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Tuesday, 5 November 1996
Page: 5117

Senator EGGLESTON(7.20 p.m.) —I would like to make some comments about what I perceived as the cynical attitudes of senior officers of the Department of Health and Family Services towards the medical profession and GPs in particular revealed during the course of the recent Senate estimates hearings. I have to declare that I have an interest in the matter, having been in medical practice since 1975. That also means that I speak from a position of considerable knowledge.

The first matter I would like to comment on is the fact that the key performance indicators of the Medicare program do not include any assessment of the views of the providers of the service, the doctors. I find it quite unbelievable that, in this day and age, an assessment of the views of the providers is not included as a performance indicator because the service providers are a major stakeholder and must be viewed as such.

In my opinion, not including the assessment of the views of the service providers as a KPI in the assessment of Medicare is an unacceptable omission. It appears to me that the exclusion of the assessment of the views of the service providers can only be interpreted as strongly suggesting an unwillingness on the part of the department to consider any view that may differ from its own predetermined policy. Assessment of the views of service providers should be regarded as a standard modern management practice. Routine assessment of the providers' opinions concerning the program could help to reveal both strengths and weaknesses. In reply to a question I put on notice about including the views of the providers as a KPI of the Medicare program, the department made the following reply:

The Department does not believe that the views of providers is an appropriate performance indicator as clearly there would be many cases where the interests and satisfaction of providers would not coincide with the objectives of the programme.

I have written to Dr Wooldridge, the Minister for Health and Family Services, expressing my concern that the performance indicators of Medicare did not include as a KPI an assessment of the views of the medical profession as service providers. I have requested that Dr Wooldridge give consideration to issuing a ministerial directive that provider assessment be made a key performance indicator of the Medicare program in the future.

Another matter which concerned me was that, during the estimates hearings, a senior departmental official suggested that each additional GP in practice costs Medicare $176,000 per year in rebates paid out due to the fact that doctors encourage patients who are not really sick to see them. He said that doctors were encouraging patients to return for more visits than were really necessary. Furthermore, I was concerned that a little later in the proceedings another health department official stated that general practitioners encourage patients with colds to come and see them, clearly implying that GPs are routinely overservicing by encouraging visits from patients with the most minor of complaints. As I said, the clear implication of this remark was that GPs are overservicing to generate extra income by getting patients with trivial illnesses to come and see them.

These remarks struck me as being extremely cynical and an unacceptable reflection on the professional integrity of medical general practitioners. In my experience of 20 years as a general practitioner, I have found GPs to be a group of hardworking, dedicated, professional people. As I said, I was profoundly disturbed by the cynical attitudes towards GPs exhibited by the senior officials of the Department of Health and Family Services at the estimates hearings. This is a very serious matter that should concern the Senate. Health services are very important to members of the community. The public expects there to be a harmonious and cooperative partnership between the bureaucrats administering the health system and the service providers who, in this case, are the general practitioners of Australia.

There is an enormous level of dissatisfaction among GPs in this country. This was revealed in a 1995 Australian National University epidemiology unit survey of GPs across Australia. There were 2,165 GPs in the survey who, on average, had been in practice for 15 years, 95 per cent of whom were vocationally registered. I had this report tabled in the estimates hearings. Senators will no doubt be concerned to learn that the report showed that 76.3 per cent of GPs were disillusioned and that 83.7 per cent cited poor remuneration as a factor in this. A figure of 34.4 per cent of GPs said that they would leave general practice immediately if they could, and 94.6 per cent felt that their contribution to Australian medicine was not valued by the government. From my impressions at the Senate estimates hearings, one would have no alternative but to conclude that the doctors were quite correct in their perception that their contribution to Australian medicine appears to be undervalued, at least by the Department of Health and Family Services.

Finally, I would like to put on record in the Senate my view that the department cannot have it both ways. They cannot on the one hand call upon GPs to practise better medicine and then on the other criticise them when they comply with that request. In the interests of thoroughness, GPs cannot spend more time with patients, resulting in having longer consultations, ordering more tests, writing more prescriptions and making more selective referrals. only to have the most senior officials of the department cynically criticise them for overservicing. I request that the ANU survey be tabled and incorporated in Hansard.

