As a GP working in Sydney, I heartily endorse the recent call on Crikey to overhaul the way in which we provide primary care services, to make them more accessible and useful to our communities.

Part of my own practice is centred around a great group of people, namely middle aged and older Aussies who have a high degree of control over their lives and who aren’t marginalised from the rest of society.

This group often has complex medical needs, and the previous federal government should be lauded for the steps that it initiated to move away from time-based consultation items for patients who are elderly or have chronic and complex medical diseases.

My own practice has been revolutionised by these changes, and my colleagues regularly confirm that general practice has been a better place to be for the past few years, because we are being rewarded for providing care the way it should be, and deflected from the previous treadmill that directly equated service with patient throughput, largely ignoring quality care outcomes.

That said, there is another significant part of my practice that hasn’t been particularly helped by the current Extended Primary Care items. Homeless and unemployed individuals, people with chronic psychological health or substance abuse problems, and isolated young people whose needs were largely ignored by the previous government can’t have their needs met without a comprehensive reassessment of how we provide care and support to these groups.

They are often mired in a morass of bureaucracy, bounced from Centrelink to Medicare to the Department of Housing to the desperately under-resourced state health outpatient services.

Sitting with a middle aged man recently in my surgery, he cried about how he was unable to get his life together in the face of this insurmountable and faceless bureaucracy. He had been told this week that in order to access further services he needed to check his eligibility “online” — this for a proud and intelligent man with no resources, no home and no knowledge of how to use a computer!

By the end of a session that included several similar consultations I was gutted — these patients need so much more than I alone can give them — where are the social workers, drug and alcohol and mental health advisors and carers that my much loved middle class patients have easy access to, and who are essential in helping marginalised folk get back on their feet?

In today’s society these are presented as “medical” issues, but are probably more a manifestation of community breakdown and neglect. I console myself that at least this guy could get an appointment with me, but realise that many marginalised people don’t get that opportunity, not because my colleagues are uncaring, but rather the opposite — encountering such desperation day to day with no resources to address it becomes too hard emotionally.

As GPs we can all fill our books with our functional and well supported patients — where is the incentive to enter the miserable world of the marginalised?

As Melissa Sweet recently suggested, this can only be done by changing the model of care. Not surprisingly Aboriginal health service models are an obvious template, given that they arose in response to the needs of a highly marginalised group.

However, there are lessons to be learned from the AMS experience if we truly want to improve the life (and not just the “health”) of the most disadvantaged. For what it’s worth here are some parameters that I feel need to be addressed.

  1. Avoid dominance by any single “interest” group — no matter how valid and altruistic the initial concerns that motivate those who establish new systems, they often end up pitting marginalised groups against each other in a competition for support and resources.
  2. Define your goals in terms of individual autonomy and self respect — have leadership from inspirational and non-aligned individuals who truly model a philosophy of inclusion.
  3. Be quite upfront at the beginning that this work can not be incentivised financially. Staff should be salaried, and should be expected to contribute to outcomes.
  4. Make sure that most (if not all) staff have some role at the coal face — avoid the administrator/service provider split that so often causes discontent.
  5. Encourage your staff to put boundaries around the time they devote to the hard parts of practice — none of us are immune to burn out — there is good sense in balancing part time work in a salaried position supporting marginalised people with other roles in a more profit-oriented sector.

My experience tells me that I am a fairly average person — and that if I feel this way so do many of my colleagues. Given good support and leadership, I’m confident that the profession would embrace new models.

Peter Fray

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Peter Fray
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