GPs face mounting pressures as wait list crisis extends to private specialists

Filip Vukasin

25/05/2023 4:56:43 PM

Four GPs reveal which private, non-GP specialists have the longest wait times, the effect this has on patients, and the unintended benefits.

Specialist waiting room
Non-surgical specialties appear to be the most affected, with many already closing their books for 2023.

It is well known that the pandemic has had a profound effect on our society, including delaying non-COVID related medical issues such as cancer screening and prevention.
These delays inevitably led to a rebound effect and now wait times in public hospitals for some specialities are over six years. In the past, one way to reduce the burden on the public system has been for patients to see a private non-GP specialist to expedite their treatment.
However, Dr Rebecca Hoffman, a Sydney GP and lecturer, says even in the private sector there are significant delays.
‘Locally, we can be waiting over 6–9 months for some private non-GP specialists,’ she told newsGP.
‘The longest wait I know of is developmental paediatrics. Our local specialists have closed their appointments for 2023 and not yet opened them for 2024, so we are unable to make a booking at all.’
Dr Hoffman says psychiatry also has a significant wait time, but ‘some telehealth options’ are available if patients are willing to use that service.
According to the Australian Institute of Health and Welfare (AIHW), there were 28.2 million non-hospital referred medical specialist attendances in 2020–21.
The most widely accessed non-surgical specialities were cardiology and dermatology, while the highest repeat attendances were with psychiatry, addiction medicine and medical oncology.
Psychiatry also received the most government funding – $370.1 million in 2020–21.
Dr Prakash Pattnaik, a GP in Townsville and RACGP Queensland Faculty Board member, said long wait times are worse in regional and rural towns than big cities, with neurology, paediatrics and psychiatry the three worst offenders in his region.
‘Depending on the acuteness of the situation, category three can be over 12–16 months,’ he told newsGP.
Meanwhile in Brisbane, GP and fellow Queensland Faculty Board member, Dr Tony Bayliss says surgical waiting times are ‘pretty good privately’, with the more significant issues associated with specialties such as rheumatology and obstetrics/gynaecology.
‘I am seeing more issues with non-surgical specialties,’ he told newsGP.
‘Some are having to close their books or ration services by increased out-of-pocket fees.’
According to OECD data, more than 39% of Australians wait over a month to see a non-GP specialist.
In relation to surgical waiting times, AIHW figures show that 50% of patients in 2021–22 were admitted for elective surgery within 40 days, a decrease from 48 days the previous year. The greatest reduction was with ear, nose and throat (ENT) and orthopaedic procedures.
All four GPs said non-surgical specialties were currently the most affected.
Perth GP Dr Andrew Leech believes this is because less surgical conditions tend to be chronic.
‘This difference is most likely due to the faster turnaround of surgical issues, in that they don’t necessarily require as much follow up and can be sent back to the GP for after care,’ he told newsGP.
‘Patients can usually see a private surgeon within a month, but if the matter is urgent, but not urgent enough for ED, and I call up, the patient can often get in to [see] them within the next few days.
‘Some of the longest wait times I’ve experienced with referrals to private physicians have been for neurologists, rheumatologists, endocrinologists, haematologists, infectious diseases/immunology and psychiatry.’
Dr Leech says that in Western Australia these specialties can take anywhere from three months to over a year for an initial appointment.
‘Some have closed their books,’ he said.
‘Developmental paediatrics, a key area I’ve been advocating for, has very little availability in Western Australia and patients may find that no-one accepts their referral. 
‘Again, if the matter is more urgent, I find calling up the rooms of the specialist may help them to triage patients quicker. For example, a patient with recently diagnosed cancer really should be seen quickly and, in most cases, will be able to get an appointment quicker.’
Managing the delays
All four GPs say a way to get around long wait times is to call non-GP specialists directly. However, prolonged wait times often means they still have to manage these patients in the interim.
Dr Hoffman says she is generally comfortable doing this.
‘Most of the time, yes,’ she said.
‘If I am worried clinically about an acute issue, we can often call the specialist to ask for phone advice whilst they await an appointment.’
However, patients with more complex and special needs require escalation, according to Dr Pattnaik.
‘We try to liaise with what we can manage by calling on phone with a non-GP specialist either privately or at the Townsville Hospital,’ he said.

