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.
 
 

On the health of our profession: Are we our own worst enemies?
 
Dr Ayman Shenouda
 
On career choice
 
High quality placements in general practice is key to combating current trend which sees medical students turning away from our speciality.
 
But this too will fail if all they see is the effects of low job satisfaction whether it be remuneration, recognition or hours of work. 
 
This only reinforces the already impaired image internalised by both medical school culture and attitudes from role models – dominated by hospital doctors where our training system direct them.
 
And workplace culture really is everything. Unconscious bias is the hidden obstacle we really need to deal with if we are going to turn this around.
 
We need to ensure that what they see dispels some of these myths and allows them to make a more informed choice.
 
On career choice - we are currently sitting at 15% of final-year medical students (2018 cohort) stating general practice as their preference.[1]
 
Educational reform to help shift mindsets and ensuring exposure more realistically aligns towards workforce need would go a long way toward shifting these results.
 
But there’s so much more to this stat and we have more power than we think – pay differential aside.
 
On our role
 
So, what more can we do to ensure they resist the pull of the hospital-based specialisms?
 
Firstly, as a discipline we are not helping by talking down our profession.
 
I find discussions with some of my fellow colleagues frustrating when we ourselves are not pushing the value of general practice.
 
We focus on a lack of quality, on those providing sub-optimal care an of 5-minute medicine. The business of making money as rebates drop in value every minute after the six-minute mark.
 
Members feel they are not adequately remunerated for the job they do but still contribute to this vibe of a lack of quality.
 
Positive role modelling
 
We know positive role modelling is key. This is really the only pull factor that remains in our control. And it starts with the power of talk.
 
Clearly it is more difficult to control badmouthing between disciplines.
 
This obviously affects students’ career choices. And there is more we should be doing collectively – across the medical colleges - to stop this.
 
Do we know what they want?
 
But first, do we know what do Gen Y doctors really want from a medical career?
 
One survey[2] showed that if they were interested in a career in general practice, it tended to be because it fit well with a desire for work and lifestyle balance. Is that still something we have on our side with our recent survey showing more GPs reporting they have an excessive workload[3]?
 
Doctors do differ by generation and if you were a recruiter you would say there’s a good fit here.
 
Gen Y graduates want to constantly learn new skills, be challenged intellectually and both professionally and continually achieve.[4] Dealing with uncertainty and undifferentiated nature of symptoms encountered most certainly sets you on a course for continuous learning.
 
Achievement is an important one and this is where we come in.
 
Talk about our achievements
 
We need to convince medical students that general practice is exciting and real medicine happens here. We need to find a better way to tell our discipline’s story.
 
We need to celebrate the achievements of general practice - state what is positive about our profession.
 
It’s true that preventive medicine takes time to be seen.  But we have plenty to be proud of here.
 
Public health
 
On our public health achievements alone – on immunisation and disease illumination, cervical screening, and reduced smoking rates.
 
Our immunisation achievements are world–leading. We’re set to become the first country in the world to eliminate cervical cancer. And, we’re a pioneer in tobacco control with fewer people dying due to smoking.[5] 
 
It is in these achievements that we should be most proud as without the dedication of GPs this would not have happened.
 
Chronic disease
 
And with multimorbidity on the rise, our work in managing chronic disease also needs to be highlighted.
 
General practice provides the majority of care to patients with chronic illness. Most GPs manage patients with multiple health concerns.
 
Mental health
 
Our work in mental health with most now occurring in general practice.
 
Mental health remains the most common issue managed by GPs and is showing an upward trend (from 61% in 2017 to 65% in 2019)[6].
 
Talk more on our achievements
 
Clearly, we’ve achieved a lot. General practice is no longer a gatekeeper – it is the cornerstone of our health system.
 
We’ve done this despite having to find workarounds within a suboptimal health system designed to combat acute care of single conditions.
 
On the health of our profession we seem to be our own worst enemies. It’s time to turn this around and focus on the areas where we still have influence.
 
We have so much to be proud of and I think we should start focusing on the key role we play in keeping Australians healthy.
 
 
Unpacking the stats
 
This is clearly not a new issue here but the continued underinvestment shows in the stats predicting a very grim future of health unless we can turn this around.
 
No doubt this will continue to decline unless we see real action through more investment in general practice.
 
When you place the career choice stat alongside the other standouts for general practice it’s easy to see why there is such disinterest.
 
In terms of total health expenditure – general practice is at 7.4% of total health expenditure. This is despite general practice being the most accessed part of the health system.
 
But then there’s the pay differential. Remuneration as it stands is certainly not going to get them there either.
 