Leave granted.

The document read as follows

Preliminary Report on the Future Role and Operation of Australian General Practice

A questionnaire on the future role and operation of Australian general practice was circulated with the August 4th 1995 edition of the Australian Doctor. 2187 completed questionnaires were returned by the end of October.

The circulation list for the Australian Doctor which contained the questionnaire included 16,900 `general practitioners in private practice'. A follow-up telephone survey showed this list to be outdated, inaccurate and somewhat duplicated, with 30 per cent of the doctors listed not responding on the given telephone number, no longer in practice or away for an extended period. The estimated response rate is therefore approximately 18.5 per cent. However, the profile of responding GPs on a range of socio-demographic and practice characteristics was not significantly different from non-respondents interviewed in the telephone survey. The profile of respondents to this survey was also remarkably consistent with that of a similar survey conducted in 1991, results of which are incorporated in `W(h)ither Australian General Practice' (NCEPH discussion paper No. 1, 1991), and with the profile of Australian GPs obtained from HIC data. The profile of respondents to the 1991 and the 1995 surveys indicates that respondents are broadly representative of the general practice community in Australia. Representativeness aside, the results of the survey reflect the opinions of a considerable proportion of Australian GPs.

The results of the survey are currently being explored in a number of themes, and we anticipate publishing a number of reports. This preliminary report is being widely distributed both to those who participated in the survey and requested copies of the results, and to various stakeholder organisations. There is no copyright to the information. We simply ask that in citing the figures reported here, reference is made to Bailie RS and Douglas RM: `The future role and operation of Australian general practice survey results', NCEPH, Canberra 1995.

