The General Practice (GP) profession in government funded models

Australia’s “universal medical insurance scheme”, Medicare, offering healthcare to Australians, is based on the British NHS model. For too long, a critical shortage in investment into general practice in UK has lead to unsustainable pressures that are beyond the coping threshold.

On average, a general practice receives £136 per registered patient for an entire year of unlimited medical service. This is less than the cost of an annual cable TV subscription. Not surprisingly, patients are lining up for this free-for-all, leading to waiting lists of up to 3-4 weeks.  Under the contractual agreements between general practices and the NHS, practices are prohibited from offering a private service to their registered patients, due to a conflict of interest. Here are some of the consequences that UK is experiencing with this model:

  • Growing resentment amongst GPs, leading to an ever increasing number of GPs quitting full time work, or prematurely retiring from the profession all together, and not being replaced by younger trainees due to a lack of incentive, enthusiasm and practically unrealistic service targets.
  • Surgeries are facing a recruitment crisis.
  • Increased demand and poor funding from the rather stagnant Federal budgets means that the demand simply cannot be met. Safe, effective, efficient and high quality comprehensive medical care would become a distant dream.

As such, general practice is on the brink of collapse under UK’s current model. It’s a real shame that Australian politicians and the Grattan Institute are looking up to this model, without learning from the UK’s lessons. The only way general practice will be sustainable is if there is increased investment into the industry, whether it is from the government or from patients directly, or both. Under-investment is simply not feasible. Bulk billing is not feasible unless the Medicare rebate is in line with the AMA recommended fees, which at present is around $80 for a standard consult. $37.05 is the current Medicare rebate, which is a far cry from the minimum funding required to deliver healthcare.

It’s a shame that the Australian government is already planning to trial this “annual subscription” aspect of the UK model with its Australian title, “health care homes” :

http://www.health.gov.au/internet/main/publishing.nsf/content/health-care-homes

Unrealistic Expectations when visiting your GP

Here are some common scenarios that I encounter frequently:

Patient books a standard consultation (10-15 minutes depending on the practice), but..

The patient then comes up with a shopping list of problems that they want solved then and there itself. The doctor then offers to discuss these issues during another consultation. Many patients will be reasonable about this, especially after the doctor explains that in order to offer quality care, the ideal consultation involves a number of steps for each issue, including taking a relevant history, performing a relevant examination, explaining the possible differential diagnoses, and offering a variety of treatment options. However, there are also many patients who choose to respond with aggression, often using one of the following arguments:

  • “I have never met a doctor who refused to address more than one issue at a time” <– I’m sure you haven’t. They must have solved your life story in 10 minutes.
  • “but this is the main reason I came in today” <–which is why you mentioned it at the end of the consultation
  • “how rude” <–offering an explanation is considered reasonable and polite.

The moment the doctor informs them that it will cost them more, they tend to opt to book another appointment, or disappear all together. Win win situation.

“It should all be on the record. I’ve been through this with others before”

Yes, I do understand it can be frustrating to have to explain a problem more than once. However, there are many reasons why a doctor you’re seeing for the first time should take a proper history from you:

  • It may not all be on the record. This could be because not all notes have been transferred from another clinic, or not all the information you discussed with another doctor in the same clinic may have been documented.
  • If there is a library of notes about you, it’s really not prudent to review in detail every note and correspondence prior to your arrival. This can not only be time consuming, but your presenting problem may have nothing to do with what’s on record. If you go to the library looking for a specific book, you can enquire about it with the librarian, and she can look up the relevant section and point you in the right direction. The librarian will not go through every book on the shelf prior to a patron making an enquiry. The GP setting is no different. Just as a librarian has to know what sections are stocked where in the library, it’s good practice for a GP to familiarise themselves with a summary of your relevant medical conditions prior to a patient visiting them. Once the patient opens up about a specific problem, the GP can then focus on evaluating that particular problem in the overall context, and retrieve the relevant available correspondence.

At the end of the day, transparent two way communication and cooperation from both parties translate to improved healthcare outcomes.

More to come on expectations..