18 OPINION
18 OPINION
14 FEBRUARY 2025 ausdoc . com . au
Insight
Salaried GPs is the fix our health system needs
Dr Scott Douglas President of the Doctors Reform Society and a Perth anaesthetist .
Dr Tim Woodruff Vice-president of the Doctors Reform Society and a Melbourne rheumatologist .
The concept would finally see the fulfilment of the original aim of Medicare .
IT is time for salaried general practice to become the norm . Access to timely , equitable , comprehensive healthcare is a human right — a right that our fee-for-service system no longer provides .
Fee-for-service funding is not efficient or equitable for providing high-quality healthcare in the modern age .
It distorts the distribution of our medical workforce to communities able to afford high fees , drives overservicing , does not foster collaborative multidisciplinary care and creates inequities .
For many patients , it has led to unaffordable out-of-pocket payments and barriers to healthcare , particularly non-GP specialist care .
A new era in health funding is needed .
Only a publicly funded , integrated primary and secondary healthcare system can meet our healthcare challenges effectively and fairly .
Such a system requires a single national funder , independent of politicians and lobbyists , to distribute funds on the basis of need ( including remoteness , complexity and socioeconomic status ).
State governments and Primary Health Networks would then decide on the specific needs of their communities .
The concept is not radical ; rather , it would finally see the fulfilment of the original aim of Medicare .
Fifty years ago , the Doctors Reform Society ( DRS ) was formed to support
NEWSPIX
Gough Whitlam .
the introduction of universal health insurance , under the Whitlam and then Hawke governments , and was opposed by the AMA and other vested interests .
At our recent anniversary meeting , founding members recalled a time when
patients risked bankruptcy as a result of medical costs or delayed care with obvious consequences .
Gough Whitlam was determined that any new system would be free at the point-of-care for everyone .
Medibank , and later Medicare , fully funded access to public hospitals for everyone .
While the early architects of Medibank were not necessarily wedded to fee-forservice , only so much could be achieved in a single sweeping reform .
Bulk-billing was a revolutionary policy when introduced and transformed equitable access to healthcare in the community in Australia , but it entrenched a fee-forservice funding system .
Neoliberal thinking about healthcare permeates our society , seeing healthcare as a cost .
The AMA and all major parties now support Medicare , but the system is sick and needs urgent treatment .
As an early edition of the DRS journal New Doctor stated : “ Fee-for-service is the fundamental pathology in the system .”
Key symptoms of this pathology are :
• Progressive erosion of the bulk-billing rebate . The rebate has failed to keep pace with inflation , while some members of the profession have charged aggressively high fees , particularly in non-GP specialties . Allowing ‘ market forces ’ to self-regulate private gaps has proven to be a spectacular failure .
• GP ‘ gap ’ fees . Gap fees are growing and are a significant impediment to accessing timely and high-quality primary care .
• Disparity in incomes between specialties . This undermines the morale of lower-paid specialties and influences the choices of medical graduates .
• Health challenges strongly linked to the social determinants of health . People on low incomes , without work and living in insecure housing bear the burden of complex , multiple health conditions . Fee-for-service payment systems cannot support the integrated multidisciplinary care needed to address these health challenges , for individuals or communities .
Neoliberal thinking about healthcare permeates our society , seeing healthcare as a cost . It is not . It is a human right . And spending on healthcare is not an ‘ expense ’; it is an important investment in a just and equal society .
Salaried practice is the norm for public hospital doctors and creates a foundation for all Australians needing urgent and critical healthcare .
The precedent for salaried multidisciplinary primary care has been set by Aboriginal Community Controlled Health Organisations and ( in a few locations ) statefunded community health centres .
Fairly funded primary and community healthcare can provide salaried employment for doctors , dentists , nurses and allied health professionals so they can focus on providing optimal care rather than running a business .
Policies to reduce the dominance of fee-for-service in general practice ( Labor ) and expand publicly funded salaried primary care ( Greens ) are a beginning but do not go far enough .
Fifty years after our founding , DRS continues to advocate for truly universal healthcare and welcomes the support of the wider medical profession in striving for this goal .
It is time to finish what Whitlam started .
The salaried doctors were called the ‘ lazy bums ’
Emeritus Professor Max Kamien
IN addition to Medibank , the Whitlam era spawned community-organised health centres .
In 1976 , I spent a day at the Kippax Community Health Centre in Canberra .
The receptionist asked me if I wanted to see a private doctor or a salaried one .
Being on a visit of enquiry , I ended up having tea and bickies with each group in their separate common rooms .
The salaried doctors , inappropriately situated on the right side of the building , referred to their private counterparts as “ rapacious bastards ”.
The salaried doctors were in turn called “ lazy bums ”.
Being of an academic bent , I used the patient registration books to count the number of patients they saw . To their mutual surprise , the numbers were close to identical .
The receptionist looked like an advertisement for hay fever treatment . I suggested
They referred to the private doctors as ‘ rapacious bastards ’.
that she would benefit from consulting a doctor from either the right or the left of her health centre .
She said she would not see any of them because “ they all ask about your sex life ” — probably a result of the preventive sexual health concerns common in the 1970s .
Instead , she was going to see the old doc down the road who “ didn ’ t ask stupid questions but just gave you the script ”.
I supported Medibank / Medicare because it elevated the poor from mendicants to paying customers .
Sadly , it has been debased and abused by numerous false prophets from Canberra and entrepreneurs from everywhere and is no longer fit for purpose .
One size will not fit all , but for those who heed lessons from the Nordic countries , Medicare could also provide more comprehensive primary care for patients and greater work satisfaction for GPs who would like to be on a salary .
Look at those doctors working in Aboriginal Community Health Services — salaried , high autonomy and happy .