29 January 2021
The case for a new GP organisation alongside the RACGP and ACRRM (Part 1)
When the Department of Health released its expression of interest for GP practices to become COVID vaccination clinics last Saturday there was palpable distress and anger across the profession at an offer per patient less than the standard bulk billing rate of an A consult.
With all the conditions that the DoH was placing around practices to set up to vaccinate, it would have been more than obvious to the government that any GP practice that wanted to help out with the nation’s largest national health initiative in history would likely have to do it at a loss compared to continuing normal operations.
The government, which had been on TV for weeks praising the sector, seemed to be playing a morality card, hoping, that although a woeful offer, it was enough for the sector to front up regardless , as they have always done in the past, and put their patients and community before their livelihoods.
For Dr Chris Irwin, one of the candidates at the last RACGP election, it was groundhog day. He’d seen it, and heard of it happening to other RACGP national leadership in the past, so many times before. He decided it was “the last straw”. He would launch an alternative organisation to the RACGP which was going to focus mainly on effective lobbying.
It’s not unusual to see primary practice being dudded by the Department of Health (DoH). But this particular bait and switch episode was a little worse than usual.
Health Minister Greg Hunt had been singing the praises of the RACGP and the GP sector all year amid COVID, and in the run up to this announcement had appeared on national TV, a couple of times hand in hand with the new RACGP president Dr Karen Price, announcing to all of Australia that GPs would be both “front and centre” and the “cornerstone” of the national COVID vaccination program.
At least when a Labor government started the great MBS freeze there was lots of sombre talk about big budget problems and a clear message going into negotiations that things were tough and compromises needed to be made.
Last week’s set up was a shocking for a lot of GPs, especially given how far the DoH had seemed to have come over 2020 in understanding the sector by eventually recognising the need for and backing substantive additional funding for telehealth during COVID.
What felt immediately apparent in the deep dark recesses of the DoH, where ultimately the key decisions are made about the structure and future of our healthcare system, including how GPs fit into it, is that GPs aren’t a force that need to be reckoned with (like say pharmacists or miners can be from time to time) and will, in the end, mostly lay down and do what the government requires them to do.
In the bigger picture the DoH seems to be taking its lead on health policy from some of the big-C consulting firms – organisations full of smart (but not real world) people that no public servant gets fired for hiring. Reflecting on trends around the world, particularly in the US but also parts of Europe, and working from a local political premise that health can be an effective mix of private and public organisations, they are playing with ideas like:
- Capitation – which is used in the UK to pay GPs by capping funding per region depending on a regions past and future needs, and which some see as a more effective spend of a primary healthcare dollar
- Allowing professions like nurses and pharmacists to go significantly upstream into general practice in order to get more done at a lower cost, especially around chronic health management.
- managed health care models like in the US where giant private insurance entities run your health journey from cradle to grave by owning every asset including your GP, your hospital, your pharmacist and even a network of specialists. If you think this is just crazy and the DoH wouldn’t be going here, then Medibank Private just bought half of the MyHealth GP practice corporate. It’s hard to imagine anything else that a private health insurer with significant political clout in Canberra would be doing with an asset like that if they hadn’t at least asked the question of the health mandarins first about the possibilities of such a future.
None of these are necessarily bad ideas. They are all about common sense and basic evolving economics in healthcare. Unsurprisingly, primary care doctors all over the world aren’t all that efficient in how they operate these days given the march of technology and modern health systems. Things will need to change. That’s what the DoH is trying to figure out.
And now they’ve been thrown COVID out of left field, and have significantly less money to achieve any changes going forward, making the whole problem even more twisted, even ‘wicked’.
Some of these ideas might even be good to introduce in modified formats into Australia, but not without a great deal of care and forethought about in what context you would introduce them and how. If you did any of these things you would need to be very careful about not killing the so far poorly recognised ‘golden goose’ of our healthcare sector (present and future): general practice. This is especially given its current fragile state.
Our current GP community is an asset the DoH is going to need to be a lot more careful about.
The problem is, the DoH isn’t being all that careful. You could even say they’re being pretty cocky and laissez faire. What they need to set them straight is a good lobbyist to scare them just a little – to get them thinking.
It’s a classic sign that an industry sector has a hopeless lobbying presence when the government thinks that they have all the input from that sector that they need. And there is no friction in that dynamic.
It’s not that the DoH doesn’t respect the GP sector. It’s more that they aren’t in anyway in fear of the sector. In fear of what GPs could do to them politically if they properly mobilised, and in fear of what could happen to the healthcare system if they keep treating the sector so poorly.
GPs, as last weekend proved, are not a political threat of any sort to anyone.
The DoH would certainly recognise the sector’s overall importance to the future of our healthcare system, but it also thinks that it can plan that future and do what it thinks is best without a lot of sector input. That’s dangerous because the DoH like most government departments planning big, can really miss the mark from time to time. Not having someone on the inside creating genuine friction in this sort of planning by giving the public servants a few coal face reality checks as they plan the future is dangerous . It leads to things like robodebt and the My Health Record.
