The GP workforce: no room for complacency

We need to make primary care careers attractive: the future of our health system depends on it

In this issue of the Journal, Playford and colleagues1 ask whether there is a primary care emergency in Australia. They report evidence from one Australian medical school — a decline in the proportion of its graduates who become general practitioners — and warn that, if their finding applies nationally, it may signal an emerging primary care workforce deficit.

The primary health care sector is fundamental to optimising health system performance. The Director‐General of the World Health Organization recently stated that the “demonstrated links of primary health care to better health outcomes, improved equity, increased health security and better cost‐efficiency make primary health care the cornerstone of health systems strengthening.”2 A sustainable primary care workforce is also important for successful long term health system improvement.3

According to the 2020 Report on Government Services by the Australian Productivity Commission, there were 113.4 full‐time equivalent (FTE) GPs per 100 000 people in Australia in 2018 (table 10A.19), and the number has increased slightly but consistently since 2014. However, these GPs were not evenly distributed across jurisdictions or the major cities, inner and outer regional, remote and very remote geographic groups.4

The annual number of medical graduates from Australian universities doubled between 1999 and 2017, but, despite the noted increase in GP FTEs, the national number of GP specialists is growing more slowly than that of non‐GP specialists (GPs, 2.9% per year; non‐GP specialists, 5.4% per year). Non‐GP specialist numbers have exceeded those of GP specialists since 2009, and the gap is increasing.5

More than one‐third of GPs are over 55 years of age, the highest proportion of any clinician group.6 The total number of GP trainees has been relatively stable (2016, 5402; 2017, 5488; 2018, 5467), and the Australian College of Rural and Remote Medicine independent pathway added 161 trainees in 2017 and 180 in 2018.7 Increases in the number of advertised GP training application rounds suggest it has taken longer to fill these positions, but information about the number of applications per acceptance is not publicly available.

Why — when we are training many more doctors overall and when hospital training pathways are so competitive — is the proportion of doctors opting for primary care declining? The answers are complex, but factors such as students graduating at an older age and with greater debt, awareness of the significant and widening income gap between GPs and many non‐GP specialists, limited student and junior doctor training in primary care, and the greater prestige afforded most non‐GP specialties are all probable contributors. It is unlikely that more non‐GP specialists will continue to be absorbed into public hospitals, and they may shift from public hospitals to private systems, but the impact of this trend on health system sustainability is unclear.5

The national figure of 113.4 FTE GPs per 100 000 people compares favourably with those for many OECD nations, such as England.8 But we should not be complacent. The geographic maldistribution of GPs with respect to health care need, the increasing proportion of non‐GP specialists, and their urban concentration are signs that our health system is becoming less primary care‐oriented and less able to deliver equivalent health care across the nation.

We need an equitably distributed, well trained, future‐oriented, effective, efficient, sustainable primary health care workforce. There are concerning signs that we are moving away from this ideal. What could be done on the policy front? Simplify and make more flexible the Medicare Benefits Schedule, including for telehealth services. Substantially increase current Medicare Benefits for primary care and annually index them at realistic rates. Increase funding for health professional training in primary care. Make primary care careers more attractive by closing the income gap with hospital‐based specialties. Complement fee‐for‐service mechanisms with capitation funding to support preventive and complex care.9 Support primary care research.

The COVID‐19 pandemic has elicited rapid policy responses in some of these areas. More may follow, and their impact is likely to ripple beyond the emergency period. Before the pandemic, the federal government had committed itself to a Long Term National Health Plan and established a taskforce to develop a Primary Health Care 10‐Year Plan.10 We hope that the pathway to a “more person‐centred, integrated, efficient and equitable”10 health system includes actionable policy responses that help make primary care the most sought‐after medical career. The future of our health system depends on it.