“I haven’t really had a GP in years,” a single mum friend says, as we push our children on the swings. “Just popped into the local bulk-billing clinic for a quick script, but even they charge a gap now. And you’re just in and out. But I do actually need a good GP to talk about all the stuff I’ve been ignoring. You know, for me and for the kids. And for my ageing parents. Do you know anyone?”
It’s a question I’ve been asked – on repeat – for the past few years. You’ve probably had the conversation too. Many of us have been worrying about the demise of Australia’s universal healthcare. Medicare rebates for general practice have been essentially frozen for over a decade. But now, finally – finally! – the Labor government commits to pulling Australia out of the ice age. And to our even greater astonishment, the LNP – which has previously argued against socialist universal healthcare – is matching the pledge.
So should we be excited? Yes and no.
Anthony Albanese says he has a vision that 90% of GP consultations will be bulk-billed by 2030. As a public health-trained GP, I rejoice. General practice, and more broadly primary care, is the backbone of the Australian healthcare system. Done well, it prevents health crises and helps patients survive and break cycles of despair and disability. A stitch in time saves nine: primary preventive care has been shown to cut tertiary hospital costs and healthcare spending. There are many things to celebrate here: an investment in primary care and particularly the commitment to support for junior doctors entering the GP workforce.
But it’s worth interrogating what the government is promising. Medicare funding is complex, and it is getting more complex. It isn’t well known that the vast majority of GPs are not salaried health workers (unlike hospital doctors). GP practices are run as small businesses, with the government using our universal health insurance scheme to set patient rebates and incentivise GPs to work in a particular way. The government is proposing boosting funding to bulk-billing incentives and applying these incentives to all patients – not just children and Health Care Card holders. I, and many, have tried (and failed) to run completely Medicare-funded quality bulk-billing GP practices for the underprivileged. It is an extremely difficult, almost impossible, endeavour. This change will make it easier for those bulk-billing clinics that have been running in the red, especially if they have been doing a lot of short consultations.
But there are some downsides.
Albanese’s reform entrenches the notion that a quick consult is a good one. There is still more detail to be revealed about funding measures for chronic disease management and practice payments. But it appears that Medicare might still incentivise “throughput” over “quality”. And these quality consultations are what I (and many in “deep-end GP clinics” have been advocating for.
I have written before about the value of slow medicine. I’ve spent the past decade working with underprivileged people who cannot afford a gap. This pledge will support that sort of clinic to stay afloat. But I’m not sure that it will support listening, rapport or good communication. I’m not sure it recognises that longer consults are needed for people with more complex conditions, low literacy, more severe illness, mental health issues and other barriers.
For many non-bulk billing clinics, these changes may be a cut in funding, rather than a boost. I suspect that many clinicians will opt not to participate and rather continue to practise slower, more thorough medicine for wealthier people. They will continue to charge a gap. The new patient rebates are still too low to cover the cost of this sort of care. If the Labor government isn’t careful, it could entrench two types of care: good, thorough care for those who can afford it. And quick, bulk-billed care.
Prime minister Albanese has said that he wants “every Australian to know they only need their Medicare card, not their credit card, to receive the healthcare they need”. It’s music to my ears. After decades of underfunding primary care by all political parties, we have a lot of catch-up investment to do. I’m excited to see progress and a commitment to universal healthcare by the Labor government. But I’m worried that without reform for quality care, we won’t be able to provide good, free care for 90% of people.
Patients want to be heard. GPs want to be able to listen and care. We want to hear and respond when a teenager is suicidal. To debrief a woman after a traumatic birth, and support her breastfeeding and bonding. To recognise when chest palpitations aren’t just anxiety. To make good referrals, not write one-line handoffs. To call a specialist or allied health worker and ask for advice. The Royal Australian College of General Practitioners is asking for better funding for longer consults and mental healthcare. It’s an important demand because we need good medicine, not just fast medicine.
• Dr Mariam Tokhi is a general practitioner and teaches narrative medicine at the University of Melbourne
• In Australia, the crisis support service Lifeline is 13 11 14. In the UK and Ireland, Samaritans can be contacted on freephone 116 123, or email jo@samaritans.org or jo@samaritans.ie. In the US, you can call or text the National Suicide Prevention Lifeline on 988, chat on 988lifeline.org, or text HOME to 741741 to connect with a crisis counselor. Other international helplines can be found at befrienders.org
