Matters Arising

An editorial in the General Practice Issue (MJA, 17 July 2000) called for leadership and vision to guide Australian general practice

MJA 2000; 173: 668

That very "cost-effectiveness", better called parsimony by comparison with other specialties, is an important reason for their negativity. Over the past 20 years, government has squeezed as much as possible out of general practitioners. Most of the developments within general practice, such as the Divisions, have not been funded by additional money, but by diverting funds from practitioner payments.

Few begrudge higher payment for skills at the forefront of knowledge, but practitioners do not like to see their erstwhile classmates in specialist fields doing similar routine work, but getting paid much more for it. While it is difficult to obtain hard data on earning capacity, it appears that Australia has greater remuneration differences between specialists and GPs than most other countries with similar professional divisions. The relative value study was supposed to resolve these differences,² but no Cabinet is "courageous" enough to reallocate Medicare rebates according to work value.

Your editorial calls for new approaches to general practice which will require leaders and vision. While a few leaders, both political and intellectual, have emerged, this does not generally happen spontaneously; leadership qualities must be developed. Nor is it reasonable to expect them to continue in leadership roles unless they are rewarded for the hard work, emotional strain and risk-taking involved in these positions.

How can leadership qualities be developed? I offer no comment on political leadership, but academic training can produce intellectual leaders. However, there are barriers to be overcome. Firstly, despite GPs being the largest group of doctors, there are still fewer academic positions in general practice than in the major hospital specialties. Secondly, academic posts now have heavy teaching, clinical and administrative loads, with little time to think, and no extra funds for research. Moreover, senior lecturers are not paid well, and, not surprisingly, there is a shortage of good candidates for even the limited number of senior positions.

Other potential avenues also offer few opportunities for GPs. The major leadership training opportunity for specialists, the professorial registrar position, is funded by State governments through the hospitals, but State governments provide almost no funds for general practice development. A scholarship to study abroad often follows these professorial registrar posts, with the chance to develop a broader vision. Scholarships are available to GPs, but in minuscule numbers compared with the number advertised for specialists. Many specialist careers benefit from research funds and training fellowships from bequests, public appeals for special causes or bodies such as the Heart Foundation, the Australian Kidney Foundation, etc. Great benefits arise from such programs, but there are few large bequests or successful appeals for general practice development and research.

To develop leadership qualities requires investment and willingness to allow for wastage - some will try this career and then decide against it. Many academically trained GPs have moved into other, related fields, where better and more secure positions are available. Some academic training is an advantage for a specialist in obtaining a coveted post, but for GP trainees it merely delays their joining a practice.

So, be grateful for the few general practice leaders we have. More will emerge when society invests in their careers. To develop new ideas and methods and foster a good cohort of new leaders, both State and Federal governments must invest over a long timescale of 10 years or more. The new General Practice and Primary Care Research Evaluation and Development Fund provides $200000 per department of general practice, but this is merely a drop in the (almost) empty bucket - "hush money". Academic GPs are seen as self-interested and ungrateful when they agitate for more, especially if they point out that this amount is derisory compared with the (Medicare subsidised) private practice funds routinely available to procedure-based specialist departments.

Who will provide more resources for good general practice and its leadership development?

James A Dickinson
Professor of Family Medicine
Department of Community and Family Medicine, Chinese University of Hong Kong
4/F Lek Yuen Health Centre, Shatin, New Territories, Hong Kong
jadATcuhk.edu.hk

1. Van Der Weyden MB. Australian general practice: the need for leaders and vision [editorial]. Med J Aust 2000; 173: 60-61.
2. Power P, Aloizos J. The operating environment of general practice. General practice in Australia: 2000. Canberra: Commonwealth Department of Health and Aged Care, May 2000: 182-183.

©MJA 2000
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