General Practice. It used to be a dirty word among residents at the hospital. Everybody wanted to be a cardiologist or a neurosurgeon. It was more exciting to burr a hole into a patient’s skull or unplug their artery with a tiny balloon than to sit behind a desk and listen to their problems. I was no different. When I chose general practice as a career, it wasn’t for love of the job – that came later, and rather unexpectedly – but for its work-life balance and flexibility.
Primary healthcare is not, and never has been, sexy. Referred to as ‘the frontline of the healthcare system’, it encompasses a vast array of activities from health promotion to the long term, often lifelong, management of chronic illness. GPs, together with nurses, pharmacists, dentists and allied health professionals, fall under its wide umbrella. And while it may not be sexy, it is – a little like brushing your teeth – necessary.
Many of the challenges outlined in the Australian Institute of Health and Welfare’s Australia’s Health 2014 report, such as an ageing population, rising levels of obesity and inactivity, and the increasing prevalence of chronic disease, are the domains of primary healthcare, and in particular, general practice. So why is our government so intent on cutting funding to this sector of the health system?
In the 2014 Federal Budget, the Treasurer outlined plans for a $7 GP copayment. In its first draft, nobody and no service was exempt. Even the poorest members of our community would be hit with a bill for their first ten visits to a GP. Similar copayments were going to apply to diagnostic tests and medication. Under the new proposal, an unforeseen illness could, quite conceivably, break the family budget.
Not surprisingly, the proposal was met with uproar from organisations like the Australian Medical Association and the Royal Australian College of General Practitioners. The president of the AMA described the plan as an ill-conceived solution to a problem that didn’t exist. He pointed out that spending on GP services had been virtually static for the past five years, that the Medicare rebate for radiology services had not risen for ten and that the pathology budget was already capped. Surely fixed spending in the face of increasing demand indicates efficiency rather than over-servicing? But Treasurer Joe Hockey stood by the proposal, declaring that the $7 fee was the cost of ‘a couple of beers or one third of a packet of cigarettes’, clearly not having met my non-smoking, teetotaller pensioner patients.
Now, after months of opposition in the Senate, we are to believe that the government has had a change of heart. They have ‘listened to the views of the community’ and come up with a ‘better policy’. True, they have now excluded the most vulnerable (children under 16, pensioners, veterans, and people in nursing homes) from changes to bulk-billing, but their Plan B targets Medicare in a way not seen since Malcolm Fraser set his sights on it more than thirty years ago. Ironically, while we watch America sow the seeds for universal healthcare, Australia, once a pioneer, now seems set to dismantle it.
In a nutshell, the ‘new and improved’ policy proposes that instead of a $7 copayment ($5 of which would have gone to the government and $2 of which would have gone to the GP), GPs will now lose $5 for every adult non-concession cardholder they see. For bulk-billing GPs – and it should be pointed out that in the 2012-2013 period 82% of GP attendances were bulk-billed – this equates to a 13% pay cut.
If this revised copayment plan goes ahead, many bulk-billing practices will be forced to close or else charge their patients a fee. Ultimately those patients who don’t have the luxury of making health a priority, will lose. Convincing patients to attend for preventative health consultations like pap smears and blood pressure checks – arguably the most cost-effective aspect of healthcare – will be more difficult, and in many cases, impossible. Graduating medical students will be even less inclined to choose a career in general practice. And, at the risk of sounding dramatic, there will be nobody to look after us when we get old.
Such policy seems short sighted when considering that chronic diseases are the leading causes of illness, death and disability in Australia. The costs to society are huge because they encompass not only the direct healthcare costs but the lost productivity from illness and death. And the impact is not uniformly distributed. In Australia, chronic disease occurs more commonly among Indigenous Australians and those living in areas of low socio-economic status – the same people most likely to be affected by a $5 GP fee.
Consider my patient, Joe, a truck-driver from the western suburbs of Melbourne who presents because a work health check found his blood sugar to be high. We do further tests to confirm that he is not yet diabetic but has a pre-disposition to diabetes. I refer him to a dietician who gives him advice about how to modify his diet. I encourage him to increase his level of activity. He finds it difficult but manages to lose a few kilos. He continues to see me every three months for checks of his blood pressure and blood sugar. At the first sign of his sugars getting high, we start him on medication. He continues to drive trucks and support his family.
Now consider what might happen if Joe fails to attend for review because there are no bulk-billing practices in his area. Initially, nothing much. He feels well but he makes no changes to his diet or lifestyle. His sugars run high. After a few years, he develops complications from his diabetes. His eyesight deteriorates, he has a heart attack, his kidneys fail. He attends the hospital three times a week for dialysis. He can no longer work as a truck driver and his wife has to quit her job as a teacher’s aid to look after him.
If we believe the World Health Organisation’s warnings about a looming chronic disease pandemic, then we shouldn’t be cutting funding to primary healthcare, we should be increasing it.
All this makes me wonder if our policy makers aren’t suffering an affliction themselves. If former AMA president, Dr Steve Hambleton, is right and the government has seen an overfunding problem that doesn’t exist, then my diagnosis would be one of hypochondriasis. In which case, perhaps all the Prime Minister really needs is a good GP.