R.S. Bailie and R.M. Douglas

NCEPH, ANU, Canberra

National Centre for Epidemiology and Population Health

The Australian National University, Canberra ACT Australia

The Australian National University

National Centre for Epidemiology and Population Health

The Future Role and Operation of Australian General Practice

General Practitioner Survey

No. ofresponsesStronglyagreePartlyagreePartlydisagreeStronglydisagreeDon't know/no opinion
1. Satisfactions of being a GP
1.1 I am satisfied in my current role as a general practitioner2,15723.644.117.314.90.1
1.2 Important and satisfying aspects of working in general practice for me are:
(a) independence2,18071.
(b) financial reward2,18229.842.514.313.30.1
(c) developing long term relationships with my patients2,17874.422.
(d) dealing with a wide variety of patients2,18375.
(e) dealing with relatively healthy people2,17919.343.727.87.61.7
(f) dealing with families2,18566.
(g) dealing with the local community2,18341.543.910.82.21.5
(h) my role as a counsellor2,18139.147.410.02.41.1
(i) managing the business side of the practice2,17714.632.030.319.83.3
(j) involvement in research2,1795.630.629.921.212.7
(k) involvement in teaching2,17722.144.515.78.89.0
(l) the variety of activities I am able to engage in as part of my practice2,15951.
(m) doing minor procedural work2,17856.732.
(n) working with children2,18059.434.
(o) working with people who have real disease2,17256.535.
(p) providing support for the elderly2,18248.
(q) coordinating and managing the care of chronically ill patients2,17946.441.
(r) being a generalist and having to cope with what comes2,18066.
(s) providing preventive care2,17960.533.
(t) providing antenatal/obstetric care2,17430.731.417.014.76.2
(u) doing hospital work such as surgery or anaesthetics2,12815.617.320.532.314.3
(v) my role as a diagnostician2,17563.532.
(w) the intellectual challenge2,17558.833.
2. Dissatisfactions of working in general practice
2.1 I feel that general practice is a second rate area of medicine2,17815.520.
2.2 I would leave general practice immediately if I thought there was anywhere else I could go2,18015.319.517.846.31.1
2.3 The main dissatisfactions/frustrations of working in general practice in Australia at present are:
(a) poor remuneration2,18448.435.310.75.30.3
(b) long hours of work2,18444.936.413.34.60.8
(c) lack of intellectual challenge2,1834.920.030.544.30.4
(d) the contribution of GPs is not appreciated by the community2,18224.044.120.310.90.7
(e) the contribution of GPs is not appreciated by the government2,18077.617.
(f) The contribution of GPs is not appreciated by specialists and hospital doctors2,18135.644.
(g) concern over litigation2,18642.441.
(h) Government interference in the ability to make clinical decisions2,18257.429.
(i) patients expect too much of GPs2,18416.343.930.08.71.2
(j) concern that my knowledge is inadequate2,1795.637.229.427.10.8
(k) oversupply of doctors2,18018.532.628.315.84.8
(l) undersupply of doctors2,1656.519.331.434.48.5
(m) once you get locked into general practice there is nowhere else to go2,18112.632.
(n) apprehension about the changes and so-called reforms in general practice2,17857.931.
(o) the organisation, management and paperwork that go with running a general practice 2,17843.639.312.03.51.7
(p) pressure to bulk bill patients2,18655.728.
(q) competitive pressure from general practice colleagues2,18012.
(r) the points system for continuing medical education2,18120.326.829.321.52.0
(s) interference in my practice by the Division of General Practice2,17912.014.628.337.97.2
(t) ineptitude of the medico political leaders of the general practice community2,18242.131.714.95.85.5
(u) the introduction of blended payments2,18353.321.311.16.08.2
(v) pressure to introduce computers in my practice2,1757.621.
(w) interference in my practice through the Better Practice Grants scheme2,17052.322.512.26.46.6
(x) lack of financial security2,17134.237.917.78.51.7
3. The needs and expectations of the community
3.1 GPs need to have expert knowledge both of medical and social needs in their community2,17665.930.
3.2 Patients expect GPs to understand and manage both their medical and social needs2,17663.
3.3 I feel well able to cope with the social needs of my patients2,17428.
3.4 I feel well able to cope with the medical expectations that my patients have of me2,17452.543.
3.5 I feel that, in general, I am able to meet the expectations that my patients have of me2,17456.
4. The political context and representation of general practice
4.1 Health care is a public matter in which governments are inevitably involved to ensure that the community gets value for the dollars that are being spent on it2,16825.447.714.611.80.6
4.2 The influence of the government in controlling of general practice issues should be secondary to that of professional GP bodies2,17057.930.
4.3 GPs need to be proactive and develop a strategic plan regarding their future role2,17473.
4.4 In negotiations with government, the AMA is the best body to speak on behalf of general practice in Australia2,17424.325.821.023.35.6
4.5 In negotiations with government, the RACGP is the best body to speak on behalf of general practice in Australia2,1759.932.321.432.24.1
4.6 In negotiations with government, the Divisions should speak on behalf of general practice in Australia2,16913.937.117.925.75.4
4.7 In negotiations with government, the AAGP should speak on behalf of general practice in Australia2,1655.021.623.836.013.6
4.8 All of the GP organisations should work as a coordinated group to represent GPs in discussions with government2,17468.
4.9 There should be consumer representation in negotiations over general practice reforms2,16917.240.117.320.84.5
5. Better Practice Grants (BPGs)
5.1 We have to accept that GPs will, in future, not just be paid on a fee for service system, but that some form of blended payments system is inevitable2,17412.024.412.548.13.1
5.2 I am comfortable with the current principles surrounding the Better Practice Grants Program2,1752.78.316.069.33.7
5.3 Better Practice Grants are being introduced primarily to increase government control over the General Practitioner profession2,17472.318.
