I am a general practitioner, are you? When a patient says they need or want to see a general practitioner I put my hand up. But so do a lot of other people. Some of those people are better general practitioners than me and some are not so good, but what if the people who are putting their hand up are not general practitioners? Are PGPPP doctors general practitioners? I think not. Do patients know when they are seeing a PGPPP doctor? Almost always. Are GP registrars general practitioners? Not yet. Do patient’s know when they are seeing a GP registrar? Sometimes. What about the other doctors working in general practice?
The situation in general practice is now much like that in hospital. There are many types of doctors at varying levels of experience and qualifications working in general practice. The following types come to mind in order of qualification:
International medical graduates that have not passed the clinical AMC (Intern level exam) and working on the basis of exemption from Medicare restrictions
Australian graduates doing prevocational experience in general practice who are interns (PGPPP – will cease from Jan 2015)
International medical graduates who have the full AMC and working on the basis of exemption from Medicare restrictions
Australian graduates doing prevocational experience in general practice who have full registration (PGPPP – will cease from Jan 2015)
International medical graduates with full AHPRA registration working on the basis of exemption from Medicare restrictions
Doctors training to be a specialist general practitioner or a specialist rural generalist
Doctors who have VR based on experience in general practice including grandfathered Australian College of Rural and Remote Medicine Fellows (FACRRM)
Doctors who have completed their Fellowship assessment by the RACGP or their Fellowship assessment by ACRRM
The only clearly discernible group of doctors, from the public’s perspective, who have completed and passed an objective assessment by their peers (and so demonstrating that they meet a standard of care necessary to provide a quality general practice service) is doctors with the Fellowship of the Royal Australian College of General Practitioners (FRACGP). There is another small group who have completed formal assessment, the graduates of ACRRM, but these are not distinguishable from those given the qualification based on experience.
I believe the public has the right to know if they are seeing a specialist general practitioner or rural generalist who has completed formal assessment. I understand that there are many reasons why this is not transparent to the general public, but this needs to change. I suggest that we reserve the name ‘general practitioner’ for those doctors working in primary care who have their FRACGP and ‘rural generalist’ for those who have an assessment based FACRRM (FARGPs could use rural general practitioner?). The reserved name may be “specialist general practitioner” and “specialist rural generalist” if that suits but it needs to be meaningful to the public. Other doctors need to be presented in a way that the public can discern the role and qualifications attained. We can set a deadline for this in 5 or 10 years to give people a chance to be formally assessed, but after that, doctors who have not been formally assessed should not use the reserved name. After all, you cannot call yourself a dermatologist because you work in a dermatology unit; in fact you might well be taken to court.
This may all appear to be in my own self interest; I have the FRACGP and I want to see change. But how on earth do we argue for the value of training in general practice and rural generalism unless the outcome and benefit is available and visible to the people of Australia. Statements like “I will never see a doctor from overseas ever again” or “I just saw a rubbish GP” are increasingly common where I work and unpleasant to respond to. To be fair to all doctors I need to explain to this patient that there is a huge variety of doctors working in general practice and that a blanket statement like this is not appropriate. When the patient asks me how to tell if the doctor is OK, I say, “The only doctor you can be sure of based on their qualification is one with the FRACGP”. Do you have a better idea?
The Australian health care environment suffers from change fatigue and we are about to see the most massive dose yet experienced in primary care in Australia. I love change, opportunity and innovation. But I have learned that change has to be at a pace that is manageable and where the motivation is understood and embraced. The real problem on the ground is that change occurs at lots of levels – within the organisation, locally and at State and Commonwealth level. If you want to sink, guarantee failure, it is best to ensure that change takes place at all levels at once – oh and add multiple dimensions to really twist the knife.