This is where the RACGP and the sector have a big problem.
The medical college system was never meant to deal with the sorts of changes that healthcare is undergoing now and into the future in Australia. It was designed to establish sensible management around training and education of the profession.
The original group set up to lobby for doctors in Canberra was the AMA. It was set up more as a union than a medical college.
But as things got bigger and bigger for GPs the AMA found it couldn’t effectively represent specialists and GPs under the one group. They are paid differently and have very different goals and aspirations. It made the AMA more and more split personality and less and less effective.
Today its GP membership is at an all time low. And you can see why. The AMA may have been a force in the past that helped the GP sector but it isn’t any more. It’s a big reason why the RACGP decided to start lobbying on top of its core traditional role.
This week the leadership of the AMA came out in support of the government insisting GPs bulk bill for COVID GP vaccinations at a rate below the minimum for an A consult, despite knowing that such a rate could only place many GP practices under more financial strain. So much for being a lobbying organisation working on behalf of GPs. The stance reflected a group trapped in and beholden to the Canberra bubble.
Why do both the RACGP and the AMA say pretty much nothing when its so obvious they got duped and in being duped let GPs across the country down massively?
Because they can’t come out and say anything or do anything publicly without significantly affecting all other aspects of their operation as medical institutions.
They have zero leverage to make real threats as they depend on the DoH for their mandates to exist.
If an RACGP leadership team really made a serious threat to the DoH all that would happen is that their access to the health mandarins in Canberra would be diminished. And other aspects of the operation of the college would eventually suffer.
Current leadership is in fact trying its hardest and doing their best. The RACGP in particular would have been arguing the case for much more funding for GPs to do COVID vaccination once they got a sense of which way the DoH was going in funding. They would have presented very good and well reasoned arguments.
But none of it matters.
They have no leverage.
Not withstanding, Dr Price going on TV with the Health Minister and having a bit of a love in, though it’s turned out to make the RACGP look terrible in the eyes its members (and maybe Dr Price as well), was still probably the right thing to do.
Dr Price got GPs great national coverage. And the public thinks more of the GP sector for that and would believe the Minister that the government is really behind the sector and that it is an an important sector.
That’s all great PR for general practice.
Even if Dr Price knew that a week later the government would be pulling its bait and switch on funding, you’d probably take the lesser of two evils and still do those press conferences (we’re pretty sure she didn’t know BTW).
The alternative would have been to have the government say average to bad stuff about GPs as the RACGP arced up during a crisis. And nothing else would have changed. At least this way, GPs got some great national PR.
So what is the essential problem here?
Some people think the RACGP was never an advocacy organisation, and now that it has decided to be one we should give it time. The same and different people argue that if someone starts a new organisation then the GP sector will be less united and have even less of a voice and ability to talk to Canberra.
These arguments are to some extent logical but in the case of the RACGP the problem isn’t just they haven’t had time to get good at lobbying. They are structurally incapable of doing effective lobbying. Add this to multiple failures over the last few years (telehealth excepted) and you have to question the people who are still backing the college to make a difference in time.
The move by Dr Chris Irwin to set up an alternative organisation has both supporters and detractors. The supporters are sick of groundhog day. The detractors point to the degree of difficulty of the problem and the low likelihood of success outside of the RACGP power base.
But maybe there is a way to retain all that is good in the RACGP and ACRRM (of which there is a lot), make it better, and start a new organisation which is truly free to play the game in Canberra.
Such a game is rough and dirty. To do that you need be set up the right way and the leaders need to have different goals and a different perspective on their role in good medicine in the future.
If the mandarins who are setting up the future of health inside DoH are to get a complete picture of the coal face of general practice and what problems they might create if they don’t understand the sector just a little better, they are going to need a few smart people making things awkward for them so they start questioning some of their planning and ideas.
These people will necessarily not have to worry about a board to report to that has different priorities, and, protecting a possible future career in politics or the public service. They will be largely uninhibited in seeking to achieve their lobbying goals.
The RACGP and ACRRM are structurally set up to do training, education, research, and to some degree clinical governance. The mandate for them to do that has been given to them by the Medical Board of Australia (MBA), which ultimately oversees the set up and governance of all medical colleges.
That mandate has provided the college with enormous commercial power in the GP sector in the last 20 years. It has come to dominate CPD, to become a GP you have to join the college (or ACRRM), be there for at for 5-7 years at least, and if you want your CPD to be accredited directly with the government so you can bill enhanced MBS items ongoing, well, you needed to be a member of the college.
So the RACGP grew in membership, money and power rapidly.
But along this journey it lost its way significantly. It got hijacked by an executive which consciously or subconsciously recognised that they were a virtual monopoly and it started building itself a power base with the income it was getting from a growing membership and education income.
