In the calm before the budget and election storm, we asked GP representatives for their policy priorities
What do we want? Investment in primary care. When do we want it? Yesterday!
As the government prepares to hand down the budget on April 2 and the major parties formulate their policies for the May election, there are a few things that everyone in the sector can agree on.
Or rather, a few billion things.
Since the “temporary” Medicare rebate freeze introduced by Labor in 2013, extended by the Coalition and now slowly thawing, the shortfall in general practice funding is estimated at $1 billion. That figure again would be required to bring GP spending up from 7.3% to 10% of total health spending, according to the RACGP, while ACRRM says $3 billion is needed to restore parity with other specialties.
But to fix the problems in general practice, the colleges and the AMA agree, reforms are also needed in how money is spent, including on training, telehealth, mental health and the funding model itself.
RACGP President
Dr Harry Nespolon
Politicians need to recognise that general practice is a far better investment of health dollars than the hospitals they traditionally love to announce, Dr Nespolon says.
“It’s the most efficient part of healthcare, it gives the most bang for buck, so moving money from other parts of the healthcare system into general practice actually will give you better outcomes for patients,” he says.
“There’s a lot of care – and as technology improves, a lot more care – that can be delivered to patients where they live. Most patients want to stay home and in their communities.
“So we need to recover the billion that’s been lost over the past five years, and we would need to see another billion dollars put in: the cost of one hospital.”
Since our conversation, Labor leader Bill Shorten and health spokeswoman Catherine King have committed to spending $1 billion upgrading public hospitals across the country, including building new wards and new palliative care and mental health facilities.
The RACGP has been campaigning for a modernised MBS that, among other things, reflects the increase in chronic disease.
Fee-for-service funding is working well in acute care, he says, but rebates need to increase and expectations around bulk-billing need to be managed.
Chronic care, however, requires that fee-for-service be supplemented with a type of funding that would encourage more continuous engagement, including through telehealth.
“There’s a lot of non-face-to-face work involved and there needs to be a different model to reward GPs to deal with that,” Dr Nespolon says. “There are potentially better models that would mean GPs spend less time doing paperwork and more time seeing patients.
“If you did have a different funding model that was per patient, a bundle of money for a particular group of patients for a particular group of services, then that would actually result, hopefully, in better outcomes for the patients because they’d be able to deal with their doctor in a variety of ways.
“We often hear members say that for their particular group of patients that fee-for-service doesn’t work that well.”
The RACGP also wants to see team-based payments and complexity loading for doctors in remote and disadvantaged areas. “There’s still a lack of reward for the GPs who are doing the hard patients, where the longer the consultation goes on the more money they’re losing.”
What that supplementary funding would look like depends entirely on how much money the government is prepared to put into it, Dr Nespolon says. “These sorts of schemes have been proposed in the past – look at Health Care Homes: there wasn’t enough money, it was an odd algorithm.
“If it’s a good deal, a good recognition of the work that professional GPs put in, then they’ll take it up. If it’s like Health Care Homes, where we’re struggling to see the value of it, you’ll get very few taking it up.”
Telehealth will be crucial to modernising the MBS, he says, even if it may never replace in-person care to the extent that some may think.
“We need to move from a 1950s model of general practice – or a 1974 Medibank view – to a modern view. GPs want to be able to deliver care in the way patients want it.
“There will come a time soon when they need to get more productivity out of a declining general practice workforce, so things like telehealth and GP-based team care are going to be a necessity. But it’s not going to solve the problems of a maldistribution of general practice or the declining number of GPs.”
As well as increasing the value of level C and D consultations by 18.5% to align with other specialist rebates, the RACGP is calling for longer GP mental health items (up to $166.33 for an hour or more).
“A GP is much less confronting and much more accessible than a psychiatrist, and that GP is going to have that relationship with them over time, which leads to better outcomes,” he says. “Even if those changes were made, they’d still be pretty underfunded to deal with very difficult patients.”
Dr Nespolon says Canberra is listening, but he will remain sceptical until he sees what is offered and what is delivered.
“Funding of general practice needs to be recapitalised, it’s as simple as that,” he says.
