Our healthcare system is currently in a state of disaster
The United Nations Office for Disaster Risk Reduction characterises a disaster as:
”A serious disruption of the functioning of a community or a society at any scale due to hazardous events interacting with conditions of exposure, vulnerability and capacity, leading to one or more of the following: human, material, economic and environmental losses and impacts.”
There are now not enough GPs to prevent medical emergencies. Projections indicate the shortfall of GPs will continue to worsen. People who call an ambulance may discover there are not enough people to answer the phone, let alone have an ambulance available to be dispatched. People who are fortunate enough to have an ambulance arrive, are taking longer to be transferred into an Emergency Department bed for definitive treatment. According to the AMA’s last ‘Ambulance Ramping Report Card’, in every state of Australia, there are longer delays getting from the ambulance into the Emergency Department.
People who arrive at an Emergency Department may not have a nurse available to triage them. We are on track to have a shortfall of 85,000 nurses within the next two years. People who have been triaged, may not have a Doctor available to provide timely care. Emergency Departments and public hospitals are at and over capacity.
At each of these points of care, there are currently human, material, economic and environmental losses and impacts. More specifically, at each of these points of care there are currently people who are dying, or suffering losses — their sight; the use of a limb; their faculties; their independence; hope — which would otherwise have been prevented. Those losses create exponential costs and disruptions to the functioning of families and communities.
Our healthcare system is currently in a state of disaster and this disaster is evolving.
What does a healthcare system in critical condition look like?
On a shift this month in a small community hospital, there were so many people in the waiting room, the wait time to be triaged alone was more than two hours. Many of those people waiting would have seen a GP if they could, but have needed to attend their local Emergency Department instead. If it takes a triage nurse two hours before she can assess you to determine whether you need to be seen by a doctor within ten minutes, this creates an enormous risk for bad outcomes. Risk is a generous word. Let’s call it a foregone conclusion.
Statistics from the United Kingdom’s National Health Service, the NHS, published on the eve of the pandemic in December 2019, specifically quantified the risk of death according to Emergency Department waiting times. One in 83 people die waiting six hours for emergency care. One in every 30 people die waiting 11 hours.
If the waiting times are long, the headlines will come:
Report finds ‘cascade of missed opportunities’ at Perth Children’s Hospital, Launceston woman dies after nine-hour wait for hospital bed as health system faces increasing strain, Man dies on stretcher after waiting hours for care at rural hospital
Knowing there are people who will deteriorate or die because you do not have enough resources to provide care for them takes an enormous toll on healthcare providers. Specifically, this is a form of ‘moral injury’.
The phrase ‘moral injury’ originated in relation to the experiences of soldiers in combat. The concept was first introduced in the 1990s by Jonathan Shay, a psychiatrist and Vietnam War veteran, who used the term to describe the psychological harm that soldiers can suffer when they violate their own moral code in the course of their duties. According to Shay, moral injury is distinct from other forms of psychological trauma, such as post-traumatic stress disorder (PTSD), in that it results from a violation of deeply held moral or ethical beliefs, rather than simply exposure to traumatic events.
Working in a healthcare system in crisis is like trying to put out a bushfire with a bucket of water. No matter how hard you work, the sense of futility is overwhelming. Working in these conditions can lead to feelings of guilt, shame, and despair, and have long-lasting effects on mental health and well-being.
Healthcare workers are getting burnt and burnt out, and it’s not just a problem for the healthcare system in crisis. The ripple effects of burnout can be felt throughout society, as healthcare providers become less engaged, less productive, and less likely to stay in the profession long-term.
Healthcare providers are not only opting out of working, they are opting out. In December 2019, coinciding with the emergence of the Covid-19 virus, a detailed systematic review and meta-analysis of suicide rates amongst physicians in Europe, the USA, Canada and Australia was published, demonstrating a relatively high rate of suicide in General Practitioners, and female GPs in particular, second only to anaesthesiologists.
