26th June 2022, Dr Chee L Khoo
Tell me, what time did you get home last night? When did you last work a Saturday or a Sunday? When did you last truly spend time with the whole family? I bet you still fly economy class when you last went overseas. I am not telling you anything you don’t already know. Our rebates have not gone up for > 20 years. We continue to go backwards. We continue to be asked to prop up the health system to the detriment of our personal and professional health. Our income continues to fall further and further behind while the rest of society just zoom past us. We work longer and longer hours to make ends meet. Yet many of us continue to bulk bill our patients. Some of you don’t know anything better. Others do it because they do not feel that their patients can afford to pay. Yet others do it because of the fear of losing patients.
I have been a GP for 32 years now. Over that time, I have seen general practice radically transformed into a full specialty on its own. We have to thank our forebears at the RACGP who had the foresight to transform general practice into a specialty in its own right. We are no longer referralogists. We not only treat acute illnesses and save lives, we also keep the community healthy through our preventative measures. Why do you think Australia is one of the top 10 healthiest countries in the world? We are also mental health specialists as well. Despite the supposedly widely available mental health services under Medicare, as GPs, we look after the bulk of mental health illnesses in Australia. 90% of patients with depression are managed by their GPs. Many of you who have experience in other countries can see what a vibrant and professional specialty general practice is in Australia. Yet, we languished very, very poorly financially compared to our other specialist colleagues. Actually, we even languished below the average tradie!
Most of you would have noticed that over the last 20 years, the pile of paperwork has just exploded in our face. At least 30% of our time is taken up in filling in forms – centrelink, workers compensation, clearance to return to work, immunisation registers, driving medicals, over 75 year old driving clearance, disable parking and the list just goes on and on. It’s a wonder we have time to do anything else.
The pandemic really crystallised how much work we do on behalf of the community with very little remuneration for all the extra work. Remember the 8-10 pages we have to fill in to register the practice for covid-19 vaccination. Remember the 6 hours online course we had to do before we could vaccinate patients with any covid-19 vaccines. Of course we have to pay our nurses to do the course too. And there are the ongoing silly questions with the vaccine stock receivables and weekly stock management reports that nobody actually monitors and ever see. I am not sure whether to laugh or cry at questions like “who is the delivery driver” or “Are you sure the questions you answered is correct?” or “Did you put the vaccines in the fridge immediately” or “Did you put the eskee away?”. Seriously?
Are you sick of consent forms after consent forms for the vaccination? For those of you who write exemption certificates, try tracking down that elusive form. And to scan through the conditions that permit an exception that changes every week. What about finding out who is next in the priority group for vaccination, who needs the booster and when and who qualifies for the anti-virals (without interference from some specialists)?
While we get paid per patient we vaccinate with Covid-19 vaccine, I am not sure that it pays for all the time it takes to roll that out. Some of you were clever enough to stay clear of the vaccination. If there is another vaccination drive, I am not sure I will put my hand up again. Of course, my workload has increased because my practice nurse is tied up jabbing patients and observing them. She was employed to make my life easier to enable me to spend more time with patients. In the meantime, reception is busy checking and scanning consent forms while the phone rings hot.
The business side of general practice
How did we get here? Obviously, we know how we got ourselves in this predicament. We can blame the government for falling behind on the rebate increase over the last 20 years. We must also share the blame for accepting universal bulk bill. With bulkbilling rates running at 70-80% for general practice, why would the government increase the rebates. We have also spoilt our patients to expect all general practice consultations to be “free”. We also worry on our patients’ behalf that they cannot afford out of pocket fees when they see their family doctor. Yes, there are genuine cases of patients in financial hardship but it’s not universal.
Consequences of poor remuneration
This is not rocket science but there are hidden costs. Decreasing profitability means our personal income drops in the midst of rising inflation and rising cost of living for all of us. But it also means:
- Reduced capacity to hire more qualified non-medical staff (everyone out there pays better than what we pay our medical receptionists)
- Reduced capacity of smaller practice to employ more GPs leading to increasing corporatisation of general practice
- Reduced capacity to purchase more up-to-date equipment which helps us do our job better (e.g. retina camera, ABI dopplers, better foetal dopplers)
- Reduced capacity to take well-earned holiday leave more often for mental health reasons
We can’t keep seeing more and more patients without affecting quality and without causing burnout. Remember, the coroner will never accept “I was too busy”. “See your GP” keeps coming our way from emergency departments, discharged patients, preadmission, ambulances, school, child care, covid-19 community teams, RMS and the list goes on. “Go and see your GP for a mental health plan” or “Go and see your GP to get a referral for the physiotherapy”. While it is great to be the gatekeeper of the health service, it feels more than cheap labour. In fact, we are actually paid less than a builders’ labourer.
You would already have heard that enrolments for the FRACGP is down 30% this year and it is projected that in 3 years’ time, Australia will be 10,000 GPs short. What does that look like? There will be increasing GP practices that will close their books. I have and many more will. Already, on weekends, our patients are finding that medical centres are turning them away as they are full. The typical ED wait time has balloon out to 6-10 hours in Southwest Sydney.
Practices which have not closed their books will have a wait time of 1-2 weeks before patients can get an appointment. Eventually, patients will struggle to find a practice even during the weekday to get appointment on the same day. Practices that have not closed their books will reduce preventative care to cope with acute care. Will they recall patients for their regular check-up when they are overwhelmed by just walk-ins or acute cases pouring in? All the health gains we have made over the last 20-25 years are in danger of being lost.
I can’t see how the government can solve this problem anytime soon. Nor any indications that they have the will to do so. Anything short of a massive increase in rebates to stem the loss of experienced GPs retiring. They have had enough and wants to spend more time with the family and play golf. Maybe, do some travelling. Our experienced GPs will take their decades of clinical experience with them. They used to pass them down to the younger GPs as they transition towards retirement. But, now this is not happening and our profession and the community will be poorer for it.
Everyone in human resources will tell you that to solve the workforce problem, you need to increase numbers joining the workforce AND stem further loss. The current realistic cost of providing quality medical care is closer to $70-80 per 15 mins. With the current rebate sitting around $40, it will take a rebate increase of at least $20-30 to attract graduates to become GPs and older GPs to hang in there for another few more years. Alternatively, they can get rid of bulk billing. I can’t see either of those happening, can you?
What can we do? What should we do?
For now, we all have to consider stopping universal bulk billing (UBB) or at least take steps to stop UBB for new patients. Talk to your colleagues who have done it and get some tips to get started. UBB is no way to practise good medicine. I bit the bullet many years ago and now enjoy the practise of medicine in general practice. With the workforce issue looming, this have to be the best time to wean off UBB.
We need to get organised. We need to get behind GP colleagues who are working on our behalf to improve the deal we are getting from the federal government. The first of many petitions have been launched by Dr Charlotte Hespe, the 2020 RACGP Presidential Candidate. Sign the petition to get Medicare to pay for our practice nurses to administer flu vaccines. At the moment, we cannot bill an item number if your practice nurse administers the flu vaccine. If the chemists get paid for administrating the flu vaccine, why shouldn’t we?
Sign and get everyone in your family, your friends and your patients to sign as well.
You can print this for the waiting room to get your patients to sign.
This is our first step in working together. May the force be with us.