Taking the pulse of general practice

The number of GPs in Australia is falling in real terms, as more and more medical graduates choose specialisations over general practice.

A major report from the Melbourne Institute of Applied Economic and Social Research has found that, while the number of new GPs in Australia is growing relatively slowly, for every new GP there are nearly ten new specialists.

Professor Anthony Scott, who leads the team behind the report, says the trend could prove expensive in the long run, and has implications for patient care.

“If we don’t have enough GPs, patients will end up in hospital more than they should,” he says. “If patients can’t get in to see their GP they end up in the emergency department, where they’ll be seen by specialists.

“Specialists tend to do more procedures, which means more expense for the public purse. Potentially, patients may also end up receiving unnecessary treatments.”

The ANZ-Melbourne Institute Health Sector Report is the first major health check of general practice in Australia. It uses data collected through Medicare and the Institute’s Medicine in Australia: Balancing Employment and Life (MABEL) survey, which has been running for 10 years and includes data from over 10,000 doctors.

The results suggest general practice is still relatively unattractive to medical graduates, says Professor Scott.

“Money does matter,” he says. “Specialists are paid two-to-three times what most GPs are, and that’s the route junior doctors want to take. Often it is those who can’t become specialists that move into general practice.

“Unfortunately, it’s seen as second fiddle to specialisation, in terms of reputation and earnings.”

And while GP earnings are increasing above inflation and at twice the rate of real wage growth, their work satisfaction is going down – a trend researchers have observed since the introduction of the Medicare fee freeze in 2013.

The fall in morale among GPs may be the most notable impact of the fee freeze; there is no evidence to suggest patient fees are increasing or that the standard of patient care is declining. Nor has the freeze reduced GP earnings. In this context, the most likely explanation for the rise in GPs’ earnings is more efficiently managed practices.

“Falls in job satisfaction suggest decreasing morale which can, in turn, reduce the attractiveness of general practice as a career for junior doctors and compound difficulties in recruitment,” says Professor Scott.

“If this continues it could also drive more GPs away from being practice owners and encourage them to retire earlier than planned, creating issues for retention.

“It is likely practices are improving their business processes, and the co-location of services that pay rent, like pathology clinics, are contributing to their bottom line,” says Professor Scott.

“But this pressure for clinics to run efficiently, along with ongoing negative media and a perception that government policies are targeting general practice, may be contributing to GP’s declining rates of morale.”

Another trend identified in the report is the likely increase in corporatisation of general practice, as smaller, doctor-run clinics are bought up by corporate entities.

The survey identified a drop in the number of general practices in Australia (from just over 8,000 in 2002 to just over 7,000 in 2011, the last year for which reliable data exists). It also found that the proportion of GPs working in a practice with six or more doctors has risen from 47 per cent in 2008 to 61 per cent in 2015.

“On the one hand, corporate clinics might be more efficient in their use of resources, provide more onsite services for patients, and benefit from economies of scale and scope,” says Professor Scott.

“GPs themselves may also benefit from working there – particularly women who are more likely to be working part-time and may prefer a job with a steady income over practice management or ownership.

“But their downside is they are larger and there are less of them, so patients may need to travel further to see their GP.”

The report also flags the ongoing challenge of attracting GPs to rural and remote areas of Australia.

“A lot of GPs don’t want to leave the cities,” says Professor Scott. “So we find doctors from overseas fill that gap.”

However, Professor Scott warns the Federal Government’s latest crackdown on skilled immigration may have the unintended consequence of heightening the lack of doctors in country Australia.

“Without skilled migration, attracting doctors to rural areas is going to be even more challenging,” he says.

“While the government may want to ensure the increasing numbers of medical graduates all have a job, you simply can’t force someone to work remotely if they don’t want to.”

General practice requires more support, says Professor Scott, particularly in light of the country’s ageing population and increasing burden of chronic illness.

“I would welcome policies that make specialisation less attractive for medical graduates,” he says.

“One way to do this would be to increase patient choice when GPs are making referrals.

“More transparency around specialist fee structures and increased patient choice would certainly be welcome – it could increase competition among specialists and drive down their fees, narrowing the gap between what specialists and GPs earn.”

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