“We need to support the guys who are doing mental health, aged care, dementia, and we need to at least experiment with other models that better reward GPs who are taking care of patients with chronic medical problems. Because at the moment they’re certainly being left behind.”
ACRRM President
Dr Ewen McPhee
When it comes to funding, Dr McPhee says, rural GPs have a lot in common with their city counterparts.
“General practice, whether on Pitt St in Sydney or in the most far-flung rural area, is under the pump,” he says. “It’s struggling. The financial viability of general practice, keeping the doors open and paying staff and doctors, is becoming critical. There’s been a persistent lack of recognition of that by both sides of politics.
“We’ve had five or six years of meetings around primary healthcare reform – Health Care Homes, the MBS General Practice Primary Care Clinical Committee, the Primary Health Care Advisory Group – so many agencies talking about reform and simply nothing has happened.
“Government is not willing to invest the $3 billion that’s required to bring back parity to general practice. Neither side is even willing to entertain that.
“We now see young doctors walking away from general practice because they’re not seeing a meaningful career path. There needs to be a recognition that general practice is important and needs to be funded properly.”
Dr McPhee says the reindexing of rebates is fundamental. “But let’s face it: we have an archaic Medicare Benefits Schedule system that was fit for purpose 40 years ago but simply is not any more. Whatever the results of the MBS Review, I don’t think it’s going to make a difference to the viability of general practice.”
While fee-for-service still has its place, he says the small margins leave practices unable to invest adequately in team members such as practice nurses and assistants.
“We need to look at things like blended payments.”
Of course, rural and regional practices face many additional challenges never encountered in the city. These begin with training, attracting and retaining GPs. According to a 2018 Grattan Institute report, there are about 110 full-time-equivalent GPs per 100,000 people in major cities and inner regional areas, but only half as many in very remote areas.
ACRRM and Dr McPhee in particular have been pushing for a national rural generalist pathway in medical training, and want the Medical Council of Australia and the MBS to recognise rural generalism as a specialty within general practice.
“The point of it is to rediscover the country doctor of old, who has great primary care skills but also contributes to emergency medicine, mental health, Aboriginal population health and so on. Providing those generalists in rural areas does increase the ability for care to be delivered closer to home.
The Health Department announced this month that overseas-trained doctors seeking visas to work as GPs will have to work in the country – a move that shows the current training model is not working, Dr McPhee says.
Where rural generalist programs exist, he says, giving Longreach in central Queensland as an example, birthing units, local surgery and anaesthesia have been established. But there were crisis areas with no next generation of clinicians coming along.
The shortage is compounded when it comes to aged care, palliative care and especially mental health, which is a gap that telehealth can’t plug: “The fact is, a young person is not going to go on Skype when they’re feeling really sad.”
Labor health spokeswoman Ms King visited Dr McPhee this month at his practice at Emerald in Queensland, where she announced that Labor would fund a headspace centre to address the serious youth mental health issues that exist there.
“The problem is, where will we get the staff? Because we do not have the staff out here,” Dr McPhee says. “It’s not just about GPs, but about the practice teams.”
Telehealth should be expanded in the regions beyond the crisis areas where it exists – but it has to be done right.
“We recognise that some patients have to travel 500-600km to see their GP. There are great opportunities for telehealth to contribute to improving their care, but it has to be done with a known GP, in their own practice looking after their own patients, not by a call centre in the nearest major metropolitan area.
“There’s a number of organisations, including Telstra, that are keen to start national call centres, supposedly to improve access, but that will just fragment care.
“We’ve got people across Australia doing it tough who need access to great GPs, and it needs to be their local practices.”
Indigenous people, refugees and remote workers are three more groups with unique health challenges.
“Aboriginal health is always going to be a major priority for us,” Dr McPhee says. “We believe in increasing support for Aboriginal people who want to become doctors and other health professionals. We know that the pathways for our Aboriginal and Torres Strait Islander colleagues can be tough, with the other burdens and priorities that they need to meet in their lives.
“So we’re calling for alternative pathways to medicine and general practice – the rural generalist program should be the priority to make more ATSI clinicians available to their communities.”
