GPCRISIS

I HAVE JUST recently been notified of yet another general practice in South West Sydney’s outer metropolitan region that will have to close down due to the nonviability of their business.

Ingleburn GP, despite caring for the community and managing thousands of patients, cannot afford to remain open and has closed its doors on the needy population of this region due to the decades long neglect and erosion of general practice.

I recently spoke Dr John Holt, one of the general practitioners that was working there.

Dr John Holt graduated from the University of Sydney in 2011 with a Bachelor of Medicine and Bachelor of Surgery Honours. He completed his fellowship in general practice in 2016. He has experience in emergency medicine, respiratory medicine, paediatrics, ear nose and throat surgery, neurosurgery, and orthopaedics. Dr Holt previously graduated with a Bachelor of Applied Science (Physiotherapy) in 2003 and worked as a physiotherapist in a variety of settings including private practice, hospital and sports team coverage. His areas of interest are physiotherapy, paediatrics, neurosurgery, and orthopaedics.

Despite serving the community’s healthcare needs for many years, Dr Holt said the ongoing issues in general practice had forced the centre’s closure. With operational costs outstripping the indexation of the Medicare Rebate, the practice tried to make ends meet through Workcover and other forms of income. Introducing private billing, however, was not a viable option, given the population of South West Sydney largely consists of people with lower socioeconomic status who would struggle to pay above bulk billing. The practice tried to implement a small $20 gap for patients on top of the Medicare rebate but only a maximum of two or three patients a day would be considered private patients, as the majority of patients were pensioners and concession card holders.

Dr Holt said the inadequate Medicare rebate affects the quality of care. He is distressed and disappointed about the medical centre vending machine form of medicine.

According to Dr Holt, patients need a minimum 15-to-20-minute consultation to be treated properly and this was no longer viable with poor Medicare funding. Practising quality medicine and paying a mortgage seem to be impossible in the current climate.

In addition to financial instability, the practice struggled to attract GPs to work in the area.

I also spoke with Dr Tom Lieng, practice owner of Ingleburn GP. Dr Lieng graduated from the University of New South Wales in 1991. He completed his fellowship in general practice in 1996. He has an interest in chronic illness, musculoskeletal and sports medicine, work injuries and occupational health. He is an experienced doctor in South West Sydney who is committed to providing comprehensive and holistic care to his patients. He speaks both English and Vietnamese.

Dr Lieng stated that he had to make an incredibly painful decision to close his practice. He can not sell the practice as there is no buyer. He recently met with a broker who advised him that the broker’s fees alone would cost him more than the price that would be raised for selling the business. As a result, the practice which has been operating for 30 years, will fold.

Dr Lieng states the operating conditions are the hardest he has ever experienced. He estimates a 30% revenue loss to the business.

There were two and a half doctors, or equivalent, working at Ingleburn, but he was unable to retain GPs as many were attracted to working at higher paying private practices. He does not begrudge the young GPs moving to bigger centres offering more for service, but he can’t compete. The bulk billing practice lost three doctors during 2022. Dr Lieng said it was difficult to convince GPs to stay when they could move to Double Bay and earn $90 a consult.

Even a recent attempt to increase the management fee from 25% to 26% was not enough of an enticement. He could no longer continue absorbing the huge losses.

Dr Lieng said the patients that live locally are being penalised because they are poor. He is committed to fairness and believes in universal health care and that is why he decided to practice in this significant area of need in outer metropolitan South West Sydney. To introduce a fee would be like “trying to bleed the people that are already bleeding,” he said.

Dr Lieng laments that the government doesn’t recognise the needs in Western Sydney. There are efforts to assist rural health but less recognition about the significant health deficits and socioeconomic determinants of health in other areas – particularly outer metropolitan Sydney.

An alternative was to rush through 8-10 patients an hour, which Dr Liengs calls “burning Medicare,” but this is not the way that he and his fellow GPs want to practice.

Dr Lieng’s wife is a GP examiner and said that the decrease in the number of GP applicants has meant that everyone gets accepted. Dr Lieng understands why there are fewer applicants – why choose a career where there is more work, the patients are becoming more complex and more complicated ,and there is no recognition by government.