While it is not entirely clear what the suicide statistics are in regards to the impact of the Covid-19 pandemic on health workers, a recent study published in the Australian and New Zealand Journal of Psychiatry indicates more than 1 in 10 Australian health workers reported thoughts of suicide or self-harm during the pandemic.
What is a healthcare system?
The World Health Organisation defines healthcare as “an integrated system of services, organizations, and resources designed to meet the health needs of individuals, communities, and populations.”
Let’s break it down into some of its working parts, specifically focussing on primary health care, which assesses, diagnoses, treats, and where needed, refers, every or any presenting health complaint.
Medical emergencies: Putting out fires
In the Emergency Department, healthcare providers are largely tasked with putting out fires, by which I mean saving life and limb when a series of events has led to a disaster or near-miss.
They might bring you back from the brink of death, by giving life saving antibiotics for sepsis or restarting your heart, or catch you in a precipitous decline, mid-fall, by recognising warning signs of immanent organ failure. Often there has been a series of unfortunate events, or risk factors which might have been mitigated, leading up to a medical emergency — but we’ll come back to this.
The Australasian College for Emergency Medicine (ACEM) defines its scope as ‘the prevention, diagnosis and management of acute and urgent aspects of illness and injury.’
After putting out a fire, the Emergency Physician might refer a person back into the care of their General Practitioner. The GP can provide any ongoing care needed, assess what may have led to the medical emergency, and determine what might be done to prevent another medical emergency.
If a person’s health is too unpredictable or volatile to be able to go home, they will need to be cared for in hospital. If they are critically unwell or deteriorating they will need admission to the Intensive Care Unit. Otherwise, they will need to have their care continued in a hospital ward until they are well enough to care for themselves at home. Some people may no longer require medical care in the hospital, but be unable to care for themselves. These people need to remain in hospital, until alternative suitable living arrangements, such as in a Residential Aged Care Facility, can be arranged.
If the Residential Aged Care Facility is full, then the patient stays in the hospital until a Social Worker or family member can find somewhere appropriate for the person to go and live. Sometimes, many hospital beds are filled by people for extended periods of time who do not really need medical care in hospital. They simply have nowhere else to go.
When all of the hospital beds are full, an Emergency Department cannot move a person from the ED to a ward bed, and they need to stay in the Emergency Department. This is called bed block. Bed block means fewer resources are available to assess and care for people who need emergency medical care because those resources are being used to provide care to people whose care is no longer considered ‘urgent or acute’.
General practice: Preventing fires
What is General Practice? The Royal Australian College of General Practitioners (RACGP) defines general practice as the provision of comprehensive, continuing, patient-centred medical care to individuals, families and communities. It encompasses health promotion, illness prevention, diagnosis, management and treatment of acute and chronic illnesses, and end-of-life care.
The cornerstone of General Practice care within the health system is preventive medicine. Preventive care can be described as averting forms of illness altogether, such as by promoting healthy lifestyle choices. This is called primary preventive health care. Like dust which hasn’t settled, it is by definition almost invisible. Primary preventive care is most visible in its absence, when it has failed to be provided or heeded, and people become ill. Because primary health prevention is innately invisible, it can easily be overlooked and undervalued, by healthcare providers, administrators, bureaucrats, and people receiving healthcare themselves. Averting illness altogether is the most invisible, yet powerful and cost effective medical care we can provide.
When General Practitioners detect or treat a disease early they are providing secondary preventive health care. Significant costs or losses can be mitigated by preventing deterioration or progression of disease, including preventing medical emergencies.
If a person’s medical condition has deteriorated to the extent that they require emergency care, their medical emergency may be initially diagnosed and treated by a General Practitioner, before being referred to a nearby Emergency Department. Following treatment in the hospital, people will often be referred back to their General Practitioner to ensure optimal ongoing management of the disease and reduce the likelihood of further medical emergencies. This is a form of tertiary preventive care.
