If you ask an Australian city-dweller nowadays (and remember that 89% of us are urban) the name of their GP, the likely answer will be that they don’t know. They attend a bulk-billing clinic either near home or near work, and see whichever doctor is available. “If someone in my family is really ill,” they might add, “we would call an ambulance; if it is not that serious, we would go to the nearest public hospital. If we rang the local medical centre, that’s what they’d tell us to do – or to phone a deputising service for a visit from a doctor we don’t know and who doesn’t know us.”
What has happened to continuity of the care of the seriously, chronically ill, especially if they are elderly? The AMA website proclaims “Your family doctor: invaluable to your health” and the website of the RACGP states, “Your GP can help with a huge array of health issues. This includes everything from the routine to the complex at all stages throughout your life”, but both statements depend on your actually having a family doctor.
City general practice is now dominated by profit-seeking corporations or companies which ‘employ’ doctors (on a ‘contractual’ basis), many (if not most of them) part-time, with an ever-changing list of doctors’ names on a board somewhere.
Bulk-billing means that you will be called back to the clinic if you need a repeat prescription or results of tests or the re-issuing of a referral to a specialist, even one whom you see regularly.
Will you see the GP of your choice? That will depend on whether or not she (or less likely, he) is attending at the clinic on the day, or during that morning or that afternoon. If you attend a clinic near your workplace and another near your home, neither doctor will know what information about you the other clinic possesses. If a member of your family is seriously or chronically ill, it is likely that one of the specialists at the nearby public hospital will be co-ordinating their care; communication with general practice easily becomes sub-optimal, especially when it is to a group of GPs rather than to one named doctor.
So where does the blame lie for this betrayal of continuity of personal medical care?
First, with John Gorton’s government and the $5 gap between rebates paid to specialists for work which, until then, had often been done by GPs. This led to massive patient demand, at a cost of a mere $5, to see a specialist for anything and everything. This, with an accompanying move of GPs with special training into exclusively specialist practice, reduced the family doctor’s role to the periphery of patients’ coordinated care.
Second, with Laurie Brereton and the NSW Labor government (backed by the Australian Competition and Consumer Commission), which authorised advertising by doctors. This opened the door to commercial interests, better able to afford mass advertising than the local solo GP or small GP partnership.
Third, with Neal Blewett and Federal Labor, which encouraged Geoffrey Edelsten with his bulk-billing clinics and their grand scale advertising – forcing neighbouring GPs out of business and paying them to work in his clinics. Edelsten was soon followed by other like-minded entrepreneurs.
Remarkably, the bulk-billing rebates for GP services – long portrayed by the AMA as insufficient recompense for a GP’s training, experience and skill – somehow have enough ‘fat’ in them to provide dividends to the shareholders of the corporations and companies which ‘employ’ the GPs and bulk-bill.
Fourth, and perhaps fatal to continuity of patient care, has been the feminisation of the medical workforce, especially in bulk-billing GP clinics. These practices offer married women doctors the opportunity to work part-time – certain days of the week, mornings or afternoons – whatever is convenient for baby and child care, and for accommodating the needs of primary and high school children. Often married to other (well paid) professionals (often also doctors), women doctors are not deterred by low rates of pay from the clinics. The lifestyle-friendly hours are more than adequate compensation.
As for continuity of care for the individual patient? If that is what you want, move to the country, preferably one with a good local hospital frequently attended by GPs. If you prefer to remain in the city, put the non-availability of continuity of care, alongside pollution and traffic congestion, as another of the disadvantages of city-dwelling.