Chronic underfunding has endangered general practice and with it the whole health system. Urgent investment is the only way to keep it on track.
Our healthcare system is currently in a state of disaster and this disaster is evolving.
There are now not enough GPs to prevent medical emergencies. Projections indicate the shortfall of GPs will continue to worsen. People who call an ambulance may discover there are not enough people to answer the phone, let alone have an ambulance available to be dispatched. People who are fortunate enough to have an ambulance arrive, are taking longer to be transferred into an Emergency Department bed for definitive treatment. According to the AMA’s last Ambulance Ramping Report Card, in every state of Australia, there are longer delays getting from the ambulance into the emergency department.
People who arrive at an ED may not have a nurse available to triage them. We are on track to have a shortfall of 85,000 nurses within the next two years. People who have been triaged, may not have a doctor available to provide timely care. Emergency departments and public hospitals are over capacity.
At each of these points of care, there are human, material, economic and environmental losses and impacts: people who are dying, or suffering losses — their sight; the use of a limb; their faculties; their independence; hope — which would otherwise have been prevented. Those losses create exponential costs and disruptions to the functioning of families and communities.
A healthcare system in critical condition
On a shift last month in a small community hospital, there were so many people in the waiting room, the wait time to be triaged alone was more than two hours. Many of those people waiting would have seen a GP if they could, but have needed to attend their local emergency department instead.
If it takes a triage nurse two hours before she can assess you to determine whether you need to be seen by a doctor within ten minutes, this creates an enormous risk for bad outcomes. Risk is a generous word. Let’s call it a foregone conclusion.
Statistics from the United Kingdom’s National Health Service, the NHS, published on the eve of the pandemic in December 2019, specifically quantified the risk of death according to ED waiting times. One in 83 people die waiting six hours for emergency care. One in every 30 people die waiting 11 hours.
If the waiting times are long, the headlines will come.
Knowing there are people who will deteriorate or die because you do not have enough resources to provide care for them takes an enormous toll on healthcare providers. Specifically, this is a form of moral injury.
The phrase “moral injury” originated in relation to the experiences of soldiers in combat. The concept was first introduced in the 1990s by Jonathan Shay, a psychiatrist and Vietnam War veteran, who used the term to describe the psychological harm that soldiers can suffer when they violate their own moral code in the course of their duties. According to Shay, moral injury is distinct from other forms of psychological trauma, such as PTSD, in that it results from a violation of deeply held moral or ethical beliefs, rather than simply exposure to traumatic events.
Working in a healthcare system in crisis is like trying to put out a bushfire with a bucket of water. No matter how hard you work, the sense of futility is overwhelming. Working in these conditions can lead to feelings of guilt, shame, and despair, and have long-lasting effects on mental health and well-being.
Healthcare workers are getting burnt and burnt out, and it’s not just a problem for the healthcare system. The ripple effects of burnout can be felt throughout society, as healthcare providers become less engaged, less productive, and less likely to stay in the profession long-term.
Healthcare providers are not only opting out of working, they are opting out. In December 2019, coinciding with the emergence of the Covid-19 virus, a detailed systematic review and meta-analysis of suicide rates among physicians in Europe, the US, Canada and Australia was published, demonstrating a relatively high rate of suicide in general practitioners, and female GPs in particular, second only to anaesthesiologists.
While it is not entirely clear what the suicide statistics are in regards to the impact of the covid-19 pandemic on health workers, a recent study published in the Australian and New Zealand Journal of Psychiatry indicates more than 1 in 10 Australian health workers reported thoughts of suicide or self-harm during the pandemic.
Preventing fires vs putting them out
In the emergency department, healthcare providers are largely tasked with putting out fires: saving life and limb when a series of events has led to a disaster or near miss.
GPs are in the business of fireproofing, through preventive medicine. Like dust that hasn’t settled, it is by definition almost invisible. Primary preventive care is most visible in its absence, when it has failed to be provided or heeded, and people become ill. Because primary health prevention is innately invisible, it can easily be overlooked and undervalued, by healthcare providers, administrators, bureaucrats, and people receiving healthcare themselves. Averting illness altogether is the most invisible, yet powerful and cost-effective medical care we can provide.
By taking a broad perspective, GP’s are able to minimise costs and time to arrive at the probable cause of your symptoms. Minimising tests reduces costs, but also reduces the risk of harms caused by medical investigations, otherwise known as quaternary prevention.
GPs stop fires from happening. They detect smoke and extinguish fires early. They sound the alarm when a fire is out of control and provide an initial response. They assess a scene after a fire, and determine how to recover and how to prevent it happening again.
Without GPs providing preventive healthcare in the community, there are more people becoming sicker faster, and needing emergency medical care. Once those people have received medical care in the emergency department, without a GP, they are very likely to need emergency medical care again.
A shortage of GPs creates an exponential increase in the number of medical emergencies and the cost of healthcare.
Rather than increasing, or even maintaining investments in general practice, government spending has proportionately decreased in the past 10 years, from around 36% of the health budget to approximately 33%. At the same time, proportionate spending on hospitals rose from around 38% of the health budget to 41%.
Where are all the GPs?
