Complex educational, regulatory and financing rules and requirements influence the daily activities of Australian general practitioners, the scope of their professional practice and their remuneration. General practice, unlike medical specialties and subspecialties, is not built around a body of esoteric scientific knowledge and associated technical skills, and is particularly subject to influence through changes to the financing and regulatory structure under which it operates.

This article discusses changes made to the general practice regulatory environment between 1989 and 2009. Two aspects of this sometimes contentious era are highlighted: the changing narratives used to describe general practice issues and the changing political interface between general practice and government over this period.

Between 1989 and 2009, emphasis shifted from initiatives seeking to secure general practice as an autonomous professional discipline towards initiatives that sought to define and shape general practice within the broader health system. The political interface between general practice and the federal government evolved in parallel, from “corporatist” agreements initiated by national professional organisations, particularly the Australian Medical Association (AMA) and the Royal Australian College of General Practitioners (RACGP), to processes initiated and managed by government with involvement of a broad range of medical and other groups.

Between 1989 and 2009, initiatives affecting GPs included:

• Compulsory postgraduate training (vocational registration) and continuing education, introduced to enhance the competence of individual practitioners.

• Practice assessment against practice standards, with funding under some federal government programs linked to this accreditation.

• New items introduced into the Medicare Benefits Schedule covering health checks for middle-aged people, people aged over 75 years and Indigenous people, as well as management plans for chronically ill patients.

• Local networks of GPs (Divisions of General Practice), created to integrate general practice into the wider health system.

• Extensive intervention in general practice workforce matters. For example, the federal government now determines the number of postgraduate GP training positions, and “area of need” provisions channel international medical graduates into rural and other less popular areas.

• Organised representation of rural doctors and incentive programs to support rural practice.

Until 1989, a medical graduate who had completed a 1-year internship could enter unsupervised general practice. In March 1989, the RACGP and the federal Minister for Community Services and Health, Neal Blewett, announced details of their agreement to establish a vocational register linking payment of Medicare rebates with attainment of the College’s postgraduate fellowship. Services provided by registered GPs would attract higher Medicare rebates.

Vocationally registered GPs, including experienced “grandfathered” GPs, would be required to undertake continuing education and agree to random practice audits of their medical records by a statutory independent peer review organisation.

The College anticipated that annual incomes of vocationally registered GPs would increase by about $15 000.1 The Minister explained to parliament:

He further stated:

The agreement was controversial. The AMA, in opposing the initiative, denied claims that the AMA was “out of touch with the reality of government involvement in the provision of health care”, arguing that professional autonomy was at risk if parts of the health insurance arrangements were only open to doctors who agreed to participate in a government-approved scheme.3

Concern about the intrusiveness of an independent peer review organisation and lobbying by groups fearful of exclusion from the register led to review by a Senate committee. The committee concluded that “general practice and its practitioners have had to struggle for fair recognition ... [the legislation] gives recognition to general practice as a significant and separate area of medicine”. The Senate committee recommended that the proposal for an independent peer review organisation be rejected and that “the government provide the necessary legislative and other support for descriptor utilisation review to be carried out by the profession”.4 However, the Descriptor Utilisation Review Committee (DURC), established to develop this process and dominated by GP representatives, achieved nothing.

Debate about general practice moved to broader factors influencing the organisation and functioning of general practices. In January 1991, Tony Buhagiar, President of the RACGP, lamented that “general practice had drifted into a ‘morass’ and it urgently needed to be rescued ... the craft needed to have a unified direction”.5

In June of the same year, the Australian National University reported on a general practice financing think tank attended by government officials, academics and many “experienced and respected leaders of the general practice community”, which found “a surprising degree of consensus” that

In July 1992, a document entitled The future of general practice: a strategy for the nineties and beyond7 — developed by the AMA, the RACGP and the federal government — was sent to all GPs detailing a package of proposals designed to “allow general practice to reassert its role as the cornerstone of Australia’s health care system”. Proposals included establishment of Divisions of General Practice under the control of GPs, an independent voluntary system of practice accreditation, and workforce initiatives to address the oversupply and maldistribution of GPs.

Funding for these initiatives was provided in the 1992–93 federal budget.8 This was perhaps the high-water mark in the period 1989–2009 for general practice professional organisations seeking to shape the environment in which GPs work.

