‘Community health is desperate for support’: GP’s plea to policymakers

Kate Walker

24/03/2023 3:33:22 PM

For more than two decades Dr Kate Walker has been treating society’s most vulnerable. She says the situation has never been more challenging.

Dr Kate Walker
Dr Kate Walker has spent more than 20 years working in community health.

During my 20 years of working in community health in the North and West of Melbourne I have learnt the skills of engaging and assisting our most marginalised people.  

I have soaked in their diverse, resilient stories and struggled to help them to access the care they need.  

The joy of the work is to witness small shifts in my patients’ health, their loyalty and appreciation of my efforts and to be inspired by the dedication and care of my colleagues. There is a pride we share in being able to assist people with so many layers of disadvantage and complexity.  

Over this time, however, my biggest challenge has always been to make my work financially viable for my employer through MBS funding.  

That situation is now more challenging than it has ever been.

When I began in 2001, community health medical services used to turn a profit, and those funds were used to subsidise other services.  

Now, they run at a substantial annual loss for the community health organisation I work for.  

I am a GP at Footscray cohealth, which for 50 years had kept its doors open at the weekend – as a community health centre as well as in previous guises.

When it became clear it was no longer financially viable to do so, we tried to stay open on Saturdays by charging a co-payment. However, our community health patients could not afford it and stopped making appointments.  

It has now been shut on weekends since last September, to the detriment of many vulnerable patients and surrounding health services that need to soak up the extra demand.  

Despite the pressures we face, I have not seen community health GP work represented in the Strengthening Medicare Taskforce review and wanted to reflect on this further. 

Community health in Victoria includes a myriad of services, targeting the health and social needs of the most disadvantaged. There are co-located, low cost allied health, counselling, dental, refugee health, drug and alcohol, family violence, outreach mental health and homeless teams amongst the many other services.  

There are also wonderful community based, group initiatives building social networks and practical skills. My all-time favourite referrals have been to a men’s cooking group and an African women’s sewing group, reflecting the value of tailoring to diverse individuals.  

During the hard COVID-19 lockdown at the high-rise towers, community health teams were at the base of the towers, assisting residents. These pop-up services evolved into COVID-19 testing, vaccination and health promotion services and employed high-rise tower residents in their teams.  

The most complex and vulnerable patients travel long distances to see me and my community health colleagues for a number of reasons.  

We book long consultations, we work with interpreters, we continue to bulk-bill healthcare card holders, children and pensioners during the week and do not charge asylum seekers without Medicare access. We are co-located with many other services they need.  

Our schedules fill with the most complex, time-intensive patients who struggle to access care in the wider community.  

If they cannot get into our bursting schedules they present late and sicker to over-stretched EDs.  

Community health medical services are usually only funded by the MBS. As the MBS is not tailored to the needs of those with complex needs or those who cannot pay, GP services in community health are under significant financial strain.  

There is a financial disincentive to spend longer with patients and Medicare rebates have failed to keep up with raising costs.  

There is also limited financial support for GPs in team-based care models, such as that exemplified by community health.  

As such, community health GPs juggle the competing demands of their patients’ complex needs and extricating what they can from the MBS schedule to keep the doors open.  

Without this challenging work being financially valued, GPs burn out with the pressure and clinics reduce their hours.  


The closure of Footscray cohealth on Saturdays has put further pressure on emergency and after-hours GP services who do not know our complex patients.  

Meanwhile, another community health service is inundated with new arrival refugees from Ukraine, Syria and Afghanistan presenting with complex trauma, significant health and social needs.  

But it cannot increase its hours as Medicare does not adequately cover the extra time these patients need, so people are triaged to private practices for short appointments that do not address the full spectrum of their needs. 

Long telephone appointments have also recently been cut off the MBS, further limiting care for our patients who are complex or need interpreters, as many cannot access video consultations.  

When working with interpreters we usually book the appointment time twice to ensure the message is conveyed back and forth. Telephone appointment funding is equivalent to a short consultation. The maths is simple. If we spend the time the patients need, our centre loses even more money.  

Coordinating care with the other health professionals and support agencies both within and external to community health is essential to meeting the needs of our most complex patients.  

Around once a week I have managed to book formal case conferences with the other providers. Understanding the nuances of my patients’ needs and triaging and prioritising a team-based management plan has been invaluable.  

However, case conferences, like care plans and team care arrangements require administrative support to organise and time to ensure they are compliant with Medicare requirements.  

The threat of not meeting requirements – as reported recently in newsGP in upsetting detail – is a great disincentive.  

The bulk of the informal, incidental team-based work is not supported by the Medicare fee-for-service model.  

