existed only 20 years ago - we viewed a hologram of a GP’s surgery from the year 2008. Typically, they thought I was very ancient to have actually visited a GP who knew me personally, knew my ailments and was subsidised by the federal government to provide healthcare.

Now in 2028 those who can afford it can go to a full fee paying clinic where they receive some of that personal attention. However, these clinics are few and far between as GPs are scarce.

In 2028 those people - the aged, low income and chronically ill - who need that personal care formally given by a GP can sit for long hours in crowded public hospital emergency rooms or even die without treatment. At each visit they see a different doctor who reads the brief medical notes: but is no continuity of care.

Is this little journey into fantasy fiction just nonsense? Well, given the current state of primary healthcare, I wonder.

Our Prime Minister has promised he will fix the health care system in Australia. He has promised that “the buck stops with him”.

At a recent COAG meeting Prime Minister Kevin Rudd and Nicola Roxon, Minister for Health and Ageing, gave money to the states to address the efficiencies in the public health system i.e. the hospitals. However, one of the problems for the hospital system is the increased numbers of people attending emergency units. The 2007 Australian Health Ministers Survey noted that 75 per cent of people attending emergency departments did so directly because of poor access to GPs.

In Queensland, Stephen Robertson, Minister for Health, attributed a 4 per cent increase in the number of emergency department patients at the Princess Alexandra Hospital to a shortage of GPs.

The problems associated with a shortage of GPs - a federal responsibility - are transferred to the hospital system - a state responsibility. This is particularly a problem in inner city areas and rural areas.

It is difficult to address public hospital efficiencies without addressing the issue of access to GPs. We are aware of the difficulty that rural people experience in accessing GPs and as an attempt to rectify this, the previous federal government created areas designated as “district of workforce shortage” (DWS). It is only in these areas that overseas trained doctors (OTDs) are allowed a provider number which gives them access to Medicare. They are allowed to work between 8am and 6pm. OTDs are able to be employed out of hours in other areas.

The reality is, however, that many inner metropolitan medical practices are also experiencing problems employing doctors.

One of the reasons GPs are a vanishing profession is that many medical students no longer see general practice as a desirable career. GPs work long hours and are poorly paid, largely because the Medicare rebate no longer reflects the true cost of a consultation. The GPs we do have are ageing.

It is probably because of these problems that many doctors are moving their clinics to “specialities” such as weight loss clinics, skin clinics, wellness clinics, vitamin therapies and so on. These cater for a niche market, mostly do not bulk bill or provide general practitioner services. Even so, the Department of Health and Ageing classes these places as GP clinics when looking at ratio of population to doctors.

As part of the solution to the health system, the Prime Minister has committed the federal government to establishing super clinics. These are planned for outer metropolitan or rural areas. They will not address the problem of the shortage of GPs in inner metropolitan areas.

The vision for these super clinics is that they will house GPs as well as allied medical professionals. The federal government is offering “incentives” to doctors to work in them, thereby putting them in direct competition with private practice GPs. In reality the government has to find the GPs first. The Australian Medical Association (AMA) has lodged a submission to the federal government pointing out the concerns (The Courier-Mail, March 14, 2008).

Another long term strategy the Howard government set in place was to increase the number of university places to train doctors. At present in one Queensland university a quarter of the students enrolled in medicine are full fee paying. This means they are not necessarily available for the Australian workforce. Anecdotal evidence suggests this percentage is higher in some other universities. Since the late 1990s the number of GP training positions have declined which means most students will move into other specialities.

Here is an example of the problem.

The Logan Road General Practice, Stones Corner is situated in “inner metropolitan” Brisbane in the heart of the Prime Minister’s electorate of Griffith. It is a long established practice that services not only the residents but also the commuters from the outer suburbs who work in the area. Patients are largely those with low incomes, refugees, the aged and chronically ill, as well as the young professionals who are moving into the area. It has about 4,000 patients on its books and is one of the few practices which still bulk bills (under certain circumstances).

The practice is in danger of closing for the simple reason that they are not permitted to employ an OTD.

A few years ago in the same shopping strip of Stones Corner there were four practices. Now, a practice further down the road in Greenslopes will close very soon. With both these practices closed, 7,500 patients will be looking for a GP: it also means that on a line from Kangaroo Point to Holland park there will be no GP.

Most neighbouring GP clinics, already over-burdened, have closed their books to new patients.

A group of concerned patients, together with the practice owner Dr Janet Clarkson, set up a survival campaign. Letters were sent to Mr Rudd, Ms Roxon, the AMA and other appropriate people. Unsurprisingly, and without fail, the replies have been conciliatory and ineffective. Mr Rudd’s reply listed the virtues of the proposed super clinics; medical peak bodies replied that their surveys had indicated a problem.

Ms Roxon told the local newspaper South-East Advertiser (March 26, 2008) that patients could attend a super clinic to be built at Coopers Plains, about 11km away, which will “service the needs of Brisbane’s southside”. Luke Royes, a reporter from that paper, travelled from Stones Corner to the proposed site. It cost him $46.00 (one-way) by taxi and took 14 minutes outside peak hour time. By public transport, he needed three changes of bus and a trip of 40 minutes. How accessible is this if you are ill, aged or a pensioner? Imagine doing this trip with an attack of diarrhoea.

Of course, no one quite knows when this super clinic will be built, so where do patients go in the meantime?

This campaign has brought into sharp focus the urgency of reinvigorating general practice in Australia as it is evident that this is a problem facing many inner metropolitan medical centres throughout Australia.

It seems to me that access to good primary healthcare, which a family GP provides, goes a long way towards easing the overall health system problems in Australia. At present that is under threat by the decline in GP numbers, the inability of existing practices to employ OTD doctors and help doctors who have left the profession return. All this is exacerbated by the decline in the numbers of practices that offer bulk billing. (Mr Rudd’s electorate has a bulk billing rate that is 11 per cent below the national average of 67 per cent.)

Some short term solutions that have been suggested to Mr Rudd are:

• ease the placement requirements for certain overseas trained doctors. For example, an OTD who has family commitments should be allowed work in a these doctors have to work in a ” district of workforce shortage”, work after hours or leave the profession. Skills are lost to the profession, the community and the economy;
• OTD who are Australian citizens and are fellows of The Royal Australian College of General Practitioners should not be obliged to work in a DWS;
• make access to re-skilling easier for doctors who have left the workforce for various reasons and who may be induced to return. This would include help with medical indemnity and cost of re-skilling;
• give support and incentives to doctors who would prefer to work part time;
• make bulk billing more attractive for GPs; and
• increase the Medicare rebate to reflect the real cost of a consultation.

So, this story of a medical practice in the Prime Minister’s electorate, struggling to serve the community, highlights the urgent problems facing the Australian healthcare system in providing for some of the most vulnerable people in our community.

We have set our case out here.