This is my situation – from where I read the Federal Budget. I work in a GP Super Clinic, a non-profit, that is owned jointly by two universities and supplies 24/7 services to a rapidly growing local community with huge industrial development 30 Kms south of Darwin. The service is evolving into a training and primary centre provider throughout the Top End of the NT. We have a few specialist general practitioners, 5 registrars, 9 medical students coming and going, our PGPPP doctors are no more, and our solid group of IMGs are now under the pump. We have contracts with the somewhat fluid NT Department of Health, who after the Federal budget changes will no doubt be reviewing our arrangements. We now have a relationship with a Hospital Network faced with delivering on budget (never happened before) and our Medicare Local. Both are just finding their feet, the NT Medicare Local recently emerging like a phoenix from a merge of Divisions which itself only lasted a couple of years. NT Medicare local is already a formidable alliance of interests that is aiming to support general practice better and working hard on closing the gap. They are working closely with NTGPE – our soon to be dissolved local training provider which has been a pillar of stability lasting over 10 years! NT Medicare Local is now being dissolved to form a new PHN whatever that means. OMG – does anyone in Canberra know what it is like out here?
I cannot imagine the cost in capital, social and human terms of this change. Add to that a $7 copayment which will cause problems with our local community, many of whom will not pay – no way. Is anybody happy? What is this for?
I know that this sort of upheaval is happening around the country in one form or another. WentWest Medicare Local in Western Sydney has been a trail blazer in provision of integrated Medical Local services and GP Training – the result of considerable planning and negotiation. But when there is only political impulse and convulsion, how can we plan? Should we say enough is enough? Should we plea to the tax payers of Australia that these changes amount to massive waste?
The price of change at this pace is staggering. What should we do?
I must confess that I cannot see any benefit from the proposed Medicare copayment either as a price signal or a revenue saver. And I stress that I am loath to write off any approach to improving health care in Australia. It is difficult to think of a blunter, more chaos inducing instrument to apply to Medicare. How will it save money? Largely from committed general practices located in deprived areas – the more committed the higher the saving.
The most lucrative savings will arise from pressure on practices to accept the lower bulk billing rebate – this will save $7 per visit. Let’s face facts, GPs already do this for the majority of patients; in poorer areas GPs will have to continue to do so at a very high rate because many people will be unable to or will refuse to pay. What will we do for a 29 year old who has no income and new onset diabetes? How will we manage an infection in someone who drinks their weekly income on pay day, or a refugee who has no income. In many Aboriginal Health Clinics it will be devastating. Please imaging living in poor over crowed housing on the edge of a town or in a remote area without public transport or any other facilities, with high prices for all consumables and getting the same income as a person living in a well resourced urban area. In the NT discretionary spending may be little more than a single visit to the clinic. The $7 (plus test on costs) will be a care killer. The primary care ‘Closing the Gap’ initiative has provide free health care and has had a big impact where I work. The copayment will reverse these gains immediately. Government Ck-Ching, primary care Ck-Chang.
The safety net is a massive administrative issue – $70 a year limit for an individual ($490 for a family of 7). How on earth will this be managed? Such approaches may have worked while the money was reimbursed but this is a payment at the time of service, prior to service for many I suspect. Who will keep tabs on who has reached $70? What a nightmare. We have had Medicare fraud with sharing of Medicare cards for some time. This will certainly add to incentives to share cards, only presenting with cards that have reached the limit.
The Corporate Practices who are profit focused will be working on ways to generate the same income without adding disincentives to patients. Such practices appear to be the primary target of this copayment but I am equally sure they will be best placed to minimise the loss of income. We are likely to see a major escalation of SIP payments and payments for non-attendance items in response to this. Government will get their dollars back, but new leakage is likely to occur. Successful approaches will put pressure on surrounding practices to match them.
I am the first to admit that there is wastage in primary care and that we do more harm that we intend. I am very interested in spending Medicare dollars where it is likely to return greater benefit. I have already raised one such approach in a previous blog Saving Medicare. But I do not think that the proposed copayment will do anything but harm in many areas of this country. I would like to work with Government to come up with focused responses to the use of Medicare funds that are wasteful. Our College is the vehicle to do this and has developed the slogan #CoPayNoWay using social media – the top tweets can be found here.
One challenge we have as specialist general practitioners is that our work is never done. There are thousands of special interest groups who vie for the attention of both general practitioners and our patients. Often the agendas are not transparent: a favourite concern of mine is the push for PSA testing by the Urological Society of Australia despite the lack of evidence of benefit. Faced with patients that seek an intervention they have seen or read about, we are overcome with the need to help and do good. Our education on topics is largely sourced and funded by those with financial interest in our behaviour. We often do not have the tools and information to unravel the evidence and be in a position to provide sound advice to our patients. Very few of our colleagues are equipped or brave enough to challenge these sources: a notable exception has been Prof. Chris del Mar getting the evidence together and going public on PSA testing. Do urologists get lead time bias?