Many people think of GPs as a public service. They are in many ways. We know over 80% of the population has seen their GP at least once in the past 12 months, many of course seeing their GP much more frequently.
Except GPs aren’t in the public service. When I became a specialist GP in 2018, I learnt I was now self-employed with no employee benefits, no superannuation provisions, no sick leave, maternity, or holiday entitlements. People who are self-employed typically need to ensure their fees are adequate enough to allow for all of these expenses.
On 1 July next year, it will be the 40th anniversary of Medicare as we know it. Within a couple of years of its introduction, well over 80% of GPs accepted the Medicare rebate as full fee for their work, being $16.50 for around 10 to 15 minutes.
In 1984, you could head out in your Wham T-shirt and acid rinse jeans with a great perm and that $16.50 would get about 22 loaves of bread.
For a 10-19 minute appointment with your GP today, the federal government will contribute $39. Today an average loaf of bread costs about $3, which works out to be worth about 13 loaves of bread. That’s much less bread.
The fee of course doesn’t go to bread. It must also keep the lights on in the clinic, pay the manager, the nurse, the receptionist, and the cleaner, wound dressings … it’s a long list. A GP’s proportion is also in that list, and a bulk billing GP today is paid about $26 for most healthcare visits.
The government knows perfectly well it hasn’t kept up. We’ve sent them a few graphs over the years, like this one:
The federal government is fully aware of how it has been chipping away at the patient rebate since its inception. In 1984, the Australian Medical Association’s recommended fee for a standard GP visit, that $16.50, matched the Medicare rebate. Today the $39 rebate covers just over 40% of the recommended fair fee. It’s been failing to keep up with inflation pretty much since it was implemented.
Be assured the Ministers of Health and Finance have got the stats on hand. Meanwhile, they keep spruiking Medicare as if “bulk billing” is feasible, as if it deserves to be given a name, as if they are providing for the cost of your healthcare. They’ve been maintaining appearances for a long time. This is Bill Shorten in April 2022 in a facebook post:
This is what gaslighting looks like.
Almost one year later, with the gap between a fair fee and the Medicare rebate having only grown, Health Minister Mark Butler informed us of the “shocking decline” of bulk billing, as if it might be surprising. Except, it really isn’t shocking or surprising. The chronic underfunding has been forecast to fail Australians for decades.
In short, the backbone of our healthcare system, general practice, is buckling under the strain. It is breaking down.
Deloitte’s November 2022 GP Workforce Report forecast that the shortfall of GPs, created by an increase in GPs choosing to leave or retire, and a reduction in medical graduates willing to enter the specialty, would only worsen. In 10 years’ time the shortfall in GP care is estimated to be around 30% of the demand.
That will create a spillover effect with an exponential rise in health costs, as people resort to emergency departments for minor issues, or worse, are unable to access timely preventive or early care, with poorer outcomes and higher costs to people and our communities. Those costs are not only economic, they are in lives, and reduced quality of life.
Looking for the exits
After decades of underfunding, GPs are not expecting a trend spanning almost 40 years to reverse. Many GPs are now deciding not to bulk bill, or even not to be a GP at all.
Sometimes it is too overwhelming to contemplate, and they check out altogether.
It is difficult to find statistics specific to GP suicide in Australia, particularly since the pandemic. In 2018, Medical Journal of Australia reported a suicide rate in female doctors of almost 2.3 times higher than the general population, compared to a suicide rate of 1.4 times higher than the general population in male doctors.
If we factor in that female GPs fall into a higher risk category, and that the stats predate the onset of the pandemic, it is probable the current rate of female GP suicide in Australia is now markedly higher.
In an online poll I conducted of almost 150 female GPs in April, almost 60% of respondents personally knew a medical colleague who had committed suicide.
Of all suicides known to female GPs polled, almost half were reported to have occurred in the years since the onset of the pandemic.
Among all of the other challenges currently faced by our workforce, when you see a female GP in Australia, she may well have personally lost a medical colleague to suicide within the last three years.
Why am I even here?
I am currently writing this in my pyjamas and dressing gown on the couch because I needed to quit my job in a bulk billing clinic.
My decision crystallised when, after having phased in a proportion of “private fee” appointment slots, a patient pointedly took two crisp $50 bills from his wallet, threw it at me, and walked out in disgust. This was after he realised that when we had explained earlier there was a fee, we meant for him to pay it.
Another couple were so outraged to learn I would be charging a fee, they remarked to the receptionist that this must be illegal and they were going to report me.
I understand people feel entitled to receive my medical care. They should. Medical care is an essential service every human being needs in order for people, families, and communities to flourish.
In the middle of a healthcare crisis, it would be better if I were using my 20 years of hard-won knowledge to provide healthcare, rather than sitting here writing to people who wish they could get a medical appointment.
The truth of it is that healthcare providers are exhausted, burnt out, and disillusioned. The threats, tears, insults, and abuse directed at GP about medical fees will not solve the problem of patient healthcare costs. GPs cannot continue to personally fund the ever-widening Medicare shortfall.
We have done what we can. Patients now need to take the fight for federally funded healthcare to the federal government.
Dr Louise Karan is a GP in the Blue Mountains, NSW; this is an edited version of a piece posted on her blog tekhnomed.org.