5.4 The profession should work cooperatively with government to devise a system for the allocation of BPGs2,17319.328.012.335.15.2
5.5 BPGs should be based on measurable aspects of quality of practice2,16628.731.97.320.311.9
5.6 The accreditation of practices should be the basis of BPGs if they are going to happen2,16516.432.511.628.510.9
5.7 I might as well sign up for BPGs, as everyone else seems to be doing2,1708.822.710.952.15.5
6. The gatekeeping, case management, and resource management roles
6.1 GPs are the best placed people in the health system to coordinate the use of the services that patients need for their holistic care2,17876.421.
6.2 GPs, through the decisions they make in the consulting room, are inevitably involved in making decisions about the use of scarce health dollars2,17573.622.
6.3 GPs should not take dollars into account when they are making decisions about their patients' care2,17716.332.632.618.30.3
6.4 GPs need to be free of the `gatekeeper role' in order properly to act as advocates for the care of their patients2,17320.728.631.215.73.8
6.5 GPs should be rewarded financially for efficiently managing and coordinating their patients' care2,16855.329.
6.6 I am interested in becoming involved in some form of budget management for the care of my patients2,1767.018.821.044.58.7
6.7 Decisions about efficiency in use of health dollars are part of the practice of good medicine2,17428.
6.8 Doctors' incomes should not, in any way, be related to their gatekeeper role2,17250.823.511.94.29.6
6.9 I find great difficulty in providing continuity of care to my patients because of their excessive freedom to shop around2,17324.938.718.716.21.5
6.10 We need to develop a system in Australia to improve continuity of care by GPs2,17337.537.
6.11 All Australians should be registered with a single practice, or individual GP for basic preventive services2,17113.220.516.446.83.2
6.12 All Australians should be registered with a single practice, or individual GP, for all primary medical services2,17111.718.517.050.02.9
6.13 GPs should play an important role in the provision of preventive care2,17579.418.
6.14 GPs should play an important role in the provision of palliative care2,17773.923.
6.15 There should be better training and support for GPs in the provision of preventive care2,17450.838.
6.16 There should be better training and support for GPs in the provision of palliative care2,17352.339.
6.17 Where specialised care is necessary, GPs should provide care in partnership with specialists2,17471.824.
6.18 I have been successful in providing shared care with specialists in my area2,17345.639.
6.19 Specialists are drawing patients away from my practice2,1669.429.
6.20 GPs should provide care in partnership with allied health professionals2,15948.443.
6.21 I have been successful in providing shared care with allied health professionals in my area2,16338.648.
6.22 Allied health professionals are drawing patients away from my practice2,1698.629.
7. Medical Records and Computers
7.1 The medical record should be maintained jointly by the patient and the GP2,17310.020.819.047.62.6
7.2 GPs should own and maintain the medical record and patients should not be able to get access to them2,17432.627.324.814.01.3
7.3 The medical record should be owned and maintained by the government2,1760.
7.4 The patient's medical record should be on a `smart card' which they should carry in their wallet2,1759.230.216.637.56.5
7.5 The patient should decide who should have access to his/her medical records2,17327.631.514.325.21.4
7.6 GPs need to make better use of computer technology than they do currently2,17538.739.
7.7 The best place to store the patients medical record is on a handwritten record kept in the GPs consulting room2,16931.739.818.56.63.4
7.8 I already make significant use of computers in management of my accounts2,17034.714.29.935.45.8
7.9 I already make significant use of computers for medical records2,1685.78.815.964.05.5
7.10 I already make significant use of computers for other purposes in my practice2,16518.825.411.838.65.4
8. The Future of Divisions
8.1 The development of the Division of General Practice in my area has been an important advance2,17622.535.816.618.17.0
8.2 Divisions are another step whereby government is increasing its control over private medicine2,17630.433.
8.3 I am actively involved in the activities of my Division2,17320.225.320.430.43.7
8.4 Divisions are starting to make it possible for GPs to expand their role in such things as public health, coordination of care, teaching and research2,17620.943.114.413.68.0
8.5 I would like to be able to depend on paid sessional involvement in the work of my Division2,17510.
8.6 I see my Division as the principal agent representing the service provision role of GPs in my area2,17114.928.
8.7 I believe my Division's role should be strengthened by it becoming involved in budget holding or some health services in my area2,1745.216.719.647.411.0
8.8 Divisions should be involved in planning the size of the medical workforce in a geographic area2,1728.629.616.637.77.5
8.9 I feel much less isolated as a GP since the advent of my Division2,17413.124.718.535.28.5
8.10 Divisions are a waste of taxpayer money2,17320.826.820.824.86.9
8.11 Divisions have an important role to play in the organisation and staffing of after hours medical services2,1708.727.518.732.512.7
8.12 I would like to see my Division testing new approaches to the coordination of patient care in my area2,15414.839.314.620.410.8
9. The COAG Proposals
9.1 I do not understand what these are all about2,15249.324.18.26.811.6
9.2 It is good at least that the Federal, State and Territory governments are starting to agree about where are health and welfare system is going2,12118.340.69.18.323.7
9.3 I would like to become more involved in coordinating the health and welfare needs of my regular patients2,13426.545.
9.4 I would sooner leave the coordination and management of complex care to people who do it as a full time job2,1327.523.827.732.58.5
9.5 In trying to look after my patients, I constantly come up against bureaucratic barriers and divisions between various state and Commonwealth health and welfare services2,14636.637.
9.6 I do not wish to get involved in the social areas of health care2,1415.921.