I would like the RACGP to engage in a direct dialogue with the Australian community and investigate the needs felt in primary care and seek innovative and practical solutions that are commercially sustainable. It will be important to include peak bodies in this discourse, while seeking to understand their funding models and motivations. We need to learn how to deal with issues with more trust in our clinical know-how, less medications and fewer tests. Patients prefer such approaches when accompanied with understanding.
Enduring issues that arise in such discussion are the expressed need to have timely access to care when a person is sick and to maximise continuity. These pose difficulties for all of us; hence their appearance in surveys around the world. Meeting these needs can bring more satisfaction than many might think. I work in the large Palmerston GP Super Clinic providing 24/7 general practice and urgent care, covering a population out of hours of 25,000 or so. It amazes me that patients understand the pressures we are under and genuinely value the fact that we deal with emergencies – although it is only 30 minutes to the hospital. Working some shifts is necessary to provide comprehensive primary care just as it is in retail. Continuity means that we need to stay engaged, not referring at the drop of a hat. Generalists need to take responsibility for a broad range of presenting problems and work with patients to come up with solutions. Patient satisfaction is not the sole aim – it does not lead to better health. Getting these things right is a real challenge and requires resources and genuine investigation.
At the heart of our work is care; primary care, health care – what ever you call it. It works better if we care and we can only care together. That’s what our College is for.
I am pleased with the attention our President of the RACGP is giving to the issue of prescribing Roaccutane.(isotretinoin). It is a serious drug that is used to treat a common condition. Liz Marles is advocating that the prescription should be made in general practice.
There are good reasons for this. First, at least in my experience, if I refer for this purpose to a dermatologist they invariably prescribe. Second, contraception and adherence is something we know about and is the main argument for specialist review. Third, NZ GPs have been doing well since being able to prescribe the drug in 2009.
I would argue that, where such regulator concerns exist, at least in the first instance, Fellows of the RACGP should be able to prescribe the medication as specialist general practitioners. This provides evidence to regulators and patients that the GP has reached a suitable standard to take such action and monitor progress. I understand there are good doctors working in general practice without Fellowship, some no doubt far better than I. However, when actions demand high standards of care it seems reasonable to initially back doctors who have put themselves through assessment by their peers to ensure they are suitable for independent practice.
I would go further and promote those specialist general practitioners, their training and commitment to standards. Does the general public understand what Fellowship means? Do politicians? Do they understand that no one has been grandfathered by the RACGP?
Does your practice draw attention to Fellowship and what this means to your patients? Do they have a right to know?
I personally worry at the waste in healthcare and how we can save on Medicare. Unless we do something we will have to start thinking about how to save Medicare itself. To give an example: prior to the arrival of bulk billing practices in Darwin a few years ago we had one radiology provider and a couple of pathology companies. We now have 4 radiology providers and a few extra pathology providers. These also bulk bill. So I can now order unlimited blood tests and radiology without cost to myself, the practice or the consumer (a more appropriate name in this setting). I can get an MRI in 15 minutes and almost any test apart from an ultrasound within the hour.
I can’t imagine the actual increase in costs – is anyone imagining? I do see the result of confused patients with multiple positive obscure serological tests and a cascade of radiology – each new test suggested by the radiologist to rule out the sinister nature of some incidental finding on the previous view. Further tests require further brief visits while time heals almost all things. Dollars all round – nobody’s money.
This is not ideal and the opportunity cost of unnecessary attendances, laboratory tests and radiology investigations is probably massive in terms of non-health fields such as housing and other basic services. So why don’t we come up with some alternatives for consideration. A $7 co-payment doesn’t seem to do the job at all and seems to have few advocates. Here is an idea of my own which has had as little thought as the co-payment but might help funds go where they do more good.
Any attendance resulting in issuing of a private medical certificate for a period off work of less than 7 days will not be billable to Medicare. This would apply at the time of the visit or at any point in the future (to avoid being able to issue the medical certificate at a later date in order to claim the fee) but would not apply to parent or carer certificates for children.
Would this reduce medicare claims? Would it reduce the time off work for minor illness? Could it work? Would it be open to gaming? Let me know what you think.