And while rural communities can be very warm and accepting places, he says, settling refugees in the country often leaves them with few supports, compounding the language and cultural barriers to care for problems that often include trauma and mental illness.
Finally, he says, the occupational health of agricultural and mine workers is an ever-present issue.
“We have some major health issues around drought and flood, miners who suffer from fatigue and dust-related lung diseases that had dropped off our radar for a long time. Immunisation for Q fever remains expensive and difficult to access.
“We’re calling for acknowledgment that the health of our rural people is important and that there are unique issues they deal with and they deserve more attention.”
In the lead-up to the election, he says, the rural college wants the major parties to stop paying “lip service” to general practice and promise serious reinvestment.
“We’ve been talking reform for over five years. We can’t continue to have more commissions, reform advisory groups – we need to stop this march of consultations and make some decisions.”
AMA President
Dr Tony Bartone
Dr Bartone says securing investment in general practice has been his first priority “from the day I was elected”.
“We need to ensure there is a longer-term focus on continuity of relationships with your regular GP and a focus on quality,” he says.
“That can be further achieved with a split level B or an additional moiety on top of the longer standard consultations. We know the average consult is 14 minutes, we know there are more problems being discussed in each consultation, and we think we need to reward those doctors who are spending more time with their patients.
“That’s with the background of 30 years-plus of lack of appropriate indexation and more recently five years of freeze. The level B consult in its current $37.60 iteration bears very little resemblance to the cost of providing quality care in the community. However, we know the vast majority of consults are being bulk-billed at the moment and that’s putting a strain on general practice. Anything that supports longer consultations should be facilitated so we can spend more time with our patients on complex issues,” Dr Bartone says.
He says much work is being done on how the fee-for-service model might be reformed or supplemented, but that results might not be seen before the budget.
On the MBS Review, Dr Bartone says, the AMA’s support has always been conditional on any savings being directed towards making the schedule fit for purpose in the 21st century.
“This MBS schedule was really designed in the middle of the last century and has had only piecemeal, episodic [revisions] since,” Dr Bartone says.
“It was due for a health checkup. But we say any dollar saved should be channelled right back in. And it’s not just about volume – any savings should go into funding innovation and modernisation in the schedule.”
Team-based care payments are one aspect of this, telehealth another.
“We know telehealth has its specific role in rural and regional [areas], but we think it has more to offer, especially in aged care facilities. But obviously, telehealth is underpinned by a long-term relationship between the practice and the patient. We need more flexibility and more efficient use of resources.”
Dr Bartone says mental health needs reform beyond reimbursement for longer consultations, though that is essential.
“When it comes to mental health we need a strategic policy framework that is across the entire health system,” he says. “We know that these conditions don’t occur in patients in isolation, they’re often attended with comorbidities, and the importance of that needs to be recognised. So the GP is the optimum place to start managing and coordinating that care.
“You can’t rush patients in and out, that’s to miss the picture. Mental health consults are long, are complex, are really taxing. This is an important community health service that is completely misunderstood and underfunded by the system.
“Secondly it’s about ensuring that when things need to be escalated we’ve got that opportunity to refer into supports in the community and the private system, between the practice and inpatient emergency care. There’s a significant lack of resources and programs and referral pathways in that middle space.
“What we call step-up and step-down care is extremely underfunded and patchy in availability, and virtually non-existent in the public system, leading to a real lack of equity of access.”
He says he will continue to advocate for public education to increase health literacy and for money to move upstream from cure to prevention.
“Prevention is an extremely important part of the conversation. There’s been cuts over many years by all sides and it needs not to be seen as an expense item, but as an investment in the health and future of the community, including increasing the productivity of the workforce.
“At the moment, they’re all listening [in Canberra], they’re all aware of our requests, they’re all engaging.
“What we’d really like to see is a comprehensive vision from [the major parties and the Greens] about how they intend to advocate for the health system going forward. One that extends beyond an election cycle, that’s about more than cost containment, that’s about improving outcomes into the future and not looking at how we manage the outcomes of disease. We need to prevent disease, and any conversation that doesn’t have that is missing the boat.”
