 Dr Ayman Shenouda General practice is the foundation of Australia’s healthcare system. Our profession is vital to the health of our nation, yet it remains the most devalued profession. We are underpaid, underprioritised and overstretched by rising demand. This is despite the strong trust patients place in their GP’s - being the most accessed healthcare service with more than two million appointments made every week. Here I discuss some key areas in tackling the funding crisis in general practice. General practice in crisis General practice in Australia is now at crisis point. Many general practices remain on the edge of viability specially in the current pandemic . Practice closures are on the increase as GPs are simply struggling to maintain quality services. There are more and more timebomb towns emerging where GP to patient ratios stretch to breaking point. Despite the rhetoric, bulk billing rates have dropped by -0.1% to -0.5% throughout rural Australia, while out-of-pocket cost has risen by over a dollar to $38.05. These are all factors deterring our doctors in training from pursuing a career in general practice. This all leads to a worsening workforce crisis, particularly in rural Australia. Rural registrar placements have already declined by 40% in some areas and unless we start making careers in general practice attractive, including remuneration in line with hospital specialities, there will be serious consequences. And with a declining general practice workforce, the true cost will be seen in future years in the declining health of the nation. Urgent trust and investment in general practice is now needed. The shift needed Our healthcare system is already the envy of many countries around the world. But how healthy is it when less than 9% of annual funding goes to general practice? The hospital system and other tertiary services continue to be prioritised. Despite the evidence, policy makers seem intent on preserving a reactive and acute care focused system. Yet we know the impact of chronic disease will only intensify and this requires a strong preventive focus. Australia faces a rising chronic disease burden, an ageing population and a significant rise in mental health problems and palliative care need. According to the latest National Health Survey almost half of all Australians (47.3%) are now living with a chronic disease. We know that a third of chronic disease is preventable yet there is an allocated health spend of only 1.3% of our health total budget. We know that without strong and effective primary health care countries will struggle to maintain their health services. It is by far the most efficient and cost-effective part of the healthcare system yet it remains so grossly underfunded. There is clear global evidence that health systems with strong primary care will secure long term efficiencies. Benefits from prioritised investment include achieving lower rates of hospitalisation, fewer health inequities and better health outcomes including lower mortality. A solid foundation Chronic disease is complex and difficult to manage. The only way to curb the impacts of the rise in chronic diseases is through prevention. We have the key components already in place to underpin strong population health outcomes. The unsustainable rise in healthcare funding needs structures towards prevention and management and we already have a solid foundation to work from. General practice provides the foundation for what can be the best and most effective, high-quality and sustainable health system. An equitable system that supports optimal outcomes which see patients actively managing their healthcare needs to stay as healthy as possible. Missed opportunity The Government is clearly not capitalising on this opportunity. Why do we find it so hard to direct funding to where it is most needed? Despite having had the best policy intentions the funding committed towards primary care unfortunately has not been spent in the right places. Lots of investment in different organisations has had a destabilising effect – contestable funding and competitive service markets are just not commensurate with addressing significant unmet health need. This approach is having a negative impact on the delivery of vital health services. It stifles innovation making it very difficult to be creative to deliver quality care for patients. Direct investment in the most effective part of our health system – general practice - in driving patient centred outcomes is what’s needed. United leadership In my journey in general practice I have met a lot of amazing GPs. My colleagues continually inspire me with their passion and tenacity to overcome these challenges and their enduring commitment to serving their communities. The reality is that the majority of GPs are doing exactly that. Governments are using this passion and commitment to their advantage. A lack of appropriate government investment in general practice has put our health system at risk. General practice services in Australia are close to breaking point. A strong investment in general practice is what is needed to secure a healthier future for all Australians. The health of our nation is an enormous responsibility and more funding is needed so that we can continue to provide optimal care. Strong united leadership with a united approach to this major crisis is now urgently needed. Urgent need for investment There is an urgent need for financial incentives, to reward GPs for increased scope, complexity, special interest, continuity of care, and patient coordination. We cannot ask GPs to perform an advanced-level job, but remunerate them with the lowest rates of all medical specialties. This has to change.
