The current federal government is bringing the NHS to Australia by stealth.
Many people in Australia and almost all people working in health know of either a doctor or a patient who has come to Australia fleeing the nightmare that the NHS has become.
The King’s Fund Independent Investigation into the National Health Service in England found that the UK has underfunded the NHS by AUD$72 billion since 2010 and the vast majority of the failings come from a flailing general practice sector.
Report author Lord Darzi wrote that “GPs are expected to manage and coordinate increasingly complex care, but do not have the resources, infrastructure and authority that this requires”.
Sound familiar?
The situation is so miserable in the UK that only 4% of GPs are satisfied or extremely satisfied with their work. They are compelled to work in 10-minute consultations and to see 34+ patients a day. Fifty-four percent have low or very low morale and 40% are intending to leave the NHS altogether. Seventy-nine percent feel that their workload is inherently unsafe to patients.
From 2009-2014 alone, 12,690 GPs left the UK, with 45% of those being under the age of 50. Of the 14,325 GPs trained between 2018 and 2023, around half are not working in the NHS. In fact, there is now a 212% increase of GPs registering to work in private practice, abandoning the NHS as a funding option altogether.
Rather than respond with concern and respect for GPs and the services they provide, the UK government has doubled down by seeking to force a seven-day working week, and the GMC recently suspended a GP for five months for daring to alter her last two appointments in order to pick up her child before the daycare centre closed at 6pm.
Now we are seeing policy after policy that suggests the NHS model of general practice and community care is being deployed in Australia.
What makes the NHS so bad for GPs and patients?
Access is prioritised over continuity and quality.
In this reality, the goal is getting the patient so see someone, but it’s very difficult to see a doctor. And you’re only allowed one problem at a time.
To meet access KPIs, the UK now has a Total Triage system. Replacing the clinic reception team, every patient must fill in a digital form explaining the reason for needing care, every single time they need to see a GP. Their request is reviewed by a triage GP.
The morning shift triage GP may process 90-100 requests in a morning, allocating these to the other GPs, but also very often to non-GP staff like physician’s assistants and nurses. Whatever cannot be allocated, must be dealt with single handedly by the triaging doctor.
After five hours, the triaging doctors swap over and the whole things starts again for the afternoon.
The triaging process tells the patient who they are allowed to access; the patients do not get to choose. Most contacts are telephone based. GPs do 10 10-minute consults and only six 15-minute consults a session, so face-to-face medicine is less commonly offered.
Patients are limited to a single issue per consult. Routine care is less of a priority as KPIs dictate goals for on-the-day services. There is no continuity as patients must see whomever they are allocated. The GP who did your investigations is often not the one conducting your follow up.
Because of the emphasis on access over continuity, the government stance is that as long as you get to speak to someone quickly, it doesn’t matter who that person is or whether they know your history.
Funding for anyone but a GP.
While the complexity of care, numbers of patients and patient demands have continued to rise over time, the UK government has not increased the funding for general practice to reflect these realities.
The financial pressure on UK general practices is now so extreme that the British Medical Association states that “general practice is critically endangered” with GPs being asked to do more and more, GP-to-patient ratios expanding to 2241 patients per GP, continuity shrinking, and a huge 30% exodus of practice partners since 2015.
Yet while there is critical shortage of GPs in the UK, the available jobs for GPs has reduced by 44%.
Alongside the lack of funding for general practice, the UK government began prioritising specific funding for non-GP personnel, like physician’s assistants, pharmacists and nurses.
This means practices are incentivised to hire anyone but a GP. In a country with a dire shortage of experienced GPs, one can find a GP driving for Uber because the local clinics cannot afford to have them on the payroll. Those GPs still working are spending more time supervising non-GPs and less time seeing patients who desperately need their expertise.
The reality is, that to be an experienced GP, you need to study, train and have the skills and knowledge of a GP. You cannot suddenly do the job safely because a funding stream says it should be so.
Physician assistants have been linked to six patient deaths and the UK Pharmacists’ Defence Association has warned about patient deaths and other serious harms associated with pharmacist prescribing back in 2019.
A staggering 18,000 UK doctors responded to a survey calling out a shocking scale of concerns about physician and anaesthetist associates in the NHS in 2023. The government ignored the warning and British patients have subsequently been harmed or killed.