I welcome the Medicare taskforce’s goal of affordable primary healthcare with GPs as a central member of the team. But to properly implement this plan we must tailor it for patients with complex needs and for those who cannot pay.  

Increasing the rebates for long consultations, adding extra long consultations and making chronic disease management plans and case conferences flexible and with administrative support are important steps.  

However, complex multidisciplinary team-based care like that delivered in community health does not fit well with a fee-for-service model. The Medicare taskforce should look to community health to explore an established example of how to do complex multidisciplinary team-based primary care.  

We know how to do the care, but we desperately need help with the funding. 

Dr Kate Walker is a Melbourne GP at cohealth. She belongs to the RACGP’s Refugee Health and the newly formed Deprivation and Poverty Specific Interest groups. Join the groups via the RACGP’s online membership form.

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Dr Elizabeth Rouse Bates   27/03/2023 5:52:41 PM

What Dr Kate said! I am one of the many middle aged GPs who is burning out emotionally, mentally, and physically from trying to care for a panel of patients with complex trauma, chronic illness, and often undiagnosed neurodiversity in the setting of a “regular” GP practice. It just is not possible to do a good job for patients with this degree of complexity in 15 minutes. Nor does this general population have the funds to pay a gap. The moral injury involved in always doing a substandard job while losing money and running behind for my “typical GP” patients is real, as is the pressure of being the only consistent care provider many of these patients have.

Mariam   27/03/2023 6:44:56 PM

Well said, Kate. Often it feels like we do good work in spite of Medicare, not because of it. Especially for the most vulnerable/complex of patients.

Prof Max Kamien, AM. CitWA   27/03/2023 7:17:43 PM

Another example of the better and more difficult the primary and secondary care, the less the financial reward. UWA DCP set up something similar in Fremantle in 1998. One aim was to relieve the pressure on the Hospital ED. It was successful in doing just that. The ED lost staff . They declared foreign bodies in the eye , suturing, etc, to be the province of ED. That was the straw that broke our back and led to our closure. It is not possible to be financially viable when the mean consultation time is 50 minutes

Dr Mira Helena Kapur   27/03/2023 7:49:17 PM

I also am a GP who chooses to work in community health in a refugee health clinic in Gateway Health Wodonga and in the past for 10 years in Broadmeadows. I totally endorse Dr Kate Walkers comments. Our GP clinic is on its knees, unable to retain registrars or attract new GPs and now is resorting to charging non health care card holders in a desperate attempt to make ends meet. Our GPs are all contractors paid a fixed percentage and understandably it’s hard to recruit when the clinic depends on altruism.
We need to consider how we as a society provide health services to those who are unable to pay as well as supporting those who provide the services.

Dr Megan Elisabeth Barrett   27/03/2023 9:35:00 PM

Great article . I totally agree.

Dr Steven Hambleton   27/03/2023 11:51:21 PM

Hi Kate,
A future world where General Practice is funded to the level of need of the patients of the practice was certainly considered by the SMTF. I would be happy to have a conversation with you about that and I am sure that our President Nicole Higgins would too. Preventing an ED admission of a person otherwise later and sicker (and costlier) is our job as GPs. The current throughput focused funding model is in conflict with the team based models of longitudinal care you describe which is why we need blended funding models that will support such care models.

Dr Elizabeth Dorothy Hindmarsh   28/03/2023 5:13:00 PM

Dear Kate and all your wonderful Colleagues,
thank you for all the work you do for some of our more disadvantaged members of society.
I am devastated that you are not being paid a wage that means your work can continue. Mr Mark Butler and the Labor Government - what are you doing. We came as the RACGP in November and spoke to you and other elected Members of the National Government about the dire state of Australian General Practice and here is proof it cannot survive

Dr Tuan Quoc Lieng   1/04/2023 5:20:26 AM

I totally understand your situation Kate. I run a small medical centre in southwest Sydney in a low socioeconomic area. Most patients are NESB and socially disadvantaged people on welfare. We have been in operation for 62 years and is the longest medical centre in the area, if not in Sydney. We have been training Registrars for 15 years, but none of the Registrars choose to stay.
We closed our Saturday clinic 2 years ago as we made financial loss running the clinic. We have 20 years of doctor drought and down to 2 doctors.
We recently changed to mixed billing, charging $20 gap fee for non-HCC. To our surprise, 95% of our patients are excluded. That reflects our demographic.
We want to continue bulk billing but financially it is not possible.
If we close down a clinic that operated for 62 years due to financial reason then it’s death to bulk billing and death to general practice.

Dr Katherine Anne Walker   18/10/2023 1:26:35 PM

Thankyou all so much for your comments and support. Apologies for the delayed reply, but I only just read these now!! Very keen to talk though more at WONCA next week where there is the appropriate forum .