General Practice buffers the healthcare system by providing care which prevents disease from occurring, and preventing medical emergencies from arising.
The ‘G’ in GP signifies ‘generalism’, which means analysing your symptoms from a broad perspective in the process of making a diagnosis. Where an eyelid specialist (yes, that really is a thing) might diagnose and treat your persistent eyelid inflammation using their specialised knowledge, GPs might look at your eyelid inflammation, and then also diagnose and treat your seasonal allergy with asthma. By taking a broad perspective, GP’s are able to minimise costs and time to arrive at the probable cause of your symptoms. Minimising tests reduces costs, but also reduces the risk of harms caused by medical investigations, otherwise known as quaternary prevention.
GPs prevent fires. They detect smoke and extinguish fires early. They sound the alarm when a fire is out of control and provide an initial response. They assess a scene after a fire, and determine how to recover and how to prevent it happening again.
Without GPs providing preventive healthcare in the community, there are more people becoming sicker faster, and needing emergency medical care. Once those people have received medical care in the emergency department, without a GP, they are very likely to need emergency medical care again.
A shortage of GPs creates an exponential increase in the number of medical emergencies and the cost of healthcare.
Rather than increasing, or even maintaining investments in General Practice, Government spending has proportionately decreased in the past 10 years, from around 36% of the health budget to approximately 33%. At the same time, proportionate spending on hospitals rose from around 38% of the health budget to 41%.
Where are all the GPs?
Many people think of GPs as a public service. They are in many ways. We know over 80% of the population has seen their GP at least once in the past 12 months, many of course seeing their GP much more frequently.
Except GPs aren’t in the public service. When I became a Specialist GP in 2018, I learnt I was now ‘self-employed’ with no employee benefits, no superannuation provisions, no sick leave, maternity, or holiday entitlements. People who are self-employed typically need to ensure their fees are adequate enough to allow for all of these expenses.
GPs aren’t a public service, but the Medicare rebate is provided by the Federal Government to assist with medical costs when you see a doctor.
On the 1st of July next year, it will be the 40th year since Medicare as we know it was introduced. Within a couple of years after it’s introduction, well over 80% of GPs accepted the Medicare rebate as full fee for their work, being $16.50 for around 10 to 15 minutes.
In 1984, you could head out in your Wham T-shirt and acid rinse jeans with a great perm and that $16.50 would get about 22 loaves of bread.
For a 10-19 minute appointment with your GP today, the Federal Government will contribute $39. Today an average loaf of bread costs about $3, which works out to be worth about 13 loaves of bread. That’s much less bread.
The fee of course doesn’t go to bread. It must also keep the lights on in the clinic, pay the manager, the nurse, the receptionist, and the cleaner, the dressings for your wound, … it’s a long list. A GP’s proportion is also in that list, and a bulk billing GP today is paid about $26 for most of your healthcare visits.
But why don’t we just tell the Federal Government that they aren’t really keeping up so they can just fix it?
We did. They know. We sent them a few graphs over the years.
The graphs show the ever increasing gap between what a fair fee to see the GP is, and what the Medicare rebate is.
The Federal Government is fully aware of how they have been chipping away at your Medicare rebate since its inception. In 1984, the Australian Medical Association’s recommended fee for a standard GP visit, that $16.50, matched the Medicare rebate. Today the Federal Government’s $39 covers just over 40% of the recommended fair fee. It’s been failing to keep up with inflation pretty much since it was implemented.
Be assured the Ministers of Health and Finance have got the stats on hand. Meanwhile, they keep spruiking Medicare as if ‘bulk billing’ is feasible, as if it deserves to be given a name, as if they are providing for the cost of your healthcare. They’ve been maintaining appearances for a long time. This is Bill Shorten in April 2022 in his facebook post.
Sometimes I keep photos like this one to remind myself why it feels like gaslighting.
