The doctor shortage that wasn’t: too many GPs
- Share
Australia is not in the grip of a GP shortage — in fact, there is a costly oversupply of doctors. Monash University demographer Bob Birrell crunches the numbers and has some suggestions for future policy.
The federal and state governments base their GP manpower policies on the assumption there is a shortage of GPs in Australia, particularly in non-metropolitan areas.
This assumption is founded on a mindset that dates from the mid-2000s when there really was a shortage of GPs in some of these areas. There is a formidable bureaucracy and powerful vested interests with a stake in preserving the shortage story.
However, with a few exceptions, mainly in remote areas, it is wrong. There has been a sharp increase in the number of Full Time Work Equivalent GPs (FWE GPs) billing on Medicare since the mid-2000s. The level of GP services in both metropolitan and non-metropolitan is well above that considered by medical manpower authorities in the past to be adequate. This over-servicing is showing up in high bulk-billing rates. By 2011-12 these were more than 80% in both metropolitan and non-metropolitan areas.
Another indicator of the change is the number of GP services billed per person per year in Australia. This increased from 4.9 in 2004-05 to 5.7 in 2011-12.
The oversupply is about to get worse. The number of fully registered Australian-trained GPs who will enter the GP workforce will double to around 1000 per year over the next few years. Most will locate in metropolitan areas because they can practise wherever they chose. In so doing, they will add to the over-servicing problem. They can do so because patients who are bulk-billed face no financial constraint on their consumption of GP services and GPs make the judgements about what services are needed.
GP over-servicing is very expensive for the Australian taxpayer. In 2011-12 the Commonwealth government paid out $6.7 billion to GPs billing on Medicare and for GP incentive programs. This amounts to an average of $317,000 for each of the 21,119 FWE GPs billing on Medicare in 2011-12.
The emphasis of government medical manpower policy should switch to ensuring that the GPs serve where they are needed. Part of the solution must be to restrict the right to practise in over-serviced areas.
This is not equivalent to the conscription of doctors. The government can limit the places where GPs are permitted to practise through its controls over the issuance of Medicare provider numbers. This already happens with GPs who are international medical graduates, or IMGs. They are only issued with provider numbers if they serve in districts of workforce shortage. All that would be required to limit over-servicing in metropolitan or any other locations would be to not issue additional provider numbers in such areas until the oversupply situation ends.
In the case of policy regarding IMGs, the recruitment of IMGs on limited registration into districts of workforce shortage should cease. Surveys of morbidity indicate that regional communities require more medical service per person than do metropolitan communities. The demands on GPs skills are also greater in these communities because GPs are often required to provide procedural services in local hospitals as well as GP clinical services. Regional GPs also do not have the same access to specialist back-up as do GPs in metropolitan areas.
It would be far preferable if the impending surge of highly trained and accredited local GP registrars served in shortage areas when they complete their training.
There is no need for more limited-registration IMGs, yet the numbers being sponsored on 457 visas is surging — reaching 2663 in 2011-12. This reliance is now built into the business model of some corporate employers. One of these, Tristar, had established 40 clinics in regional Australia by 2012, all heavily reliant on the employment of IMGs on 457 visas.
*This is the first chapter of Bob Birrell’s report Too Many GPs, published today through Monash University’s Centre for Population and Urban Research
There are powerful vested interests with a stake in promoting the over supply story, current medical practitioners represented by their union, the Australian Medical Association. It was they who created the shortage from the 1990s.
The sexist term ‘manpower’ should be replaced by 1 of several acceptable alternatives, such as labour force.
Try telling that to the many ageing GPs in rural and regional Queensland trying to stay on top of increasingly busy solo practices,supervising students when they can get them, providing a supervisory role at their local hospitals and trying and failing to plan for their retirement. There may be a lot of provider numbers around but a large number are not being used and - that is a key problem. The Federal Government should introduce a ‘use it or lose it’ policy immediately and get some of these numbers back or put into use.
Why are high bulk-billing rates an indicator of oversupply ? What proportion of metropolitan practices are not taking new patients ? Perhaps high bulk-billing rates are a result of bulk billing clinics having more elderly patients than private GPs ?
In 1983, we had a medical workforce of about 27000-29000, and were graduating about 1350 doctors a year, or about 5% replacement (DEIR source).
At 2001, after the AMA had conned government into choking off supply, annual graduations were about at 1983 levels.
At 2011, we had a medical workforce of about 79000 (AIHW), and we were back to graduating about 2950 (Medical Deans), or 4% replacement. It’s rather less, if you exclude the international students.
These historical trends don’t support that we are graduating too many doctors, in raw terms at least.
But there is something to be said for restricting provider-number issuance to areas of need, as long as it’s not a life sentence.