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 Unsettling times in our communities and across the world
It is an unsettling time. We know young people, their parents and teachers have been preoccupied with school closures for several weeks. We are aware that families in our community are facing new challenges, juggling the responsibilities of caring for family members – young and old. Thousands of people are adjusting to new working arrangements, while others, in casual employment or small business are fearful about future incomes. And then there are the health professionals. The GPs and their teams. The medical and nursing professionals working at hospitals. The Nurses working in aged care. The Aboriginal Health Workers reaching out to support communities. These professionals have been working for weeks to respond to, and prepare for, the spread of COVID 19. We knew COVID 19 was coming and its impact was to going to be significant. Australia’s leading medical professionals and GPs having been working around the clock to prepare Australia, the health system and GP practices. Thankfully, our politicians have been listening to the medical experts and responding to their advice. But more needs to be done. As at 3:00pm on 25 March 2020, there have been 2,423 confirmed cases of COVID-19 in Australia. This figure is rising I am still hopeful it will flatten in response to the recent restrictions . GPs are on the frontline. Every day, we see patients who need testing or who are displaying symptoms that are causing them to be concerned. As GPs we balance keeping our staff and ourselves safe, whilst also attempting to achieve continuity of care. There is a long road ahead for each of us and our communities. Our patients look to us as the calm providers of advice. They seek out our guidance and look to us to reassure them. We have the skills and expertise to be at the frontline of the campaign to keep all of us healthy and safe. However, to do this role well, we need open lines of communication with decision makers, access to evidence, timely testing and plenty of PPE. Australia has more than 26,000 specialist GPs[i]. We are working in communities all across Australia. We want to help our patients and their families through this time. To do this we are going to need our support networks, our leaders and our resilience. I am confident that Australia’s GPs are up to the challenge. Our communities are depending on it. [i] Medical Board of Australia. Registrant Data – December 2019. Accessed 22 March 2020 https://www.medicalboard.gov.au/News/Statistics.aspx
A collaborative approach is what we need for rural GP training
I recently had the opportunity to host a Rural GP Summit in Alice Springs. The summit brought together the key people and organisations that contribute towards ensuring there is quality general practice in rural Australia. At the summit, we analysed what is working well to support GPs to train in rural Australia. We also acknowledged the need for improvements. Including harnessing innovative contemporary learning models, which are flexible, and offer new opportunities. For more details about the announcements the RACGP made at the Rural GP Summit and the opportunities this will create for registrars, see link here. For me, the greatest outcome from the Rural GP Summit was seeing the willingness of delegates to come together to talk about, and debate, the future of rural general practice education and training. There was such generosity in the sharing of ideas and solutions. There was also courage to discuss what is not working well. We all know about the challenges associated with supporting general practitioners to train and work in rural Australia. We know about the struggles to enlist experienced supervisors, and the barriers that prevent registrars from feeling confident to undertake their training in a rural community. We have lived through the historical division between GP organisations and have witnessed the arm wrestling that occurs between Commonwealth and State Government agencies. All of which creates confusion and duplication and further prevents GPs from addressing community need. However, we also know that working in rural Australia, as a GP, is one of the best jobs there is. Where else do you get to use all of your training (sometimes before lunchtime) to provide continuity of care for your community. Rural general practice is about teamwork. Working in teams to address community need in a rural community, is immensely satisfying. Listening to the discussion and ideas at the Rural GP Summit has given me hope. It has confirmed to me that we need to build collaboration into the design and delivery of future rural general practice training. We need to ensure junior doctors and registrars are at the table when the education and training frameworks are created. We need to invite medical educators and supervisors to be part of the discussion about how we deliver general practice training in rural Australia. We need to regularly invite feedback from our partner agencies and rural stakeholders. We also need to work with our stakeholders to monitor trends and to mobilise our collective energies and resources, when there are obstacles that are hindering high quality general practice training in rural Australia. If we can work in collaboration, I am confident we can reform our current approaches to rural general practice training. I am hopeful we can create new flexible models that reflect the aspirations and expectations of our current and future registrars. If we can harness the energy and insights of our registrars, educators and rural stakeholders we can achieve great things. Our rural communities will be the big winners if we can get this right. Ayman Shenouda
Comprehensive community general practice, coupled with emergency management, is the heart that will keep rural generalism alive