Meanwhile, almost one year later, with only an increasing disparity between a fair fee and the Medicare rebate for GP care, Health Minister Mark Butler informs us of the ‘shocking decline’ of bulk billing, as if it might be surprising. Except, it really isn’t shocking or surprising. It has been forecasted to fail Australians by chronic underfunding to breaking point for decades.
In short, the backbone of our healthcare system, General Practice, is buckling under the strain. It is breaking down.
Deloitte’s November 2022 GP Workforce Report forecasts the shortfall of GPs, created by an increase in GPs choosing to leave or retire, and a reduction in medical graduates willing to enter the specialty of General Practice, is on a trajectory which will only continue to worsen. In ten years time the shortfall in care which GPs will be able to provide, is estimated to be around 30% less than what will be needed.
The shortfall of General Practice care will continue to create a spillover effect with an exponential rise in health costs, as people resort to Emergency Departments for minor issues, or worse, are unable to access timely preventive or early care, with poorer outcomes and higher costs to people and our communities. Those costs are not only economic, they are in lives, and reduced quality of life.
After decades of underfunding, GPs are not expecting a trend spanning almost forty years to reverse. Many GPs are now deciding not to bulk bill, or even not to be a GP at all. Sometimes, it is too overwhelming to contemplate, and they check out altogether.
It is difficult to find statistics specific to GP suicide in Australia, particularly since the Covid pandemic. In 2018, The Medical Journal of Australia reported a suicide rate in female doctors of almost 2.3 times higher than the general population, compared to a suicide rate of 1.4 times higher than the general population in male doctors.
If we factor in that female GPs fall into a higher risk category, and that the stats predate the onset of the pandemic, it is probable the current rate of female GP suicide in Australia is now markedly higher.
In an online poll of almost 150 female GPs in April 2023, personally conducted in the course of writing this article, almost 60% of respondents personally knew a medical colleague who had committed suicide.
Of all suicides known to female GPs polled, almost half were reported to have occurred in the years since the onset of the pandemic.
Amongst all of the other challenges currently faced by our workforce, when you see a female GP in Australia, she may well have personally lost a medical colleague to suicide within the last three years.
Why am I even here?
I am currently writing this in my pyjamas and dressing gown on the couch because I needed to quit my job in a bulk billing clinic.
My decision crystallised when, after having phased in a proportion of ‘private fee’ appointment slots, a patient pointedly took two crisp $50 bills from his wallet, threw it at me, and walked out in disgust. This was after he realised that when we had explained earlier there was a fee, that we meant for him to pay it.
Another couple were so outraged to learn I would be charging a fee, they remarked to the receptionist that this must be illegal and they were going to report me.
I understand people feel entitled to receive my medical care. They should. Medical care is an essential service every human being needs in order for people, families, and communities to flourish.
In the middle of a healthcare crisis, it is arguably ideal if I were using my 20 years of hard won knowledge to provide healthcare, rather than sitting here writing to people who wish they could get a medical appointment.
The truth of it is, healthcare providers are exhausted, burnt out, and disillusioned. The threats, tears, insults, and abuse directed at your GP about medical fees will not solve the problem of your health care costs. GPs cannot continue to personally fund the ever enlarging Medicare shortfall needed for your medical care.
You need to take the fight for Federally funded healthcare to the Federal government, and, you need to value your GP.
If you or anyone you know needs help:
- Lifeline on 13 11 14
- Kids Helpline on 1800 551 800
- Beyond Blue on 1300 224 636
- Suicide Call Back Service on 1300 659 467
- Headspace on 1800 650 890
- Aboriginal & Torres Strait Islander crisis support line 13YARN on 13 92 76
- ReachOut at au.reachout.com
- MensLine Australia on 1300 789 978
- Care Leavers Australasia Network (CLAN) on 1800 008 774
- Head to Health at headtohealth.gov.au
- Open Arms Veterans & Families Counselling 1800 011 046