Reject, redirect, resubmit: referrals that go nowhere.
A system on its knees quickly develops ways to reduce use of its resources.
In the UK, GP referrals are rejected by non-clinical administrators. Often no reason is given. Sometimes it’s “haven’t met the criteria” or “insufficient information” or sometimes just “wrong form used”. Unfortunately, there are hundreds of forms for hundreds of services. GPs must seek approval for ultrasounds and MRIs, which often take weeks to occur and weeks to report and sometimes are simply refused.
The latest diktat? GPs must request “advice and guidance” by email before being allowed to even write a referral in the first place.
A simple blood test can take two weeks to be approved.
The thing in certain abundance is red tape.
A 2024 report from the RCGP found that UK GPs spend 23% of their time on administrative tasks. Red tape is one of the key reasons GPs cite for wanting to leave the NHS.
Poor IT systems and interoperability and arduous KPIs to demonstrate quality standards have strangled GPs with bureaucracy and pushed workloads to a point that clinicians feel patient safety is compromised. Mandatory approval systems severely restrict what GPs can investigate, refer for and prescribe.
Patients are not happy.
The NHS glory days are over. Patient satisfaction has plummeted, falling from 70% to 21% in 14 years. For all the accessibility policies, patients cannot get the care they need. One in 10 patients are harmed by either NHS treatment or delays in getting treatment, and 45% of those harms are significant.
Is the NHS all bad?
No, of course not. There are elements that are laudable.
UK GPs are trained to a very high standard. Contraception is free. Services for mental health conditions like eating disorders are more accessible.
The NHS also provides medical care for free. This seems ostensibly a good thing, but when one considers the harsh reality of underfunding, blocked access, GP burnout and attrition, soaring costs and reliance on physician’s assistants, it indicates that the totally free NHS is unsustainable.
The move by GPs and patients into private services indicates the emergence of a two-tiered system.
This raises the question about rational health systems encouraging those who can contribute to the cost of care to do so and leaving totally free services to those in need. The fiscal reality is that everything free to everyone all the time is beyond the means of public purse.
Signs the NHS model is arriving in Australia by stealth
There are myriad signs that the Australian government is seeking to introduce NHS-like policies into our health system.
Taken one at a time, some people think that’s jumping at shadows. Take all of them together and suddenly you are standing in the shadow of a looming, solid wall of poor health system policies, laid down one seemingly innocent little brick at a time.
The government’s bulk-billing policy.
Almost all general practices are small business and are not run by governments like public hospitals are.
During the pandemic, the Morrison government “mandated” vaccine consults be bulk billed, but the legality of them dictating to a private business how it should charge for its services was questioned on constitutional grounds.
Five years later, that conundrum appears solved as the Albanese government has linked a practice incentive payment of 12.5% to the condition that 100% of consulting services by every single GP in the practice must be bulk billed.
It’s coercive financial control, but it’s not illegal.
In addition, participating clinics must display Medicare signage all over the premises to receive their payments. Suddenly Happy Valley General Practice is an Australian Government Medicare Clinic.
Now the rebranded clinic with its new business model is totally dependent on the good will of the government to raise Medicare benefits in line with inflation. It also hopes the government won’t remove more item numbers.
Within months of implementing the new policy, the government removed mental health item numbers, devastating the morale and deflating the income of GPs who do that work.
The move to capitated funding.
While it seems the majority of federal government effort is focused on reducing spending on general practice, only 4.2 to 6.8% of the federal health budget is spent on our sector.
The government continues to pour money into Australia’s hospital system, agreeing to raise funding by 12% in 2025 to a record $219.6 billion, while leaving general practice relatively flat.
Despite claiming its bulk-billing incentive investment of 2025 indicates high levels of new investment, those benefits dictate control of clinic billing systems and have been taken up by only 3000 clinics, around 1000 of which are not traditional small-business general practices.
In fact, since 2005, a huge number of MBS item numbers have been removed from general practice, stripping the sector of its capacity to survive and manage the costs of delivering care. Mental health, joint injections, fracture care, wound care, chronic disease cycles of care, nurse item numbers, smoking cessation, four-year-old checks, all gone.
Many GPs report now making a loss when bulk billing procedures because current item numbers do not cover the costs of the equipment they use in their treatment rooms.