Thanx, Stephen, for introducing some facts and sensible analysis. I agree that temporary restricted provider numbers are well worth considering.
I note that the Australia ran Birrell’s stuff on the front page today.
Having spent almost 50 years in the health industry, I have been commenting for over 12 months on this site, that the only way to stop the grouping of doctors in “wealthy” suburbs in our major cities is to change the way medicare provider numbers are issued. Since the taxpayer is paying the bill for GP services - to the tune of %317,000 each - then it stands to reason that “we” should be employing doctors where there is a demand, and not allowing over supply/servicing to occur.
This arrangement should not be a “life sentence”, and when demand outstrips supply in the more desired areas, then replacement provider numbers can be issued. New graduates can then take up their positions in the less desirable areas until more urban places become available.
Why on earth is the taxpayer paying GP’s to over-service in areas where there are too many doctors? This article makes very good economic sense.
Sorry, should be $317,000 (dollars)….
Lets face it the greedy doctors union are running the usual rubbish argument of too many doctors. This is just to keep their incredible incomes sky-high. Time to stop this disgusting monopoly, especially the surgeons.
Figures can prove what you want them to prove. It is one thing to claim:
“Another indicator of the change is the number of GP services billed per person per year in Australia. This increased from 4.9 in 2004-05 to 5.7 in 2011-12.”
This could instead be due to the well publicised increase in chronic health problems like obesity, diabetes and heart disease, if you wanted to make that claim.
I wonder if the rest of his figures are as rubbery.
The explosion of Corporate Medicine, with chains of practices owned by companies rather than GPs, and often referring internally for lucartive pathology testing, could explain why bulk billing remains high.
Dear Gavin Moodie. If that is your real name, so be it. But if younare using the name of the highly respected health economist whontragically died earlier this year to gain attention, shame on you.
Could you please outline any mechanism by which the AMA “created the doctor shortage from the 1990s”. You won’t because there is none. GP numbers are controlled by the number of medical students recruited (decided by commonwealth govt and universities) and numbers of doctors specialising in General Practice, with training places determined by the federal government and the RACGP.
I would also point out that $317,000 per FTE GP amounting to $6.7 billion out of a total health expenditure nationally of around $100 billion is the best value govt spending in the whole health system, given it funds the GP primary care sector including capital investment, rent , salary and wages for all staff . Only about half of that would remain to pay the GPs themselves
The shortage of doctors in Australia from the 1990s was created on the advice of the Australian Medical Workforce Advisory Committee under the heavy influence of the AMA and related associations (Brooks, Lapsley and Butt, 2003). It recommended that places in medical schools be cut, and cuts in undergraduate medical school intakes from around 1,200 to 1,000 pa were announced in the 1995 Commonwealth budget (DEET, 1996: 16). These cuts were maintained for much of the term of the Howard Government.
Medical school numbers are determined by the Australian Government, which continues to monitor them very closely.
The health economist was the late Gavin Mooney.
Brooks, Peter M, Lapsley, Helen M and Butt, David B (2003) Medical workforce issues in Australia: ‘tomorrow’s doctors — too few, too far’, The Medical Journal of Australia, 179 (4) pp 206-8.
DEET (1996) Higher education funding report for the 1996-98 triennium, 8 January, paras 3.53 to 3.55, p 16.
If there isn’t a GP shortage why do I need to ring my GP for an appointemtn 2 weeks before I get sick?
I am with Gavin Moodie, I suspect the AMA like keeping the number of GP’s low so the can justify charging $300+ an hour
The AMA has been calling for an increase in the numbers of medical students and GPs since the late 1990 s at least. The final nail in the coffin of GP workforce was Wooldridges restriction of provider numbers in 1996. The argument was GP numbers had to be reduced to reduce supplier induced demand. We are reaping the harvest of that miscalculation now. It has nothing to do with AMWAC a committee of which whould have one AMA rep out of a total of 7 or 8 members. The issue of geographic specific provider numbers is a separate issue that has its own merits. But the repeated assertions that the AMA has lobbied for restricted numbers of doctors are rubbish
Usual rot from the self serving doctors. They only thing they’re interested in ‘saving’ are their own sky high incomes. Fear mongering about an ‘oversupply’ so they can cut the numbers yet again.
Good on you, Gavin Moodie! What you say is correct.
Jimmy, it’s like that in the Blue Mountains: a week’s notice to get a doctor’s appointment at my local. I sit in the waiting room and hear the receptionists repeatedly telling phone callers that they are not taking new patients something which friends tell me is repeated at practices throughout the district.
A friend in Ballina who has a serious heart complaint and cancer has to make his GP appointments two weeks in advance like you.