I recently had the opportunity to spend a few days in Western Australia meeting with GPs, government officials and experts in rural and remote health. It is apparent that comprehensive community general practice, coupled with emergency management is the heart that will keep rural generalism alive. This was evident during my visit. The leadership of GPs such as Dr Michael Mears in Esperance and Dr Michael Livingston in Ravensthorpe demonstrated how rural generalism is thriving. I met Dr Mears and 11 of his colleagues, early one morning. This group of 12 GPs, representing a number of local GP clinics, provide comprehensive primary care, as well as emergency medicine, anaesthetic, obstetrics and surgical services. They shared with me their collaborative model for addressing patient need within their community. They are outstanding educators and are committed to supporting the next generation of rural GPs. I enjoyed the opportunity to discuss the RACGP’s vision for general practice and to hear their ideas for the future of rural generalism. I was also privileged to meet with Dr Michael Livingston at his practice in Ravensthorpe. His practice supports a community of 2000 people and he is a passionate rural generalist. His approach to comprehensive patient care is leading to outstanding health outcomes. It was also great to meet with his wife and family. The commitment and sacrifice they offer to the community of Ravensthorpe is remarkable. Michael shared with me his concerns about the viability of general practice in rural WA communities and the impact on patient care from a lack of integration between Commonwealth and State governments. Michael has many ideas for enhancing the sustainability of general practice in rural and remote Australia. When I am next in Canberra, I intend to speak to the issues and ideas shared with me in Esperance and Ravensthorpe. I am keen to ensure that MPs and government officials hear and act upon the voice of grassroots GPs. The visit to WA gave me the opportunity to meet with leaders and rural health experts at a number of relevant agencies including WAGPET, WA Department of Health, WACHS, Rural Health West, the AMA, Rural Clinical School of WA and the WA Primary Health Alliance. I was briefed on the challenges of recruiting health professionals to work in rural WA and how communities thrive when there is continuity of care from a GP. It was good to receive an update on the efforts of many to provide medical students, junior doctors and registrars with fantastic education and training experiences. Rural and remote WA is a wonderful place to learn how to become a great GP. I have returned from my trip, energised about rural general practice and inspired by my colleagues in WA. I extend my appreciation to Adj Professor Janice Bell and her team at WAGPET for arranging the visit. I also wish to acknowledge the following individuals who meet with me and shared their expert knowledge on rural health care in Western Australia.
Photo 1: Dr Michael Livingston and family in Ravensthorpe, Western Australia Photo 2: Dr Mears and colleagues in Esperance, Western Australia Dr Ayman Shenouda  When we stand together, great change is possible
I love being a GP. I love being part of the general practice profession. Our community of GPs is vibrant and diverse. We are passionate about the profession of general practice and compelled to improve the health of our patients and families. As I think about how to make general practice even better, I think about creating new opportunities for GPs to come together. I believe it is through working together that we can make change happen. In my experience, collaboration to bring about change is never clear cut, quick or easy. It is messy, fragmented, divisive, confusing and draining. However, collaboration when it works can bring about change that was never thought possible. Throughout my career I have joined committees and working groups in a hope my voice and actions will contribute to bringing about change. Sometimes these roles have led to positive outcomes, other times I have become frustrated at the barriers put in the way of positive progress. One of my most positive experiences, in collaborating for change, has been as Chair of RACGP Rural. It has been in this role that I have seen how change can happen. One such change, achieved through the collaboration of many GPs across Australia, relates to rural generalist medicine. The focus of the rural generalist reforms have been about obtaining recognition and subsequent remuneration for the advanced skills of rural general practitioners. Debates have centred on how to enable general practitioners to work in both primary care and hospital settings in rural communities. It has also been about supporting the next generation of rural general practitioners to acquire and maintain skills in advanced areas of general practice. I am optimistic that the rural generalist reforms, championed by so many GPs, will be positive for the profession and for rural communities. Bringing about fundamental change to general practice is hard. I have seen general practitioners spend their whole careers championing rural general practice and rural generalist medicine. I have seen them represent their profession on committees and working groups where change has not seen possible. But I have seen how change can happen, when there is alignment on vision, sustained leadership, a willingness to try something new and a commitment to collaboration. Hard working general practitioners know how to get things done. When these same GPs find commonality and a way to work together change becomes possible. I am hopeful as a profession we can create other opportunities to come together to make general practice the profession of choice for young doctors. I am keen to hear your ideas. How can we work together to make change happen in general practice? Send me your thoughts or give me a call. Dr Ayman Shenouda |
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