What is it we do exactly?

4 minute read


I do not understand why my complex 40-minute consult is worth $1.50 per minute and a brief consultation with something simple is worth $7 a minute.


I had a conversation with a close friend recently, who, as close friends often do, made me think.

One of the problems we always have in general practice is defining what it is we do. It makes it hard to advocate for our profession, because what GPs do in western Sydney, Darwin, the Tiwi Islands and inner Melbourne is different. And it changes a lot over time.

If I had to define it, one of our key functions is to see the people no one else wants, or can manage, or can fit in. Every single service has a disclaimer on the bottom which says: “if your symptoms don’t settle, see your GP”. No wonder our job is so hard to define.

When I was studying value-based healthcare one of the things that always bothered me was that value was defined as “outcomes that matter to patients, divided by cost”. Outcomes are easier to measure when the population is relatively homogenous. I always found it difficult to explain to policymakers that this was difficult in general practice.

Perhaps we need a multiple-choice question to explain the problem. 

Which groups of patients are likely to want similar outcomes?

  1. Those accepted into a cardiology clinic;
  2. Those accepted into a respiratory clinic;
  3. Those accepted into a neurology clinic;
  4. Those accepted into a psychiatry clinic;
  5. Those accepted by none of the above (the ones with us).

At the moment, we have a lot of other primary care health professionals seeing a certain subset of patients, “taking the pressure” off us.

The problem is the more gated communities there are in our primary care swamp, the deeper and more hazardous the gaps in between, where we live and work. Many of us are drowning, because the complexity is now impossible for us to absorb.

We are now seeing a lot of refugees from healthcare: the people who are discharged from public psychiatry, the people who don’t get in to hospitals, the people who never had the disease that pharmacy treats, the people who are complex and see specialist after specialist after specialist, all of whom tell us what the illness is not, but not what it is.

The tighter the boundaries on healthcare, the messier our world becomes. Someone needs to, as one author puts it, sweep up after the parade of partialists have passed by. Which means we need three things if we are to continue.

1. We need support. Watching a patient deteriorate while being utterly unable to get advice is soul-destroying. It’s one reason we leave. Facing the coroner for an utterly preventable death we can’t prevent, because there are no resources, destroys us. Governments should consider involving us in outpatients clinics. If I had one request, it would be for a “diagnostic dilemma” clinic, partnering with other specialists. If we are going to continue to see the patients rejected by everyone else, it would help if we could at least ask for help when we need it.


2. Medicare needs to stop disincentivising complex work. We used to cope financially by seeing simple things, which cross-subsidised complex things. Now simple things go elsewhere, and complexity stays with us. I do not understand why my complex 40-minute consult is worth $1.50 per minute and a brief consultation with something simple is worth $7 a minute.


3. Governments need to understand what we do. Which is why axing BEACH was so silly. Understanding what we do shows everyone what is missing from other services. If nothing else, surely that is useful data about what the public need.

We are the only service with no wrong door. You can turn up to us with literally anything. We are the experts in uncertainty. What isn’t obvious is the more standardised the other services, the less easy it is to define what we do.

When we communicate, we are not “whining” – we are giving governments essential information about what is and isn’t working.

Listen to us.

Lose us and everyone else will be up to their knees in complexity they are not designed to handle.

Associate Professor Louise Stone is a working GP who researches the social foundations of medicine in the ANU Medical School. She tweets @GPswampwarrior.

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