The erosion of general practice continues and this will inevitably result in poor outcomes for patients in our community. Without a highly functioning and adequately funded GP lead primary care system, the entire health system falls over. Evidence from the UK, the US, Europe, and locally has found general practice is the most cost effective and most efficient form of healthcare in the community. Despite this, our state and federal governments continue to ignore the crisis in general practice.

We need urgent increases in Medicare rebates for quality general practice care. We need the system to be reviewed to provide blended payments for GP lead primary care and our teams to develop and enact systems and protocols to assist our local communities. We need it urgently otherwise our system falls over and Ingleburn GP will not be the last medical practice to close its doors forever. dr.

ABOUT THE AUTHOR:

Dr Kenneth McCroary is the owner of Macarthur General Practice and Chair of the AMA (NSW) Council of General Practice.

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Antimicrobial resistance

Antimicrobial stewardship has never been more important. Without intervention, antimicrobial resistance could be responsible for 10 million excess deaths globally by 2050.

WE ARE ALL too familiar with the phrase ‘too much of a good thing’, an adage which has become increasingly synonymous with antimicrobial drugs in the past number of years. Considered one of the most significant medical achievements of the 20th century, antibiotic overuse and subsequent resistance to these drugs has since been labelled by the World Health Organisation as one of the top 10 global threats to health.

Antimicrobial resistance (AMR) is spreading in ways that are becoming increasingly difficult to detect and manage. Researchers at the University of Western Australia have found a novel mechanism of resistance whereby Group A Streptococcus has demonstrated the ability to take folate directly from its host, rendering antibiotics such as sulfonamides ineffective. This form of resistance was found to be indistinguishable under traditional testing making it more difficult to administer targeted antimicrobial treatment. Such resistance can easily be spread among pathogens via horizontal gene transfer (HGT), enabling resistance in pathogen populations not yet exposed to antimicrobials. Key findings from 2021 data from the Australian Group on Antimicrobial Resistance (AGAR) highlight further worrying developments. These include the emergence of specific types of extended spectrum betalactamases (ESBLs) in E. coli in the community, a longitudinal trend of increasing resistance in gram-negative organisms, and carbapenamase-producing gramnegative pathogens.

Contrary to popular belief, AMR is arising not just from its use in human health but also from its utility in the animal and environmental health sectors, all three of which are inextricably linked in a model known as One Health. Antimicrobial use in agriculture, and veterinary and human medicine can produce antimicrobial waste which enters the environment. These points of antimicrobial entry into the environment include hospital sewage, crop spraying, livestock feed, and manufacturing effluent. This usage of antimicrobials concurrently leads to the development of antimicrobial resistant pathogens which are also released into the environment through waste, and which can share their genetic resistance factors through HGT mechanisms. These pathogens can then be transferred through a multitude of pathways, including high-altitude winds, movement patterns of wildlife, and routes of surface water, to re-enter human living spaces and environments. As such they are capable of being transferred to humans and animals through food, the environment, or by direct contact with vectors.

With resistance comes increased financial burdens on the economy. The current costs are already large enough to warrant major intervention, with Australian hospitals spending $16.8 million per year treating the five most common resistant hospital- associated infections. A resistant infection can add as much as $10,000 to the cost of treatment when compared to susceptible infections. The annual impact on the Australian economy is estimated to rise to anywhere between $142 billion to $283 billion by 2050 under a worst-case scenario.

The cost to the patient is likewise severe, with 4.95 million deaths associated with resistant bacterial infections in 2019, including deaths directly attributable to AMR. This figure is projected to rise to 10 million deaths each year by 2050, a figure tantamount to the death toll from cancer in 2020. In terms of the patient quality of life, AMR is associated with poorer outcomes, requiring stronger antimicrobials which carry greater side effects, including nerve damage, hearing loss, and organ failure. Like many diseases, the risks associated with AMR disproportionately affects patients who are vulnerable or disadvantaged.

Dr Kenneth McCroary, a general practitioner and Chair of the AMA (NSW) Council of General Practice, said part of the issue is prescription practices, stating that his LGA has the highest prescription rates of Amoxil in the country. This may be due to the high incidence of solo practitioners in his area who engage with minorities from culturally and linguistically diverse backgrounds who often have different cultural experiences with health systems and health literacy. He considers that deprescribing would require a multifaceted