It’s time to cut the red tape

It had taken a year to organise the required paperwork to make the move from the Netherlands, and finally I was here, about to start my job in a remote hospital.

However, the manager on the other side of the desk had other ideas. She looked at me over her glasses and shook her head. I wasn’t allowed to work, she said, because my Medicare provider number would take another month to come through.

Of course, this was just the beginning. After a few years working in the bush, I was thrilled to qualify for a permanent Australian residence visa. But first I had to pass the international English language test — again.

“G’day mate, do you really need me to come to the big smoke?” I asked a clerk at some department over the phone. “I’m flat out looking after this mob in the back of Bourke. I passed that exam ages ago, before I came to the Lucky Country. Surely me Strine hasn’t got worse since I’ve been here. Crikey, the rellies back home reckon I have a dinky-di Aussie accent.”

Needless to say, I had to sit the English test again.

Red tape bugbears

This was a decade ago, but things haven’t got any better. The GPs Down Under (GPDU) Facebook group, a new, quickly growing online community of Australian GPs and registrars, listed their ‘red tape bugbears‘ earlier this month.

The amount of time and energy GPs waste filling out forms and jumping through bureaucratic hoops is gobsmacking.

One GP recently posted on the GPDU Facebook page: “For practices employing a new rural doctor, there are at least 14 different forms across Commonwealth and State jurisdictions. Some have to be completed online, some need to be scanned, some mailed — yes, with a stamp. And some faxed.”

Hospital bureaucracy is also a big bugbear for many GPs. For example, in Queensland the public hospitals have an extensive referral ‘criteria’ for each department. GP referrals that don’t tick their boxes – often checked by non-medical staff – are simply refused.

One orthopaedic outpatient department doesn’t accept a referral until GPs have faxed a completed three-page ‘hip and knee questionnaire’.

Other health professionals can also add to the GPs’ burden when they selectively take over parts of our job under the notion of helping to reduce our workload.

But it doesn’t always work out that way as one GP on the GPDU site recently highlighted when she told of how her local pharmacy happily manages her patients’ warfarin doses, but only as long as the INR is within a safe range.

“Apparently this service is more ‘convenient’ as well as lucrative for the pharmacist. Until the INR level is more than 2.5. Then, late Friday afternoon, the pharmacy demands I manage the warfarin dose. So then it’s suddenly my problem,” she posted.

Knee-jerk reaction

Red tape is often a knee-jerk reaction to a problem and not usually the best solution.

An estimated 25,000 patient consultations are lost every month while doctors are waiting for PBS Authority call centre operators to answer the phone. Meanwhile, our Medicare-funded sick certificate ceremony is estimated to cost the Australian economy $3 billion a year.

It’s time we did something about it.

Collaboration with other professions and organisations is more important than ever. If we help hospitals solve some of their outpatient department problems, our workflow will improve too. GPs need to negotiate innovative solutions that are mutually beneficial and acceptable. Building relationships, communicating and networking are the key to success.

We are in an ideal position to show leadership. This means we have to organise ourselves better, learn to be good followers, and support those who are trying to build bridges, including our peak organisations. No doubt we will occasionally have to compromise and, in some instances, lift our game.

I realise this is not easy in the current climate of cuts and freezes, but if we fail to do this, others will continue to take control of primary care. I love Australian general practice – it’s a great profession and the reason why I came to Australia. But we must protect what’s good and make it future-proof.

My call to action to colleagues, the colleges and the AMA is simple: please help and make things easier.

This article was originally published in Australian Doctor Magazine.

UK doctors in Australia – Why they won’t be going home any time soon

The numbers are telling: About 1,500 UK doctors move to Australia and New Zealand each year. This exodus is causing havoc in England. A GP-shortage creates high workloads and overstretched doctors, and a survey showed that over half of UK GPs plan to retire before the age of sixty. This stressful situation has prompted a coming home campaign to entice doctors to go back to the United Kingdom.

Why are doctors leaving, and, will they move back to save the NHS?

Dr Nathalie Departe is a UK-trained GP working in Fremantle, Western Australia. “I moved to Australia in 2009 for a change of scenery. I had visited Australia before and loved it, so when my husband found himself in a career hiatus, we thought we would enjoy the sunshine for a few years.”

“Working in Australia was a breath of fresh air. Patients were pleased to see me, understanding if I ran late, and I was rewarded and not penalised if I spent time with a complex patient to sort out their management. Access to pathology and radiology services was prompt, rather than a standard 6-8 week wait for an ultrasound, and access to allied health services didn’t compare – good luck trying to see a clinical psychologist on the NHS.”

“Initially it was a bit odd to bill patients and not provide free care at the point of need, but I soon came to value the transparency of the transaction. The integration between private and public care makes private care accessible and affordable in Australia, rather than in the UK where private care has to be funded in full.”

Escaping the NHS

“In Australia I can arrange imaging quickly, receive the results the next day and organise appropriate and timely care

Dr Janaka Pieris moved to Brisbane in 2010 to ‘escape’ the NHS: “When I think back to my working life as a GP in South East London, I have two overriding memories: there was never enough time in the day to do the work asked of me, and there was no means of limiting my workload. NHS General Practice is a sink for everything no-one else will take responsibility for. Many GPs feel unable to decline these demands – many of which are not NHS work and therefore unfunded – and as a result, are drowning in work.”

“When a patient presents with painless obstructive jaundice in the UK, I have no option but to refer in to hospital, because I have no access to appropriate imaging, or I cannot get it done in a timely fashion. In Australia I can arrange the imaging quickly, receive the results the next day, discuss the case with a specialist and organise appropriate and timely care. It is much more satisfying from a professional perspective.”