Someone try telling the general public like me that there’s a surplus of GPs and I’ll laugh in their face.
The AMA has invested billions of dollars trying to decrease the number of doctors and so artificially boost doctor incomes. Re andrew pesce, post 10, yes, I can explain how the AMA creates doctor shortages. Over the last twenty years, the AMA has been trying to drive a group of GPs, the “Non VRs” out of practice. The AMA has a policy of lower rebates for these doctors and has had since 1993. If the AMA ever succeeded the GP workforce would drop by up to 20%. Even as recently as 2010 the AMA lobbied the medical board to exclude Non VRs while at the same time asking for even more money for overpaid GPs (Letter in the public domain, Andrew Pesce to Joanna Flynn 19/2/2010). The fundamental problem is not an over or undersupply of doctors, it is a maldistribution with too many doctors in the city and too few in the country. Dr James Moxham, GP.
Restricting provider numbers is a blunt tool. Pharmacists are restricted in where they can set up shop. Although it prevents oversupply, it also insulates pharmacists from market forces.
If provider numbers are locked to areas, does that mean they will become a bit like taxi licences? Eg doctors selling provider numbers from wealthy areas to highest bidder? People buying GP businesses to access the provider number only?
This whole ‘shortage’ argument is a furphy, and the contortions required to support the claim of ‘over-servicing’ are so tenuous as to be laughable.
This, like any argument based around a premise of professional entitlement, start with a basic assumption that doctors are unlike any other professional and entitled to guaranteed, 100% employment in their chosen field as a matter of right. (For comparison, for lawyers, the number that ever practice is around 50%.)
Like in other parts of the workforce, aiming for a minimum unemployment rate of 5% is surely a good thing because it serves as incentive to drop the bottom few percent of under-performing graduates off into slightly less life-threatening fields, and keeps a lid on wages (and fees), keeping health costs down.
Arguments about how bulk billing rates are evidence of over-supply are simply laughable, given the logical conclusion of that position is that we’d be better off eliminating bulk billing entirely - another holy grail for professional vested interests to pad their member’s cohort’s wallets even further.
So competition is is forcing costs down to bulk billing rates, and fewer people missing out on care because they can’t get an appointment with a GP… heaven forbid, seriously, the sky must be falling! One could just as easily argue that greater availability of GPs is ensuring that potentially costly problems are more likely now to be identified at a preventative stage, saving everyone money in the long run!
In any case, the world in general has a vast under supply of doctors, while the medical profession is highly mobile. Were Australia to become a net exporter of doctors, this couldn’t be anything but a good thing for all concerned.
Perhaps, we might even be in a position to return some of the doctors we’ve poached from the third world where they’re desperately needed.
Has Birrell’s “research” ever found anything positive about foreigners, immigrants, international students etc.?
The “research” seems to be conducted backwards, first form a negative conclusion i.e. less IMGs allowed into Australia (etc.) then use headline data from Medicare (without qualitative analysis), draw a direct correlation between data and conclusion, without evidence of a causal link, then straight out with a media release (who accept without question).
As others have suggested here, and if one reviewed various sources, there maybe and are many other important factors and (+ve/-ve)correlations that could be drawn, but ignored by “research” to reach desired conclusion.
Similar media strategies are used by John Tanton’s Social Contract Press in US (to whom Birrell has contributed) and network of international organisations including over a dozen concerning immigration restriction.
Strategy is to produce research for the media that finds fault with those who don’t fit into their “nativist” philosophies i.e. immigrants etc. (Southern Poverty Law Center, like others, have published damning reports of this network and its real motives).
So rather than conduct good research and analysis showing all variables and factors behind data, keep it simple for Australia, just black or white.
I can’t seem to find any evidence of this GP oversupply in the Hunter Valley.
A few weeks ago, I needed to see my GP to renew a prescription. The waiting time was a month. I’ll hopefully get in there next week. Calling around various other GPs led to the same advice - they all have at least two to three weeks waiting time for non-urgent appointments.
When I was sick a few months ago, and wanted to book in for a check-up to make sure it wasn’t serious. It was the same advice then, too. “We’ll see you in a couple of weeks, if it’s urgent, see the hospital or use their after-hours clinic”. By the time the appointment rolled around, I was well again, and cancelled it.
If the average wait to see a GP is two to four weeks, that doesn’t seem to reflect an oversupply, at least here in the Hunter.
Peter Lange seems to have a problem with preventative medicine that is cheaper than expensive repairs. Perhaps he should take good long look at the Cuban model, that is being recognised as one of the most ‘cost effective’ models for ‘socialised’ medicine, in the world. On the globalised scale, I might add. I think the AMA might have a problem as well as Peter. Is medicine a practice, or an industry?