A lot of things they spent money on were not really in the scope of the core goals of the college. They spent a lot of time and money on projects like Oxygen, a related company entity that invested in companies and ventures which were operating in the GP sphere, and which certain characters in college leadership felt would provide the college with more power and riches. Nearly all the projects of Oxygen failed and were buried in a balance sheet with cashflow to spare, which the board was well not qualified to scrutinise, and apparently never did.
The board had no continuity in oversight of spending or governance because its members were ephemeral whereas the executive had continuity. The executive convinced the board to buy lots of property , create its own online media group to compete with the commercial medical media groups which weren’t toeing the RACGP line, create its own social media play to compete with an organically grown one which was threatening its influence, and significantly expand its expert committee base to all sorts of areas, some outside its core.
It grew revenues from something like $30m in 2010 to last year’s $80m. Mistakes disappeared as the profit and cashflow was always better each year as more members joined and CPD revenues grew substantively. The college literally had so much money it didn’t quite know what to do with it Until last year it wasn’t even imaginative enough to use the windfall to reduce member fees.
Amid all this financial success, about five years ago the college started down the road of lobbying and advocacy, something it had never declared was its job before.
But nearly all of that lobbying and advocacy ended up as theatrics at best.
The person at the front of such advocacy and lobbying was for obvious reasons the president of the college – a doctor who represented the ideals of the college. The college had never stopped or cared to consider that a president, popularly elected, usually by a very small following as less than 10% of members usually voted, would nearly always have no qualifications, experience or skillset to go to Canberra and be effective.
When the college decided it was now going to be a lobby group no one in the executive or the board thought for a minute that until that time the presidential role had largely been one of ceremony and front.
For some presidents, being president was just a step on a ladder and a CV tick, opening up future prospects for jobs in politics, the public service or honorary roles at university medical schools. For those with that ambition, upsetting Canberra in any meaningful way obviously conflicted to a degree with such ambitions.
An RACGP president only ever had two years in the role. After they are elected they literally have only one month to prepare before they are thrust into the Canberra arena.
All presidents have failed by any serious advocacy or lobby group standards, perhaps with the exception of Dr Harry Nespolon. But even Dr Nespolon admitted near the end of his tenure that he had only scratched the surface, and that two years was simply not enough time in the role to succeed.
Presidents don’t fail just because there isn’t enough time for them or continuity to do their work.
They fail because the college can’t ever properly support them, because there is too much at stake in protecting the traditional and core functions of the college, and because often they need to be careful not to damage any future career prospects by upsetting the wrong people.
Presidents have no qualifications, preparation, history, skillset or time to do the job. Worse, they are conflicted between career and lobbyist. Who wants to ruin the prospect of one day becoming deputy chief medical officer of Australia through a two year stint as president early in their career?
Another important issue at play in failure is that if they actually did start doing the job as it needs be done, then they would almost certainly start to come in conflict with their own board because of the structural issues in play.
- The RACGP gets its mandate from the MBA which essentially reports to the DoH. If it loses parts of that mandate, then the core of what it has been set up for becomes threatened. In simple terms, the RACGP can’t be an effective lobby group ever because it by definition has to be in the government’s camp for most of what it does – education, training and governance.
- If you upset the government too much, the board will cut you down. The board has way too many long established vested interests in keeping the government on side to go into serious battle with their masters.
- Those vested interests aren’t just on the board and aren’t just to do with money. They are to do with the career, money, status, and the self worth of all the GPs on the board and all the GPs who are on executive and expert committees and all those who are getting research funding.
- The RACGP achieves a lot of good things but through its years of executive mismanagement it has become bloated with committees, expert groups, and self interest groups, the members of which are usually well paid, and whom get a lot of peripheral career enhancement from making high level contacts in medicine and politics, writing reports and papers, going to high level meetings, and generally mixing with “the right class of people”.
RACGP expert committee work is largely very important and effective in developing information and guidelines to improve the sector. Most of the doctors serving on these committees are not there for the money and CV. They are there to help other GPs, their patients and advance the sector.
Whether this executive committee work is important for the sector, or not, it will always be threatened to some degree by a president who was succeeding at ruffling feathers in Canberra. The two elements can’t co-exist in the one organisation and both be effective.
Even if you’re Dr Harry Nespolon, who did manage to get the MBS freeze lifted (though that probably was timing) and MBS telehealth introduced (that was all hard work, smarts, charm and stubbornness), you aren’t going to succeed as a lobbyist from within the RACGP over time.
There needs to be something else. In this something else the RACGP might still be the dominant and peak organisation of the sector. It has important work to continue – and fix, if you think about last year’s exam problems.
This of course raises a lot of big and important questions immediately about what does a new GP organisation charged only with effective lobbying look like. Some of those include:
- What would a viable structure and governance set up for such an organisation look like given the structural difficulties of herding a very disparate GP community?
- How would such an organisation be funded?
- What skills would it need and where would it get them from?
- What sort of alignments and partnerships would it need within the current ecosystem to have a chance of succeeding? (Hint: would it need some informal relationship with the RACGP and ACRRM?).
- What would its focus be in the short term and the long term?
Continued in next week’s First Draft.