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

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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