Hospital GP: the bigger picture

Photo Place THINKBRETT MONTGOMERY is a part-time doctor with the Hospital General Practice. The practice recently moved from Fremantle Hospital to East Fremantle after a stoush with the Health department, but he says some of the criticism of the department wasn’t justified.

Much has been written in the pages of the Herald over the last year about the closure of the Hospital General Practice (HGP) in Fremantle.

As a part-time GP there, I’m puzzled by some of what’s been printed, and I’d like to share my take on things.

Recent articles have got some things right. Yes, HGP existed for more than 20 years, and as an entirely bulk-billing practice for most of its life.

Buckling to financial pressures, we started privately billing some patients in the last couple of years, but we still managed to bulk bill those holding concession cards (about three-quarters of our consultations).

Thanks to low costs and welcoming attitudes, we were blessed with a diversity of patients, many of whom had complex health and social challenges, and who may have struggled to attend other practices.

But I’ve read things in the Herald that I struggle to agree with. Many articles, including those by Simone McGurk (December 22) and Steve Grant (December 29), have portrayed the closure of HGP as being solely due to the Health Department and Fremantle Hospital giving us the flick.

It’s more complicated than that.

In my view, the main problem was that we just weren’t earning enough money to stay afloat, and they weren’t able to prop us up. Why weren’t we viable?

Well, general practices are funded largely on a “fee-for-service” basis. That means if you see many patients with simple problems quickly, you earn more. If your practice philosophy is to cater to people with more complex health needs, and you necessarily work more slowly, you earn a lot less.

Our laudable philosophy became our financial undoing.

While I think it’s sad that our practice failed, I don’t think that the blame lies with the hospital or the Health Department.

Why not? Because in the Australian health system, states are responsible for funding hospitals, and the federal government is responsible for funding general practice. I am more inclined to blame the Medicare system of general practice funding, which primarily funds throughput rather than quality of care, and largely leaves prices to the health marketplace.

I think it’s great that health care is partly funded through Medicare via taxation, but as practice costs have increased faster than Medicare rebates, gap fees have increased, which are hard on many patients.

Simone McGurk fears the closure of HGP will lead to a big rise in demand for the Fremantle Hospital emergency department.

This is questionable. Studies by WA emergency medicine academics have found that GP-type workload is a minority of what is seen in emergency departments (about 10 per cent of patients) and is relatively inexpensive (about 3 per cent of emergency department costs).

After all, these aren’t the patients who are sick enough to stay in hospital.

Overcrowded emergency departments happen when there are more people who need admission than there are empty ward beds.

Preventive care in general practices can avert some hospital admissions, but this prevention needn’t necessarily happen next door to the hospital.

Finally, Simone McGurk doubts that our old patients will make the trek to our new digs in East Freo, and Steve Grant portrays the East Fremantle Medical Centre as an expensive “corporatised” practice.

My experience is that a majority of the people I’ve seen in East Freo are familiar faces from HGP, and that I’m able to bulk bill people with concession cards just as I did before, without any pressure from the practice owner—who incidentally is a person, not a corporation.

This local story needs to be seen in a national context. I think we need to build a health system that enables the survival of practices that cater to patients with complex needs, that reduces financial barriers to care, and that rewards quality rather than throughput.

We also need to remember that much ill health is driven not by poor access to health care, but by social factors like inequality.

If aspiring local politicians looked beyond local health squabbles to the big picture of building a fairer society, they’d be more likely to attract my vote.

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