Dr Tim Leeuwenburg made the move in 1999, immediately after his internship in the UK. He is now a GP at Kangaroo Island in South Australia. “I was married to an Aussie and always knew I’d be coming to Australia for love and a better lifestyle.”

“That was 15 years ago. Since then I’ve vicariously witnessed the demise of UK medicine – and am anxious that Australia doesn’t make the same mistakes: Other professions trying to do doctors’ work, capitation and performance payments, privatisation, walk-in clinics, phone advice lines, revalidation. They are all seemingly good ideas, but not evidence-based and all have served to emasculate the profession and increase the number of doctors seeking to retire, locum or emigrate from the cesspit that is the NHS. None of these measures have reduced costs or increased quality.”

“The myth of the ‘fat cat’ wealthy GP laughingly enjoying his round of golf whilst poor patients helplessly waited for his attentions was regularly portrayed in the media

Departe: “Despite working in a nice area and enjoying my job, I had a growing sense of unease with the way UK general practice was going. There seemed to be ever changing targets to qualify for practice payments with increased red tape and less time for consultations.”

“There was a general loss of respect for the role of a GP; it was not unusual for patients to demand medication, tests and home visits inappropriately, then to be outraged if you questioned the need for it. The myth of the ‘fat cat’ wealthy GP laughingly enjoying his round of golf whilst poor patients helplessly waited for his attentions was regularly portrayed in the media, and I felt that general practice was being devalued in the eyes of public and politicians alike.”

Dr Mark McCartney left the UK in 2013 because he was not happy with the working conditions in the NHS, but moved back to England after 12 months because of family circumstances. “There is a huge cultural difference in Australia, where there is a mixed health economy of private and state-subsidised services. The NHS is free at the point of access for patients, and service always struggles to meet the demand and prioritise appropriately. UK hospitals are dysfunctional places and the effects of this trickle into General Practice.”

“UK GPs are mostly paid on the basis of capitation payments depending on the number of patients registered, with additional payments for reaching clinical targets and a small amount of fee for service payments. There is now a shortage of GPs and we work in an environment of running faster and harder just to meet demands, without additional incentives or resources.”

“Australian GPs have the luxury of earning a high proportion of income from fee-for-service payments, including patient fees and Medicare payments. The more patients they see and the more services they provide, the more they earn. Clinical practice is also more interesting with rapid access to x-rays and scans. It is a professionally motivating environment to work in.”

Would you move back to the UK?

Dr Pieris is sceptical about the fully funded induction and returner scheme: “Firstly, it is manifestly insulting to suggest that doctors who have worked in similar systems, such as Australia, need retraining to work in UK general practice. I do more medicine in Australia than ever I did in the UK.”

“Secondly, if people are leaving because of a failed system, a sensible approach would be address those failings, not try to tempt people back into the same environment they left.”

“To return would require most GPs to undertake 6-12 months of supervised training, and to surrender to ridiculous bureaucratic imposts

Departe: “Why would I return to a role where I am restricted in my clinical practice by financial constraints, strangled by paperwork, stressed out by time pressures, undervalued by patients and politicians and where I would earn less money for more work and more stress?”

“To return would require most GPs to undertake 6-12 months of supervised training, and to surrender to ridiculous bureaucratic imposts,” says Leeuwenburg. “The reason doctors are leaving the NHS is because of unfettered demand from patient ‘wants’ not ‘needs’, and reduced income as a result of capitation. Why on earth would you go back?”

McCartney: “Very few GPs will return, unless they have personal or family reasons. UK GPs are retiring early, but this does not seem to be the case in Australia. There are also huge barriers to doctors wishing to move back to the UK in terms of medical registration and licensing to practice. The NHS is wasting resources trying to recruit in Australia and they look foolish because of that.”

Doctor’s advice

“My message for governments,” says Departe, “would be Stop undervaluing good general practice! Good general practice has been proven to provide better value for money and a more integrated care approach than secondary care. By all means, regulate general practice to maintain appropriate standards of care but then pay us accordingly and let us get on with being general practitioners.”

Leeuwenburg: “Listen to grassroots doctors, not NHS managers who have destroyed the NHS and are now sprucing their wares in Australia. Nor to academics who think things like capitation and revalidation are necessary. Our Australian system is marvelous and we should be proud. Sure, there is fat in the health system that could be trimmed, mostly in hospitals and specialists, but primary care is overall incredibly efficient and GPs do a great job.”

“The UK government needs to stop attacking GPs and listen to doctors and the BMA, who have been largely ignored for the last ten years

“Ofcourse there are some outliers, but there are many more who are hard working and ethical, doing the right thing for patients and Medicare. Alienate GPs and risk the collapse of a great primary care system. It will cost more if we surrender to the failed experiments of the UK or privatise us with private health funds.”

“The UK government needs to stop attacking GPs and listen to doctors and the BMA, who have been largely ignored for the last ten years,” says McCartney. “Doctors want to work in an effective service so that they can focus on caring for patients. Learn from Australia that good access to radiology for GPs can keep people away from hospital until they really need to be there.”

Pieris: “The UK Government should let us do our jobs. Trust us. Stop interfering. No-one is saying regulation and scrutiny are not required. However, GPs are not some malign enemy. Stop treating us as if we are.”

Recommended further reading: Doctors from overseas, about my experiences as as a Dutch doctors starting Australia.

Image source: www.queensland.com