Average GP’s annual earnings amount to slightly more than half that of other medical specialists – and this gap has widened in recent years.[7]
 
Then alongside stats that give an all too real glimpse of the workload we face. It is clear continued underinvestment is starting to bite hard and most visible through increasing workloads.
 
We saw this when tested in a recent survey that showed 29% of GPs either disagreeing or strongly disagreeing that their work–life balance has improved over the past five years.[8]
 
​
[1] AusDoc.Plus. Medical students shun general practice Published 4th October 2019.
[2] Ipsos Healthcare Survey. published in August 2012.
[3] RACGP. Report. Health of the Nation 2019. Available at: https://www.racgp.org.au/general-practice-health-of-the-nation
[4] GRB UK. Understanding Gen Y as a recruiter. Available at: https://www.grb.uk.com/recruiter-research/generation-y
[5] PHAA, Top 10 public health successes over the last 20 years, PHAA Monograph Series No. 2, Canberra: Public Health Association of Australia, 2018Great
[6] The Royal Australian College of General Practitioners. General Practice: Health of the Nation 2019. East Melbourne, Vic: RACGP, 2019.
[7] University of Melbourne, Monash University. Medicine in Australia: Balancing Employment and Life (MABEL). MABEL Wave 10 survey. Melbourne: MABEL, 2019.
[8] EY Sweeney. RACGP GP Survey, May 2019. Melbourne: EY Sweeney, 2019

​Future GP workforce: The strategies needed to get ahead of the crisis curve
 
Dr Ayman Shenouda
 
A recent GP workforce discussion in the Herald Sun has warned supply is set to worsen over the next decade due to recruitment failures and broader impacts brought about by casualisation.
 
There are some key issues impacting here and at this point in the election cycle, it is a good time to highlight precisely what has led us to these recruitment failures and how to fix them.
 
We know what the path to a sustainable health system looks like and it involves a solid commitment to properly fund general practice and primary care.
 
If we want to design a system around patient needs then it is in primary care where we must focus our health reforms.
 
We have strong evidence to support this. We know that general practitioner supply is significantly associated with better population health.
 
Countless studies have confirmed this – the most notable being those from Starfield and Shi – yet successive governments have failed to put in place an action plan to realise these benefits.
 
Getting ahead of the crisis curve
 
In order to get ourselves ahead of the GP workforce crisis curve, a cohesive national strategy is now required.
 
It will certainly require a much stronger national policy focus to both recruitment and retention planning than we’ve seen in the past in order to build the GP workforce of the future.
 
A longer-term vision is what is required: half promises set within short-term electoral cycles will not build the health system our patients deserve.
 
At the heart of the issue is valuing general practice as a specialist discipline. The fact is that there is a lot of devaluing happening.
 
Professional negativism exposure during training, which seems firmly entrenched within the hospital-based specialties, is very much part of the problem.
 
We have to find a way to ensure general practice is high on the list in junior doctor’s specialisation choices.
 
To do this, we need to work on the perception of primary as distinct from, and of lower status than, secondary care.
 
When to direct our efforts
 
Medical career decision making is complex and much of that occurs during the early postgraduate years.
 
This is one or two years after graduation and for most their influences or role models will be from within the hospital system.
 
This is the time that doctors are making important career decisions and where positive exposure to general practice needs to occur.
 
Understanding the career choice determinants is important and there is an abundance of literature around this.
 
I would like to see a strategy that prioritises general practice and primary care with targeted attraction policies that trigger at those key decision points for junior doctors.
 
We need to work with other specialties to address professional negativism and find ways to provide more GP role models at these critical points in career decision making.
 
Other factors at play
 
Beyond recognition, it is important to highlight that there are other factors impacting significantly on our profession.
 
These not only limit our ability to attract doctors to our specialty but are adding to professional dissatisfaction among the current GP workforce.
 
Whether it is in its financing, remuneration or barriers to integration with the broader health system these are key capacity issues which persistently impact on our specialty.
 
We can already see that the Medicare Review Taskforce’s proposed revamp of GP items is set to place a whole new set of restrictions.
 
This combined with the impacts from the Medicare freeze and a persistent lack of investment in primary care is what makes our specialty a less attractive choice.
 
These all contribute to the pressures of working in the current health system and places restrictions on the value of care we can provide as specialists.
 
GP workforce action plan
 
It is clear that GP workforce reform would need to see more funding to strengthen primary care.
 
It would need less bureaucracy and significantly more funding to support patients with complex care needs for a system aligned with the multimorbidity in the community.
 
It would require a sustained effort to lift the profile and prioritise supports to encourage junior doctors towards careers in general practice.
 