10. Demographics

10.1 Age (2,165)YearsMean 44.9SD 9.38
Median 44Range 25-75

10.2 Sex (2,172) Male—73.2%; Female—26.8%

10.3 Year of graduation (2,145) Mean 1975 (SD 9.13) Median 1976 (Range 1944-1993)

10.4 University of graduation (2,115)Adelaide (201)9.5%
Flinders (31)1.5%
Melbourne (292)13.8%
Monash (151)7.1%
Newcastle (28)1.3%
Sydney (360)17.0%
New South Wales (213)10.1%
Queensland (328)15.5%
Western Australia (117)5.5%
10.5 Country of graduation (for undergraduate degree) (2,150)Australia (1,784)83.0%
India (56)2.6%
New Zealand (23)1.1%
South Africa (24)1.1%
United Kingdom (171)8.0%

10.6 Years of hospital training prior to entry into general practice (2,147)YearsMean 3.6SD 2.3
Median 3.0Range 0-30
10.7 Years of experience in general practice (2,143)YearsMean 15.6SD 9.2
Median 15Range 0-50

10.8 State in which you currently practise (2,144)Australian Capital Territory (63)2.9%
New South Wales (682)31.8%
Northern Territory (14)0.7%
Queensland (444)20.7%
South Australia (224)10.4%
Tasmania (71)3.3%
Victoria (479)22.3%
Western Australia (167)7.8%
10.9 Postcode from which you practise

10.10 Average number of hours per week spent consulting in general practice (2,099)Mean 42.1SD 14.8
Median 43Range 3-99
10.11 Number of patients seen in an average week (2,081)Mean 136.7SD 57.1
Median 130Range 8-300

10.12 Nature of your practice (tick one) (2,155)

Solo private practitioner (601)—27.9%

In a formal private arrangement with other GPs (1,294)—60.0%

Other (260)—12.1%

10.13 Are you vocationally registered? (2,158)Yes95.0%No5.0%
10.14 Do you belong to the RACGP? (2,142)
yes, fellow25.5%}
yes, member15.8%}50.6%
yes, associate member/FMP trainee9.2%}
10.15 Are you a member of the AMA? (2,159)Yes50.5%No49.5%
10.16 Are you a member of the Doctors Reform Society? (2,130)Yes1.2%No98.8%
10.17 Are you a member of the Private Doctors Association of Australia? (2,124)Yes2.0%No98.0%
10.18 Are you a member of your local Division? (2,154)Yes76.3%No23.7%
10.19 Would you describe your practice as: (2,147)Rural19.7%Urban80.3%
10.20 Is your practice accredited under the RACGP Training Program? (2,121)Yes40.9%No59.1%
10.21 Do you use an accredited record keeping system (e.g. RACGP records)? (2,139)Yes56.1%No43.9%
10.22 Have you participated in the recent accreditation trials? (2,125)Yes21.1%No78.9%

Privately employed practitioners only

10.23 What is your current bulk billing practice? (tick one) (2,091):

I bulk bill all my patients—31.8%

I bulk bill health care card holders only—38.6%

I bulk bill a limited number of my patients—25.0%

I do not bulk bill at all—4.6%

10.24 For the provision of after hours consultations do you (1,989):

Engage a locum service—47.6%

Roster with other practice members—46.7%

Work at local after hours service?—5.7%