In 1997, Michael Wooldridge, the federal Minister for Health and Family Services from 1996 to 2001, established the General Practice Strategy Review Group to review the 1992 strategy. Members of the Group included two government officials (one of whom chaired the committee), a “consumer”, and two academic GPs. The other 11 members were practising GPs, some “independent” and others nominated by GP organisations.9

In its 333-page report, the Group noted “a widespread view that general practice still confronts serious problems. Innovative approaches are required if these problems are to be resolved”.9 The report predicted “during the next decade general practice will face an environment that is complex, fast-changing, uncertain, unfamiliar and competitive”,9 and identified low morale as a serious problem for GPs: “low morale derives from feelings about lack of direction, limited future options, low relative income, poor relationships with others and loss of control”.9 The report proposed “an ambitious and broad ranging program of activities which will ensure general practice reaches its full potential ... and consolidates its place at the centre of the health care system”.9

Recommendations of the report included:

• A listing of the core services that should be available through any general practice, including technical and medical services, with the view that provision of these core services might eventually become one of the requirements for accreditation as a general practice.

• Development and implementation over 5 years of a program to help general practices embrace microeconomic reform, including improved practice and workforce efficiencies, amalgamation of practices, and other models of cooperative working.9

These recommendations, which would have had a major impact on Australian general practice, were not implemented. The General Practice Partnership Advisory Council, which, like the 1989 DURC, was dominated by general practice representatives, was established to advise on implementation. Like the DURC, this produced few outcomes and was eventually disbanded.

During Tony Abbott’s time as Minister for Health and Ageing, from 2003 to 2007, bold reform proposals were not pursued. He argued:

Nevertheless, various initiatives were introduced, particularly significant increases in GP Medicare rebates. In 2007, the Minister claimed that these “restored morale in general practice by boosting fulltime GPs’ average Medicare earnings by about $50 000 a year since late 2003”.10

Nicola Roxon, appointed Minister for Health and Ageing in late 2007, has established a National Primary Health Care Strategy to operate within government with advice from an external reference group that is “non-representational, with members of the group contributing on the basis of their personal experience and expertise, not in terms of any representative positions they may hold”. The reference group has 13 members: six GPs (including three academic GPs), a physiotherapist, a pharmacist, a psychologist, a general practice nurse, a midwife, a health policy academic and a consumer representative.11

Priorities of the strategy are:

• to better reward prevention;

• to promote evidence-based management of chronic disease;

• to support patients with chronic disease to manage their condition;

• to support the role GPs play in the health care team; and

• to address the growing need for access to other health professionals, including practice nurses and allied health professionals like physiotherapists and dietitians.12

Over 260 submissions have been received, including proposals contesting the domain of general practice. Allied Health Professions Australia supports

It is a challenge to draw general conclusions about general practice policy evolution in the period 1989–2009. GPs expect their representative organisations to defend and promote their economic and professional interests. In 2007–2008, the federal government outlaid $3.6 billion on Medicare benefits for GP services, giving it some expectation that services would be delivered efficiently. The government also has a broader interest, believing that “health systems that include strong primary medical care are more efficient and have lower rates of hospitalisation”.14

Individual GPs, government officials and the Australian public may have quite different views on the developments affecting general practice between 1989 and 2009. Did general practice fail to capitalise on opportunities offered during the 1990s to more effectively secure its place in the Australian health system (eg, through the DURC and the General Practice Partnership Advisory Council)? Has political defence of the autonomy of individual practitioners to practise where and how they like forced the government to go outside general practice for solutions to issues such as ensuring that services are delivered efficiently and are available in less popular regions? Has the structure of the Medicare Benefits Schedule and other regulations encouraged GPs to vacate more complex, technical areas of medicine and move into less demanding styles of practice, thereby exposing them to arguments that lesser trained practitioners could do the job as effectively and more cheaply?

Some general observations influencing recent outcomes can be made:

1. Political representation of GPs is challenging. Policy debate among Australian general practice groups is robust, often played out in the two commercially owned medical newspapers that all GPs receive each week. Many factors complicate the task:

• Economic priorities among GPs vary. Many work in large, bulk-billing corporate practices and have different perspectives from GPs in smaller practices in wealthier suburbs who charge fees well above Medicare rebates. Rural GPs have other issues, including onerous on-call duties, difficulty finding locums, and threats to local hospital services.

