December 3, 2023

Almost every patient I meet in my clinic is on a Health Care Card. This used to get them free or inexpensive medical care across the country, but this is getting harder and harder for all of them.

My first patient one day, a new mother on a low income, for instance, has moved far away from where I practice, but she still returns for treatment, unable to afford a local GP who will give her the time she needs.

Part of it is Medicare. Recently, there’s been a lot of talk about “strengthening” Medicare. Finally, most people realise that Medicare doesn’t support quality care in the way that we want. It doesn’t support slow, thorough medicine. It doesn’t support GPs to care for people with complex, entwined physical and mental health struggles. GP clinics are struggling to cover the costs of anything that isn’t a “quick consult”.

The designers of the Medicare system appear to have thought that the more patients seen, the better; that general practice is for simple problems. If this were ever true, it certainly isn’t true today. Not for the woman struggling with managing her diabetes in unstable housing. Not for the young man who wants to talk about his ice addiction. Not for the elderly person who is worried that she is losing her memory. Not for the new refugee who still needs an interpreter.

But the other part of the problem is this: unlike for specialist medical services, which are sometimes offered by “public outpatient” hospital departments, there are few “public outpatient” models of general practice for the most vulnerable.

In Victoria, community health centres once bridged this divide, but as an ex-clinician for one such service, I sadly report that these GP clinics are withering from neglect. In their heyday, these GPs were employees, empowered to provide time and care for the most vulnerable. Now, many are casualised “contractor” GPs, dependent on the same Medicare schedules as everyone else and trying to squeeze in as many patients as possible, in order to bill Medicare to sustain the clinic.

Community health services for the poor and needy were once small, grassroots clinics, and later supported by the Victorian government. Many had GPs, specialists and allied health working together. In recent decades, the state government tendered these services out, and over time many have morphed into large corporations good at responding to lucrative government tenders.

General practices in these “community health” services moved to a Medicare model. Now almost all such GP clinics are run by non-clinical administrators.

Often, I find myself wishing that politicians, health economists and medical administrators would sit for an afternoon in my clinic and see what we see.

There is much that could be improved in care provision, especially for the poorest. There is great need, and many real people are suffering. Governments must invest in these systems so that we can provide caring care.

On the ground, I hear that too many smart, thoughtful GPs have left clinics serving poorer populations, or they are considering their exit, because they cannot do the good work they want to.

So how do we serve the people who cannot and do not easily advocate for their health needs? Those who have no stable housing. Those with a language barrier. People with complex disabilities. People with serious mental illness. Those living with chronic pain, or complex traumas.

Our healthcare system does not easily accommodate them, and if it does, these patients bounce around from duplicated test to test, and hospital to hospital, without the expert assistance of a GP who knows their story and is empowered to provide quality, longitudinal care. Expert primary care may be expensive but it is much cheaper than the alternative.

In general practice we desperately need two things. First, for every GP to be equipped with the time and funding to provide thorough care for medically complex people. Every time I read a guideline on how to provide gold-standard medical care, I want to know that it is actually possible in our healthcare environment.

And secondly, “community health” GP clinics need to be powered by a different model of care for communities with extra challenges. We need funded time for team meetings about difficult cases, for referral and consultation with our colleagues, for clinical leadership in our communities, and for longer consultations with our patients.

We need policy-makers to value GPs as expert primary care physicians, at the coalface of biological, psychological and social health.

These past few years, our governments have poured billions of dollars into pandemic measures, to ensure everyone had access to information, vaccination and Covid care. Recently, funding has been delivered for a limited number of urgent care centres to ease patient waits for GPs and emergency services.

But still, every week, I try to send a poor, chronically unwell patient to their local “community health” GP clinic, or to find a quality bulk-billing doctor, and every week we face a barrier: there is no such service available.

It’s time to support GPs to do good work for the long run.


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