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GP Amalgamation

An Analgamated Future for GPs?

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Last Modified 1/4/99

In light of the government's not insignificant incentives to encourage small and solo general practices to amalgamate, Andrew Binns spoke to MedicineAu about the impact of amalgamation two years after joining forces with three other doctors to set up the Goonellabah Medical Centre.

Well, it hasn't all been plain sailing, but Andrew Binns has no regrets, just enthusiasm for the professional benefits and improved quality of life that amalgamation has brought him and his colleagues.

Nearly two and half years ago, the purpose built Goonellabah Medical Centre opened, the amalgamation of three practices and seven GPs. It came about because of the doctors' conviction that their patient care, professional and personal lives would benefit from sharing workload, equipment and overheads.

Adequate time off had been a problem in the smaller practices. Amalgamation has addressed this, but more importantly says Andrew Binns, colleagues' support and working as a team have been great for morale. With difficult cases, he says it is a huge help to be part of a team comprising not only medical, but also nursing, paramedical and psychology colleagues.

'It takes some of the emotional burden off to be able to share with other professional people close at hand. I think a lot of people in single or small practices don't realise the burden. We have professional back-up at all times for all situations.'

The growth of the GMC, which has four full-time, three part time doctors and a trainee, has not come from patients leaving other practices, according to Andrew, but from providing services that people have in the past accessed through hospital A&E departments. Amalgamated practices, he says, can take some of the pressure off stretched hospital resources to the benefit of patients, GPs and the overstretched state public health system.

Unlike when the GMC opened, the Federal Government is now offering incentives to practices with five full time equivalent GPs or less to amalgamate with other practices. Twenty million dollars is available over two years for micro-economic reform in general practice, with the focus on amalgamations. Evidence from the ABS and other sources shows economies of scale in larger practices benefit both GPs and patients. One year ago, a group of GPs from Warwick (pop. about 14,000), Queensland, visited the GMC on a fact finding trip. Since then, the government's amalgamation initiative has provided the incentive to take the next step and plans are now well advanced to move into a purpose built medical centre by August 2000. The new practice will involve seven to eight GPs.

'I can see the government are doing it because they can see it will introduce efficiencies into general practice they believe are needed and they would rather put their money into that than increase pressure on fee for service,' Andrew said. 'I concede other ulterior motives, in particular the gathering of information through computer systems.'

Happy philosophically with the new process, Andrew says he is uncomfortable with the existing system that primarily rewards greater throughput of patients: 'I'd rather see a system that rewards seeing fewer patients, but with greater quality of care. I also see that some people would not agree with me - there's a diversity of views out there.'

Of course, what the government says publicly and privately can be two very different matters: 'Privately, they will be happy if there is less bulk billing, as they know this will put the brakes on how often people go to see their doctor. In public they say that doctors should bulk bill because it is politically unpalatable to be seen to undermine bulk billing. But that is in fact what is happening as the government virtually caps rebates and redirects funding to quality assurance issues.'

The weak link in the chain of amalgamation as well as a driving force is the crisis in the rural medical workforce and the difficulties attracting doctors. Andrew says a strategy to address this is to become a teaching practice, which will hopefully attract young doctors to the practice who may ultimately settle in the area. It also provides a teaching environment, which many GPs enjoy: 'It is encouraging to see recognition for teaching medical students with rewards now being offered through the PIP system after years of doing it for love,' he said.

For smaller towns with one to two doctors, he sees a solution in virtual amalgamation (no funding is currently available for virtual amalgamations, but the idea is being investigated with a view to possible future incentives). A shared practice manager and management system among a group of small practices in an area would be the key, enabling these doctors to get a large part of the amalgamation benefits.

There would obviously be economies of scale with purchasing. And today's technology provides instant communication solutions, prescribing, pathology download and so on. Using the same computer system and software between practices would have benefits ranging from managing wages to all administrative processes. Doctors could thus concentrate on doctoring and not have to worry about administration, or the burden of paperwork: 'This is steadily increasing through government initiatives like PIP and accreditation, as well as the endless filling out of forms for a multitude of causes that we are finding increasingly burdensome.'

Solo Bonalbo GP, Trevor Tierney, asks if the government is prepared to cushion practice amalgamations with financial incentives, what about helping isolated practices like his? 'I do believe that the government should be rewarding people who are already out there [in the bush] doing the job.'

He thinks virtual amalgamation could work, however. 'My ideal would be a working relationship with somewhere like the GMC, where I could access their IT and practice management expertise. But virtual amalgamation is still going to need a person to come out and train people. That's where the grant stuff comes in. Unless your virtual practice has a David Guest in it, it doesn't happen, particularly with old codgers like me who are happy with paper and pencil. It's very easy for someone to talk about virtual amalgamation, but it's a lot harder to get people with the know how in small country towns.'

Virtual amalgamation could be great for three to four things, Trevor said: computers, budgeting, practice/ finance expertise, and computerisation of all records. Not so much the consultation notes, he feels, but basic front page information, bookkeeping, HIC, appointments and bulk billing. For example, Kyogle, Bonalbo and Urbenville could become a virtual practice in terms of bookkeeping and medical records with a practice manager who could drive from practice to practice.

'The advantages to me are not clinical. I'm comfortable with my clinical methods and my patients are. In a sense they are entrapped as they have to drive 70km to Casino, although some do!'

Obviously, amalgamation is not going to suit everyone and there will always be smaller private practices, Andrew says. 'I think some people work better by themselves and there are some highly successful solo practitioners. There is still a place for these doctors in medicine and I don't think we should undermine solo practice. I think they deserve support. But probably for many others, amalgamation is worthy of serious consideration, particularly with the kickstart of funding now available. I wish we'd had $120,000 to kickstart our amalgamation process!'

The first to acknowledge that amalgamation is a big step, Andrew says the amalgamating GP has to have courage and be prepared to take risks and the associated stress, 'but there are assured long term gains for the pain that it entails'.

'Change is sweeping through general practice. Recent structural reforms have the potential to boost morale and renew hope for the challenges of the new millennium. If we don't embrace this change, we run the risk of becoming irrelevant.'

Katherine Breen Kurucsev, Media Officer

For further information on amalgamation, phone the GP Links program on (02) 9263 3570.

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