• There are wide differences among GPs in quite fundamental issues. Some GPs, in defending professional autonomy, reject any government involvement in shaping general practice. Others support measured, careful engagement and negotiation with government.

• Developments in medical science and the proliferation of specialists and subspecialists are making management decisions more complex. While many GPs seek to provide the RACGP ideal of “continuing comprehensive whole-patient medical care”,15 others retreat to niche areas such as skin cancer care.

• The growing prevalence of chronic illness and the preference of many doctors for a balanced lifestyle are shifting the emphasis towards team-based care. At the local level, practitioners seek arrangements that allow some flexibility in how care is organised, so that “one size fits all” solutions are less relevant than previously.

• Many GPs now work within large, corporately owned and professionally managed entities that provide some of the support once provided by national organisations, thus lessening ties to those organisations.

2. Over the past two decades, the direct influence of general practice national organisations has been diluted. Many medical and non-medical bodies besides the AMA and RACGP now seek to influence general practice, and the federal government exerts more direct influence over policy development than it did 20 years ago.

This mirrors a broader shift away from professionally dominated processes. Perhaps Australia is catching up to the United States. Paul Starr, in his influential book The social transformation of American medicine,16 argues that, in the first half of the 20th century, organisational hierarchies within health systems and the financing of health care reflected the organised medical profession’s priorities, but the profession is now “trying to defend its prerogatives against the drive to rationalise the organisation of medical care”. Medical organisations today see “threats of two related kinds: competition and control”.16

Laugesen and Rice, in an article titled “Is the doctor in?”,17 discuss the evolving role of organised medicine in health policy. They suggest that “incentives to restrain costs [have] prompted the formation of many new organizations and interests” and that “a parallel trend of greater political pluralism in health care and expanded government roles meant new competitors entered the policy fray”. They conclude that “today a general consensus has emerged that physicians, as a group, are not as central in influencing health policy as they once were”.

3. General practice representatives now confront a vast government-funded administrative network. In 1990, the first GP adviser appointed to the federal health department sought out those staff dealing exclusively with general practice issues. After a week, he realised there were none (Jim Dickinson, former GP Adviser to the federal Department of Community Services and Health, personal communication). By contrast, in 2007–2008, there were 328 staff involved with primary care programs.18

Also, since 1989, several government-funded networks have been developed. There are 20 regional training providers supporting postgraduate GP training and a network of rural workforce agencies to support recruitment of doctors to rural areas.

In 2007, the 119 Divisions of General Practice (now 111) employed 2637 staff, representing 1615 full-time equivalent staff, with aggregate infrastructure and program funding of about $200 million (about $10 000 per full-time equivalent GP).19 Divisions support GPs in ways that include organising after-hours services and providing expertise in information technology. They also provide an infrastructure for delivering federal government programs, such as visits to aged-care facilities and allied health practitioner visits to practices.

The RACGP has recently questioned this aspect of Australia’s primary care organisation:

What do GPs coping with all the pressures of busy professional and personal lives make of all this change? Perhaps a GP considering the past 20 years of policy innovation might see parallels in a description by the medical historian Charles Rosenberg of recent health policy developments in the US:

Policies on the ground seem less a coherent package of ideas and logically related practices than a layered conglomerate of stalemated battles, ad hoc alliances, and ideological gradients, more a cumulative sediment of negotiated cease-fires ...21

Australians want an individual, named GP to guide and advise them. This, as well as economic and demographic changes such as an ageing and wealthier population, the growing prevalence of chronic illness, and developments in medical science, suggest a positive future for general practice. Nevertheless, general practice policy is likely to remain a difficult and contentious area.

An older Melbourne GP has described the many changes to general practice during the 1970s and 1980s resulting from the introduction of Medibank and then Medicare, and commented that “most medical graduates today probably have no concept of what general practice was like in the 1950s and 1960s”.22 Proposals floating in the policy ether in 2009 include pay for performance, blended payments with a component of capitation, physician assistants and shared electronic health records. The new national health profession registration arrangements will facilitate more fluid and possibly overlapping “scope of practice” provisions across disciplines. Perhaps, in 2030, an older GP will write that “most medical graduates today probably have no concept of what general practice was like between 1989 and 2009”.