We’re doing more to ensure the training occurs in primary care but that effort is diminished if all they see is a system in crisis.
 
There is a need to include a targeted strategy which financially incentivises GPs into training and practices where they are most needed.
 
But overall, we need to strengthen the role of generalist within the health system.
 
A high-performing health system built on integrated models of care must prioritise primary care and GP leadership.
 
We need to see a comprehensive GP workforce action plan prioritised by the major parties at the 2019 federal election.

GPDU18 – Proving we’re better together!
 
Dr Ayman Shenouda
 
GPs Down Under
 
There was plenty of discussion about collaboration at the recent GPDU18 inaugural conference on the Gold Coast. This was collegiality at its best and perhaps not surprising given we know that flat hierarchies are where innovation and collaboration will thrive the most.
 
GPDU offers healthy debate which is open and inclusive with all members encouraged to moderate. There is very little censorship here provided you remain on topic – GP learning, peer support, and advocacy.
 
Enabling an inclusive dialogue is why this Facebook community of over 5000 members exists and thrives. It provides the opportunity for real-time online discussion in a forum for GPs - one that is free from corporate vetting offering a rare open communication channel. 
 
Better collaboration
 
If there was one clear connect from this conference it was that we need better collaboration.
 
Collaboration creates value in communities. It is about sharing vulnerabilities and being open and being brave enough to distribute your power to many.
 
For GPDU18, day one great debate certainly focused on a rather divisive topic: ‘The Three, Two, One Debate (how many colleges is too many?) which saw an overwhelming yes (79%) for a single united college.
 
Panelists’ Drs Cameron Loy, Fiona McKinnon, and Liza Lack in this session provided either the for or against – one, two or three (college) - noting they didn’t get to choose which side they were on. They each worked through issues including what a college should be doing for their members and more broadly about their values.
 
There was also a discussion during conference on tribalism and the stages of tribal culture led by Dr Edwin Kruys. Based on the work by Logan, King, and Wright in their bestseller Tribal Leadership which takes you through the five kinds of tribes that humans naturally form and the benefit of establishing triadic relationships.
 
It was a timely and interesting reflection allowing us to turn our attention towards building the culture we want. You could sum up both sessions in three words - we’re better together!
 
Building the culture, we want
 
In building the culture we want, it is important to understand why tribes exist. This is really important as an understanding of tribalism is a key strategy for improving collaboration.
 
And, certainly on both topics – one college and that of tribalism - I really don’t think these issues are necessarily separate. Collaboration begins with organisational culture and we are all seeking a more collaborative approach and there were plenty of lessons to take home here.
 
While I doubt the vision for a single college will ever be realised, I think what we certainly do need is more coalition building. This is what GPDU does really well and why it works. It forms coalitions with those holding similar values, interests, and goals to combine expertise and resources for a common purpose.
 
Primary care and collaboration
 
In a past blog about the possibilities of having a united front in primary care and the need to find some common ground, we established that for collaboration to work then this relies on respect and trust. A lack of trust only stifles collaboration. We need to create a shared vision of the future and move towards it together. Have an agreed common goal and sign up for it.
 
In a more recent blog, we discussed ways to position ourselves as leaders of primary care into the future and the idea of a College for Primary Care. Getting back to our value proposition to achieve integration as well as satisfy funders positioning ourselves together in the health system will be important. This is key to ensuring we make the shifts towards a health care system based on wellness rather than the treatment of illness.
 
Collaborative healthcare leadership
 
We need a focus on positioning ourselves together to advance primary care reform and to help orchestrate a collaborative culture. Formalising this structure more would create a work culture that values collaboration. It would help us to put in place the adaptive collaborative learning systems required for the future.
 
For me, GPDU18 just proved that we’re better together and certainly the key themes that emerged particularly around collaboration reinforced a need for a stronger focus around this.
Building trust and blurring traditional boundaries will help end tribalism and silos – it would help bring the ‘we’ (as in the primary care team) instead of ‘me’ (the GP) back into focus.
 
Our sector needs to find a place for more inclusive reform and opportunities for collaboration through communities like GPDU. Working together towards a common agenda is the only way we will see the sector-wide change required. Improving health value in the healthcare system starts with us and it’s time to reconnect.

 
 
Dr Ayman Shenouda
 
Proving our value
 
Recent coverage around the failed Health Care Homes roll-out saw some unsettling truths coming through in the comments by the reform architect Dr Steve Hambleton.
 
This is in the context of the continuing trend for value-based care models, Dr Hambleton’s comments highlight a need in general practice to strengthen our data capture capability to prove our value.
 
