W(h)ither general practice? Be careful what you wish for

Dr Ian Kamerman*

Let’s be quite clear. The move by the Department of Health to return general practice training to the colleges is a good thing. This is in fulfilment of their obligation to the Australian Medical Council.

This is, after all, what colleges are supposed to do, and now the general practice colleges will join their fellow specialty colleges.
However, my concern is that this may also signal a reduction in government engagement and its resourcing of general practice training.
What message is government sending?

There is no more money. The primary care bucket is now essentially capped and we will not see shifting of dollars into primary care from other buckets. Despite all the evidence in the public health arena, we will not see dollars move from the hospital system to the community sector.
Well, some may say, the patients can pay more.

Yes, they can. However, the world economy is now stagnating with almost universally low wage growth. The silver lining is that there is minimal wage growth for our staff, but one can predict that patients will be holding onto their money more tightly.
But wait! There’s more! And more!

What has the government done over the last few decades? Increased medical school output, while maintaining medical migration. We have spent significant resources training large numbers of doctors. What have we got for that investment?

Well, to start with, we have flooded the specialist market. Look at the surgical specialties. More and more doctors are spending longer and longer doing unaccredited surgical terms waiting to get onto a training scheme.

Many have masters qualifications. When they finally get through, if they get through, each will expect theatre time and patients.
We can run through the specialties and see the numbers flowing through to fellowship. The problem being that a number of them fall by the wayside. The personal dismay, the individual financial toll, and the cost to the taxpayer is significant.

Each specialty training pathway is filling up. With more interns, residents and registrars, and new models of patient care, there is less clinical exposure at all levels of training. New fellows are no longer ready for independent practice and all that entails. General practice is also filling up and the problem is that our appointment books frequently don’t.

As the numbers swell, and the economy tightens, and property prices increase, we have downwards pressure on general practice billings.
With lack of growth we will also have fewer GPs being able to afford retirement. The Medicare slow thaw is setting a low floor price for an average consultation and my feeling is that this will also lead to a reduction in the floor price of general practitioners.
Where does everyone go?

We are in the midst of the tsunami of graduates. Where are they all going? Many are still in the hospital, especially in emergency medicine. Even the less-popular specialties, such as psychiatry and paediatrics, are now filling.

Here are my workforce planning questions that many are too afraid to answer.
• Does every medical graduate have the right to enter the specialist training of their choice?
• Does every medical graduate have the right to specialist training?
I would suggest no. So where does that leave us?

General registered doctors with varying levels of experience. Traditionally these doctors have worked as CMOs and locums, but surely these jobs will dry up as well. I think these doctors will all find a new home in general practice. It just won’t be general practice as we know it.
And what do we have entering the scene, just as we are reaching a capacity constraint? The Health Care Home. A great idea, reasonable evidence, but woefully underfunded.

The model used for funding works most efficiently with employed doctors. It just might be that we will see Health Care Homes set up, with fellows as consultants and employed general registrants as community-based CMOs.

The pay will not be great because the funding is just not there, but one can see that a tipping point will arise, in the not too distant future, where this role takes off in much the same way as the after-hours doctor model did.
What has this got to do with GP training changes?

I am concerned that government may, at a time with large number of doctors in the marketplace and with significant economic restraints, push registrars and practices into a larger degree of self-funding. While I feel that registrars will begrudgingly pay more for their training, I doubt many general practices will pay to participate in GP training.

If we get to a situation where registrars are competing with CMOs for positions in the general practices of the future, they will have to do it on price as well as skills.

This is just one risk of the department of health handing over responsibility for GP training to our colleges. It allows deniability. The minister will be able to say: “This is not my concern.”

I just hope that I am wrong.
* Dr Ian Kamerman is long time GP supervisor, past president of RDAA and GPSA, and a current director of GP Synergy

Republished with permission of http://medicalrepublic.com.au/

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