The college knows what generalism is and why it matters. So what does it do about the growing share of its members who aren’t really doing it anymore and what does that mean for the profession?
It’s the year 2033 and “You may ask yourself: how did I get here?”
The RACGP in 2026 represents a membership that looks nothing like what it did 20 years ago. One GP works for Eucalyptus prescribing weight loss medication to patients she will never meet in person.
Another runs a massive ForHealth bulk billing clinic in the western suburbs of Sydney. Another a MyHealth clinic in a shopping centre in Westfield somewhere for the private health insurer Medibank.
Another does virtual ward rounds for an aged care facility three states away. Another works two days a week for a startup building AI triage tools and three days in a country practice.
They are all members of the same college. They are all, technically, accredited GPs.
But are they who the college wants as members in 2033? That is, if they aren’t actually being generalists at their core.
A bigger question maybe: are they what the system needs in 2033 from GPs?
At a pre-event planning session for one of Burning GP’s panel discussions on the future of the RACGP – featuring new AMA president Michael Bonning, past college president Adjunct Professor Karen Price, and current president Dr Michael Wright – the question of what the college actually does about its increasingly eclectic membership came up and stayed up….and never quite got resolved.
You can still buy tickets to Burning GP at Noosa on Sept 26 HERE – see the end of this story for your TMR promo discount.
The core of what these college lifers were defending isn’t that hard to articulate.
Generalism, real generalism, the kind that manages multimorbidity longitudinally, that sees the same complex elderly patient for 15 years, that holds the chaotic and the undifferentiated and the “I don’t actually know what’s wrong with me but something is” – is a component of our health system that we probably should all recognise as a “cornerstone” if we want to meet all those 10-year aspirational plans we have.
But arguably, that’s not how the government is actually treating or even viewing “real generalism” at this point in time.
Our panel zoom call got sidetracked about 10 minutes in with the “generalism” discussion: what is real generalism, how does one get the government to recognise what it is and how vital it is to retain it in a cohesive manner for the healthcare system moving forward?
The discussion is important now because there’s a suite of new existential fragmentation forces starting to smash into the profession of general practice. GPs can do any number of jobs as GPs but as a result of this fragmentation, in part driven by consumer centric and “access first medicine”, more and more aren’t actually practicing generalism.
For example, be a doctor on the end of a phone for the weight loss platform Pilot, or work for 1300Sick or InstantScripts (owned by the same group as Bunnings) or work for Medibank in a hospital in the home program.
More important than these new consumer driven external fragmentation forces, according to our panel, is the top-down fragmentation approach to the management and funding of the GP sector that we are starting to witness from the government.
Says Professor Price:
“The governance and the money was removed from general practice for after-hours care. It was removed for urgent care. So they removed it and then said, ‘Oh, we’ve got a problem. We’ll give it back [but] in optical places.’
“The [new] buckets of money are not working for generalism, and the patients are suffering.”
Says Dr Bonning on the same problem:
“It’s not just the lack of consistency, but the lack of thinking about where does need arise in all of this, rather than where do I want some shiny service to take some demand off.”
Dr Bonning says the evidence for keeping generalism healthy in what is a fast-changing healthcare ecosystem is all there, but the policy settings to support it currently aren’t.
“For every generalist you add per 1000 head of population,” Bonning noted, referencing a Commonwealth Fund paper.
“You increase longevity and decrease disability-adjusted life years. For every specialist you add, you don’t necessarily get the same result.”
The membership problem nobody wants to name
Here is some potentially uncomfortable math for the college.
The RACGP’s current definition holds that 50% of a member’s work must be in a generalist discipline. In 2026 that catches most members.
By 2033, with the proliferation of single-indication consumer platforms, corporate bulk billing networks, virtual care services, private health insurer-owned practices, GPs who have gone part-time clinician and part-time health tech employee, and so on, the percentage of members who sit outside or near the edge of that definition looks like it is trending towards being meaningfully different.
If you get to 2033 and a significant minority of your members – say 30% even – don’t really meet the generalism criteria that we are all arguing are essential to the system, does the college have a governance problem?
Does it refuse those that aren’t consistently meeting the 50% criteria, accreditation? Does it create tiered membership of some sort? Does it redefine generalism to accommodate what members are actually doing? How does it train GPs if not for generalism? Does it maintain the definition and quietly accept that a growing share of its members are technically in breach of it?