Paediatricians are commonly cited as being among the specialties with the longest wait lists.
According to the 2020–21 Patient Experiences in Australia Survey, 21.7% of people said they waited longer than they felt acceptable to get an appointment with a medical specialist.
Dr Leech says there is plenty that GPs can do to keep supporting patients while they wait. 
‘GPs are very good at keeping regular track of patients who might be waiting to see someone, but we do appreciate that a collaborative approach with a non-GP specialist is what works best for patients and ultimately leads to better outcomes,’ he said.
‘So, the long wait times can lead to frustration from both sides.
‘More pressure is placed back on GPs to manage these patients whilst waiting as generally they require more regular review to monitor their condition.
‘There is also the element of [the] unknown as they haven’t had input from a non-GP specialist yet, which can cause stress for GPs – especially those who might be in a more isolated or remote area where access to care is more difficult.
‘Some conditions can deteriorate without the additional support or input, [and] some patients will end up in ED as a result of this.’
This is something Dr Bayliss has had to contend with.
‘Often not being able to access non-GP specialists will lead to me having to refer to public services acutely,’ he said.
‘I recently sent a [Department of Veterans’ Affairs] Gold Card Holder to public ED because they were unable to access a psychiatrist in a timely manner.
‘While I am happy to be involved in the care of these patients, it does place an extra burden on GPs as well as leading to increased referrals to the public system in the acute context.’
Common harms
In Sydney, Dr Hoffman has also seen the detrimental effect of prolonged psychiatrist wait times.
‘Most commonly the harm is a delay in treatment,’ she said.
‘So, with psychiatry, [it would be] a deterioration in mood or exacerbation of addictive behaviours whilst awaiting review.’
Dr Leech has had the same experience in Perth.
‘Wait times for psychiatry can also be very long,’ he said. ‘I find this can be a challenge as patients can deteriorate or fluctuate very quickly.
‘As an example, I have had patients with eating disorders who really needed psychiatric input urgently but were unable to obtain this [and] a small number of my patients have subsequently ended up with an admission to an eating disorders unit due to the physical decline related to their illness.’
Dr Leech says in relation to developmental paediatrics, he has seen children with learning difficulties, undiagnosed ADHD and autism experience harm through lack of diagnosis or treatment.
‘This harm can be psychological and social through affecting their self-esteem and schooling,’ he said.
‘I’ve had children fall out of school as a result of this – a significant harm that causes a ripple effect on their mental health and the wellbeing of their family.’
The issues with delayed review, Dr Leech says, can bleed into multiple facets of a patient’s life.
‘I have a patient waiting to see a neurologist regarding chronic, unrelenting headaches and migraines where the standard treatments we might use have failed,’ he said.
‘This patient has had months off work, been in and out of ED, become stressed and overwhelmed by the chronic pain, and required additional GP reviews to monitor his condition.
‘Despite my best efforts to contact the neurology rooms for a more urgent appointment, he has had to wait nine months for an initial appointment with the next available neurologist privately.’
Hidden benefits
So, with GPs managing more complex and chronic cases, is there an unintended benefit on GPs’ scope of practice?
Dr Pattnaik, who previously trained as an obstetrician/gynaecologist, says there is.
‘I have a specialist background and can actually manage a fair few reasonably tricky cases,’ he said.
‘But yes, it has pushed us to be resourceful and keep abreast of what we can achieve from our end as GPs.’
Dr Bayliss agrees but also sees a possible downside.
‘I have had to use informal channels more than previously, such as calling a public registrar [or] friendly private non-GP specialist for their input,’ he said.
‘This has increased my knowledge in the area but also exposed me to increased medicolegal risk.’
Dr Hoffman says there are a number of ways her practice has upskilled as a result of prolonged wait times.
‘We now offer additional sub-speciality interests in women’s health [such as] Mirena insertion, MS 2-Step, shared care, lactation medicine, skin special interests and gender care, so we can provide an inhouse service for our patients,’ she said.
According to Dr Leech, the necessity has led to innovation, such as the virtual immunology clinic run out of Fiona Stanley Hospital where GPs can obtain quick guidance from an immunologist via telehealth while the patient is still in the room.
He also reflects positively on his increased scope of practice.
‘I have naturally up-skilled in areas I would have previously felt less comfortable managing, such as developmental paediatric problems and mental health,’ Dr Leech said.
‘We have useful tools such as the Therapeutic Guidelines and Health Pathways, which provide us some direction on next steps in managing patients.
‘I have become more confident in managing mental health conditions simply through dealing with this more often and seeing firsthand which treatments might work best for a particular problem.
‘We have had to learn to collaborate more with our colleagues in the clinic and work through the more complex patients in our clinical meetings, which has also been useful.’
However, the GP says he is ‘mindful to stay within my area of expertise and know my limits’ when it comes to managing patients.
‘So it can be stressful when we’ve reached that limit and have nowhere to turn,’ Dr Leech said.
‘I can only imagine how hard it is for smaller practices, or those in rural and remote areas.’
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Dr Anna Clare Carswell   29/05/2023 9:22:54 AM

Two comments:
1. some specialities are hard to get to in regional areas ie rheumatology neurology - but I also find these specialities seem to hold onto their patients long term where they could be handing back to GP with management plan and criteria to refer back
2. we have also had a new system where you can request advice from public nonGP specialities which is great for patients and great for rural GP skills and knowledge - referral sent in - and prompt advice back without having to wait for an appt/ travel etc