What was said really cuts to the truth in terms of where our focus needs to be and how we ought to align or perhaps realign ourselves to better capture outcomes measurement.
 
For those who missed it, here’s the quote:
“What I will say to GPs is that unless we have the [patient outcome] data to take to the government that proves the value of the healthcare we are providing, they are going to keep investing in the bits of the health system where they do have the data, which is hospitals.” Dr Steve Hambleton[1]
 
The case for Primary Care
 
In delivering more effective, equitable, and efficient health services, it is clear that strong investment in primary care would see fewer disparities across populations.
 
The value and need of strong primary health care systems are already well established. There is robust evidence to show that good primary care is associated with better health outcomes. [2]
 
Primary care improves quality and reduces costs. But primary care integration and care management are made harder by a system that has at its core a prime focus on episodic acute care.
 
System barriers
 
The shift to value-based care is inevitable. However, creating savings in the healthcare system is as much about structures as it is about payment reform or data capture in driving that reform.
 
In measuring value, the current system and structure makes this very challenging. In many ways, the Health Care Homes model provided that answer in terms of how to provide and organise care in the future while enabling measurement and the policy is still worth pursuing.
 
The key requirement in embedding value-based care as a business model into general practice will require a shift in terms of enabling more team-based care to occur in order to remain viable.
 
Value in healthcare
 
Value in healthcare is measured around patient populations requiring different bundles care, these are defined patient groups with similar needs determined by combined efforts over the full cycle of care. [3]
 
This confirms the focus needs to be on primary care or new models of primary care but we need a stronger team-based focus and more support structures to make this work.
 
We need to leverage as much as we can from the current payment system to provide integration across settings. Much of this already falls to the general practice but enabling integration is hard and often non-remunerable work.
 
Our value proposition
 
The lack of networked or organisational architecture to support the level of data capture required to measure the quality of care and outcomes achieved through preventive primary care lets us down.
 
If we are going to achieve the level of integration required, satisfy funders with data capture demonstrating value then I think part of the solution also lies in how we position ourselves in the health system.
 
We already have the right strategy to fix healthcare and that solution lies in more investment in primary and preventive care through a Health Care Homes model.
 
In establishing our value proposition, if we must face off as Dr Hambleton suggests against advanced data-capture systems like those used in hospitals to capture detail right down to the bandages, then clearly, we need to get organised.
 
Transitioning challenges
 
Capturing quality measures and measuring performance on a continuous basis will be complex and creating reliable structures will be key to our success.
 
Part of that challenge is around data capture and standardising that process and in particular who’s holding the data. 
 
The strength of our primary care system is associated with improved population health outcomes and we know that enabling service integration is key in terms of realising these aims.
 
The other challenge will be our capacity to leverage technology, integrate more and build up those required team structures.
 
It’s clear there is still much to work through here. But what often gets missed is the need to enhance professional experience and I think it is here where we have some real opportunities.
 
Time for a rethink?
 
Right now, we should be thinking about what we can do to be more proactive in terms of redesigning what we can for ourselves.
 
We’ve been a College of GPs for some time now and certainly, that structure has been integral to the world-class health system we have today through supporting Australian GPs to provide the best possible care.
 
We need to ensure we have in place the adaptive collaborative learning systems required for the future. Is it now time to think about primary care as the future and not only GPs as the centre of that model?
 
College for Primary Care
 
The new models of primary care required in response to the healthcare system shifts towards value-based care will rely more and more on team-based care.
 
In demonstrating value, we need to think about those finite costs capturing those bandages too but this also needs to be about developing the primary care team. There is a real opportunity to support all the individuals working in general practice and train the whole team to enable more integration.
 
Collaborative healthcare leadership will be needed in shaping the future workforce to support new models of care. The existing College structure can help provide this leadership model to bring about the transformative change required.
 
Taking a more proactive approach to designing the health system means less focus on payment reform and more interest in investing in the primary care team.
 
[ends]
 


[1] News Article. Health Care Homes roll out 'went wrong somewhere' says reform architect March 27, 2018. Australian Doctor. Available at: https://www.australiandoctor.com.au/news/health-care-homes-roll-out-went-wrong-somewhere-says-reform-architect

[2] Starfield B. The future of primary care: refocusing the system. N Engl J Med 2008;359:2087-91.

[3] Porter ME. Perspective. What Is Value in Health Care? December 23, 2010. N Engl J Med 2010; 363:2477-2481
DOI: 10.1056/NEJMp1011024 Available at: http://www.nejm.org/doi/full/10.1056/NEJMp1011024
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