On a Thursday morning in April, the patients in Dr Phillip Loxley’s waiting room have either been coming to his practice in south Sydney since he opened it nearly 40 years ago, or – like 27-year-old Liam there for a check up – since they were born.
Wendy Rayment, 75, is the former. Loxley has not only managed her asthma for years but was the doctor who helped her get a diagnosis for lymphoma in her eye after she experienced a range of “red herring” symptoms, starting in 2016, and then helped manage her care throughout the treatment.
Now in remission, Rayment is back at the practice after slipping on holiday in Vietnam and tearing open her calf, and Loxley is peering at the medication she received there with a magnifying glass, attempting to translate it.
Sue Loxley, Phillip’s wife, is the practice manager and a registered nurse. She has just changed Rayment’s bandages before reminding her to get her flu vaccine when she comes in next week to have the stitches out.
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The Sutherland practice’s books are full with around 6,500 current patients, many of whom are second and third generation, Loxley says. “They almost start to feel like family after a while.”
But the general practitioner (GP) says he’s somewhat of a “dinosaur”.
“Practices like ours are dying out. It would be hard to have a practice like this these days. We can do it because we’ve been doing it for 40 years,” he says.
Despite this election being dubbed a “health election”, with the government spruiking itsrecord investment in Medicareto expand the bulk-billing incentive to all Australians, many GPs say the plan willnot help the financial viability of practicesrunning on the slimmest of margins.
When Loxley began his career he was able to work as a GP with simply “a wooden bed, a desk and some cards you wrote on”.
The rent was far cheaper in those days, and in 1993, seven years after starting his practice, Loxley bought a house nearby for $240,000. Loxley estimates that today it would cost at least $1.8m.
Over the decades, the practice has absorbed new expenses like the introduction of complex software and rising costs of indemnity insurance “bit by bit rather than have to start and pay the whole lot in one go”.
Even with the advantage of starting the practice when he did, Loxley has to charge one in four patients $75 for an appointment (leaving them out of pocket $33.80after they receive the rebate for a standard consultation) to retain the practice’s financial viability. And now, as he looks to retirement, he can’t find a young GP willing to take over his practice.
Dr Louise Stone, a professor of general practice at Australia National University, says by her calculations, a GP today starts working with$400,000 debtfrom undergraduate and postgraduate Hecs, as well as the cost of GP fellowship training, including $10,000 to sit qualifying exams.
Newly fellowed GP Dr Claire Francis says she has the best job in medicine with the worst pay.
Whilespecialist doctors charge up to $950 an appointment, when Francis accepts bulk billing a patient $44 for a 20-minute appointment, she is left with about $20 after paying super, tax and the practice she works for 30% to cover rent, nursing and reception staff, electricity and other expenses.
That does not take into account the time she spends helping patients when they are not in the room, which goes unpaid.
Once her day in the practice is over, Francis’s work can include checking blood and pathology test results, making referrals, filling out social housing forms for disadvantaged patients or spending up to an hour on the phone with the state’s justice department, reporting at-risk children if a patient faces homelessness.
“That has to be done for free at the end of the day, after you’ve knocked off work, on the phone in my backyard or at the dog park,” she says.
“That’s often what general practice comes down to – it’s just doing the needful, because there is no one else to do it.”
As the nation increasingly loses its social safety nets – not only for universal healthcare but housing and liveable incomes – people are struggling more and “GPs really are the catch-all of the entire system,” Francis says.
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Stone, also a GP, says on average, they do about 10 hours a week unpaid administration. “So a quarter of our time is not paid. We estimated it at around $1.2bn a year on in labor from general practice. A lot of that is trying desperately to get patients into services.”
Working in Redfern and Broadway, Francis’ patients range from people who are chronically homeless to affluent Australians who live in $2m homes and have personal chefs. In order to afford to bulk bill the former, she says she has to charge a gap fee for the latter.
Francis says she believes thegovernment’s $8.5bn election policy, which theCoalition quickly matched, to expand the bulk-billing incentive to all Australian Medicare cardholders from 1 November, is “designed to fail”.
“I couldn’t afford to keep working if I bulk billed everyone. I still have more Hecs debt than I do in superannuation,” says Francis, who went to medical school as a mature age student.
Stone says practices are closing “left, right and centre”, and there arethree reasons behind it. The first is the shift to increasingly more complex patient presentations, such as mental health and chronic disease, Stone says.
“The sweet spot for Medicare is six minutes. If you see a doctor for less than 10 minutes, the Medicare rebate is about $6 a minute. If you see a patient for 30 minutes, it’s about $2 a minute,” she says.
“It shouldn’t matter if you need your cut finger bandaged or you need your five chronic diseases managed, you should get the same support per minute of time or per problem.”
General practices used to make more money on brief consultations, which would subsidise the longer ones, Stone says. However, many simple consultations are going elsewhere, including urgent care clinics, where the government invests$246.50 per patient, nurse-led clinics, where it invests $200 per patient, or emergency departments, which cost it $692 per patient without an admission, Stone says.
GPs are left with longer, more complex consultations where the Medicare rebate is significantly lower per minute, and the government is only investing $42 per patient, by comparison, she explains.
The second reason GPs are not able to sustain practices financially, Stone says, is because the rebate was frozen for so long it has fallen under 50% of what it costs for the service to be delivered. Despite the government spruiking bulk-billing incentives, Stone explains they are only a small bonus on top of the rebate.
The third reason, she says, is the “extraordinary political and community pressure to bulk bill everybody” despite the fact that general practice has never done so.
The health minister, Mark Butler, says: “The Albanese Government’s investment in Medicare will close the earnings gap that Peter Dutton forced upon our doctors, so that a GP no longer has to sacrifice their earnings to bulk bill every patient.”
Dr Michael Wright, the president of the Royal Australian College of General Practitioners, says while some practices that already bulk bill patients and rural ones that receive higher incentives to do so have indicated they will take up the government’s policy, the majority the college has spoken to say they are unlikely to change their billing.
Wright says the workforce incentives both major parties have agreed to will help encourage more doctors to specialise in general practice. While previously a doctor leaving a public hospital to start GP training lost their entitlements and had a large pay cut, “both of those have been fixed”. Trainee GPs will now receive an incentive payment while they’re training and be paid entitlements like parental leave for the first time, he says.
Wright says GPs are up for the health challenges the nation faces with a growing and ageing population, includingone in two Australians having a chronic health condition, but increasingly it takes more time to provide that care.
“We’re here to do it, and if we’re properly funded to do it, we can do it – but if the funding is only for quick consultations, then that’s going to make it harder and harder.”