At Ochre we like to champion the idea of medical generalism and doctors working at the top of their licence. However, in Australia we have seen a trend towards more specialisation and the growth in medical specialists easily outstrips the growth in general practitioners.
If this trend continues, we will end up with high numbers of specialists relative to generalists and there may be some unintended consequences.
We know that generalism is the specialty that makes communities heathier. In England each additional general practitioner per 10,000 population (a 15 to 20 percent increase) is associated with about a 6 percent decrease in mortality. We find in Florida that a one-third increase in the supply of family physicians is associated with a 20 percent lower mortality rate from cervical cancer. There is no cervical cancer mortality reduction when the supply of O&G specialists is increased. This is not being critical of medical specialists; it is just that generalists have a much greater role in prevention.
At Ochre, our first permanent medical recruits were Hilary and Johan, who were South African trained doctors living in Gisborne, New Zealand. These doctors had excellent generalist skills in emergency medicine and were building their GP experience.
They arrived in Brewarrina in 2002, and for the first time, the town had two doctors, and its first female GP. The mayor and owner of the Deluxe Cafe, Angelo Pippos said that bringing new doctors to town had been one of the best things he had done.
Hearing the positive feedback from patients made us curious to see if we could measure the impact Johan and Hilary were having on the health of the Brewarrina (pop 1500) community. Fortunately, with the assistance of Greg Hardes we were able analyse the admission data. The graph below shows a 30% reduction in admissions in Brewarrina and Bourke after 2002.
The independent report from the consulting firm Hardes and Associates concluded that;
“from 2000/2001 to 2003/2004 there has been a substantial reduction in acute hospital admissions for residents of Bourke and Brewarrina – a reduction not evident in comparable areas of New South Wales nor in the State as a whole.
It is understood that during the period 2000/01 and 2003/04 the medical workforce has been stabilised in Bourke and Brewarrina, and further, the local general practitioners increased the provision of public health, health promotion and other chronic disease management initiatives. These factors could have made an important contribution to the substantial reduction in admissions and relative utilisation.”
Lower hospital admissions are just one measure of better health care. Another measure is the ability to look after patients locally and lower the ambulance transfer rate to larger hospitals. We looked at the 2 year period the straddles when we started providing rural generalists to St Helens, Tasmania. Again, we were thinking that that providing great generalists should result in fewer patients needing to be transferred 170km to Launceston. This was borne out in the analysis, and transfers averaged 25 patients per month in the 12 months prior to the change in medical staffing and then 13 patients per month afterwards.
I don’t have figures for the cost of ambulance transfers in Tasmania, but it will be similar to the costs in Victoria, where an emergency ambulance trip by road costs $1200 in a the city and $1700 in a rural area. It can cost up to $5000 for an air ambulance and up to $10,000 for a helicopter, so the savings to the health system in Tasmania are significant.
The reductions in admissions, as seen in Bourke and Brewarrina are cost effective as well. In 2018 the cost of a non-admitted Emergency Department patient is $561 and an admission is over twice that.
Generalist care is relatively inexpensive with a cost of $50 – $100 per patient visit, and 65% of those visits are bulk billed (meaning they are covered by government insurance and no out of pocket costs to the patient). The graph below from the RACGP shows unreferred generalism is the least costly part of our healthcare system.
Call it what you like, family physicians, general practice or rural generalism, it doesn’t really matter. At Ochre we hope that GPs will take the opportunity to work at the top of their licence, that is to utilise the full extent of their education, training, and experience, and ideally not do things that can be done by someone else. We would advocate for a greater investment in generalism and where possible an increase in GP skill sets, as the most cost effective way to create healthy communities and a sustainable healthcare system.