None of these options are straightforward because at the end of the day, if you believe this expert panel, it looks like the system is currently on a trajectory to dilute the role of “generalism” overall within the whole system, when we should be working on the opposite if we want to meet goals on management of chronic care and system efficiency.
Our panel circled the question without fully landing on an answer, which is probably honest given that the college itself has not resolved it and doesn’t appear to be seriously looking at how it might manage it yet.
Professor Price made the useful distinction between the individual – a general practitioner is someone trained and recognised by the college – and the activity: general practice is the provision of primary, holistic, longitudinal care.
A practice full of people can be fulfilling a generalist function while an individual GP within that practice isn’t.
So like most healthcare problems, it’s complex.
You can be a GP by credential while not currently providing general practice. But you can form a part of a group that is overall practicing generalism.
Whether that distinction holds indefinitely as the credential increasingly detaches from the activity is the real question.
College management vs government management of GPs
The government is not a neutral actor here according to the panel. Quite the opposite.
Labor’s bulk billing agenda – the free green credit card framing, the direct funding for new bulk billing clinics in low-access areas, the Medicare Urgent Care Clinic rollout, the bias toward access for the easy patient rather than support for the complex one – is pushing the system to bias access and throughput, arguably for mainly retail political reasons.
Dr Bonning put it plainly: the pressure building on the system is coming from competing models rather than collaborating ones, and the result is that nobody knows where to go or what they need.
“Who says where to go? Who says what you need? This is making it much harder to deliver proper generalism, which is what the patient needs, because it’s not about setting, it’s about individual care needs,” he says.
The mental health example is possibly the starkest version of this failure.
GPs carry the overwhelming majority of complex mental health work in the Australian healthcare system. That’s for the whole system.
The bulk billing fast-throughput model, the block funding of local mental health initiatives via PHNs, which includes and excludes GPs depending on where it’s being implemented, and the Medicare mental health centre approach are structurally unfit to manage what is going on in the system.
Yet the payment system, the political incentives, and the public messaging all push toward access and volume and block funding of detached specialised care units – Medicare mental health centres for example – rather than toward the sustained, relationship-based, longitudinal engagement that complex mental health requires.
Which is generalism.
The college knows this. It says so repeatedly.
Related
It has not, to date, found a way to make government listen and that is possibly one of the key issues the college has to be looking at moving forward here.
The reality is that the government still thinks of GPs as entitled, reasonably well-paid whingers, who, without the bigger picture don’t actually understand what needs to be done at a system level.
Ouch. That’s a long standing and very hard perception for the college to start breaking down.
But break it down it must, as a big part of how it manages its future for its members and for the healthcare system.
Professor Price is one of the few RACGP presidents to ever really get through to the government that they were doing the wrong thing.
But Professor Price didn’t talk to the government, she, as president just told all her members to start private billing because the government wouldn’t listen and everyone was going broke.
That single piece of mongrel from an RACGP president did a lot for the GP profession. The new Labor government has put a lot more funding into general practice since on a gross basis, although Dr Michael Wright points out that the percentage of funding for general practice against funding for tertiary care has actually dropped in the past decade from about 9% to just under 6%.
If the government did really get the concept of generalism would they have let this happen?
What the college can do?
Professor Price summed up the dynamic between the college and the government somewhat by saying: “What can the college do? That’s philosophy. I don’t want to hear about philosophy anymore.”
The reality is the college is not listened to much by government. It lost the bulk billing argument and the urgent care argument trying to spout philosophy on generalism.
The membership fragmentation is happening regardless of what position statements say.
AI is restructuring clinical work in ways that the training frameworks have not caught up with. The corporate sector is growing in ways that serve some health system functions well and others poorly, but with capital and scale that individual practices and colleges cannot match.
What the college has, and has not fully deployed, is the data and the clinical evidence to make the case for generalism not as a professional interest but as a system design argument.
The Commonwealth Fund evidence Dr Bonning points out to the panel.
The chronic disease management evidence, the prevention data, the hospitalisation avoidance literature – there is a case to be made that generalism, properly funded and protected, saves the system far more than the cost of funding it.
What are the economics of what happens to hospitals, aged care, and chronic disease management when the generalist layer thins out too much?
The same panel will be developing this case at Burning GP on September 26 at Noosa.
Is the college articulate enough, and consistently managed enough to actually shift policy in this way?
Join us on the day, and contribute to the thinking, if you like.
Tickets still available HERE. Your 20% discount code is TMRREADER