Now the government is holding focus groups to determine how GPs will respond to capitated funding for complex patients, despite the failings of that model in the NHS and in the 2016-2021 Healthcare Homes Trial, failures that occurred due to insufficient funding and burdensome red tape.
Models around the world suggest blended funding models and healthcare homes can and do work, but only if the governments of the day are committed to appropriate funding.
The 10-year Medicare rebate freeze and Mark Butler’s vehement refusal to consider an independent pricing authority for general practice makes the sector doubt fair funding will ever be on the table.
The government is prepared to compete against struggling general practices.
While removing item numbers and refusing higher rebates for longer consultations is the trend for privately run general practices, quite the reverse thinking occurs for Urgent Care Clinics.
The cost per “free” service at a UCC is around $250, backed by the unlimited funds of the Australian taxpayer.
The rebate for a GP bulk-billing a consult sits at around $42.
The federal government is now doing to small general practice what Bunnings did to mum and dad hardware stores. Moreover, Mark Butler is using taxpayer funds to run campaigns shaming GPs who don’t bulk bill and generating negative public sentiment against clinics who simply cannot stay open and operate on those rebates.
And while the incumbent government is ostensibly committed to improving the health experience and outcomes of Australian women, it is not so much concerned that each change to MBS funding sends female GPs ever further into the gender pay gap by removing mental health item numbers, punishing doctors for spending quality time with their patients and refusing to see eight patients an hour to make ends meet.
The government doesn’t mind if you don’t see a doctor.
The federal government has made it clear that access to care, any kind of care, is what it believes will make voters happy, and what it will therefore provide.
Before the pandemic, the RACGP and AMA had asked for years for telehealth item numbers to enable better and more equitable access to healthcare and they were consistently refused. That refusal generated the narrative of limited access to medical services and too few doctors for the population’s needs.
The pandemic forced the government to budge, and despite its perennial fears of a billing tsunami, all that has happened is that patients have sought out care with an appropriate blend of face-to-face and telehealth interactions.
But the access crisis narrative took hold nevertheless and the Pharmacy Guild had been building its strategy for prescribing in retail stores from the mid 2010s at least. Successive years of donations to the tune of $400-600K per year has resulted in endorsement of pharmacy prescribing in retail environments in line with the Guild’s vision to “administer, obtain, possess, prescribe, sell, supply, review and/or use Schedule 2, 3, 4, and 8 medicines, within their individual, self-determined, documented and authorised scope of practice”.
This now feels a bit like a solution looking for a problem, because data tells us that patients in Australia can, in fact, see a doctor very readily now that telehealth and more GP training places have become a reality.
Now, however, reports about harms and adverse outcomes about pharmacy prescribing from doctors continue to fall on deaf ears.
Repeated requests from RACGP for funding to have pharmacists working alongside GPs withing the clinical governance framework of general practice have also not been heard, and that’s despite the government warning GPs to set up multi-disciplinary teams or risk being left behind.
What’s a GP to do?
We’re at a crossroads. I do not want to work in or be treated as a patient in a system that resembles the NHS.
We must also recognise that the system needs changing, funding needs to move on from its 1984-based thinking, chronic and complex care needs to be managed appropriately, and a sustainable system must be designed.
We’ve been saying it for decades: a rational healthcare system has a flourishing general practice and a commitment to managing patients wherever possible in their communities and away from hospitals. The international literature is so clear on this, it screams the truth of it from all around the world.
The single biggest issue is it is so very easy to disparage and undermine what a GP does because it is poorly understood, it is difficult to demonstrate all the bad things you stop from happening, and if you don’t know better, you might think you can divide a person’s health into a series of finite tasks that can be delivered in disparate services throughout a dysfunctional system.
We could watch and wait and when it all falls apart say “we told you so”.
But I’d prefer to wrest back respect and recognition for my noble profession, assert the enormous super-power of the highly trained medical generalist, decline the invitation to endorse a dysfunctional model and instead offer up a sincere commitment to co-designing a primary care that will realise its potential to make Australian’s healthy and its health system exemplary.
We have the best healthcare system in the world. Any change we make must be certain to deliver better outcomes and not squander what we have.
Dr Anita Muñoz is a GP and chair of the Victoria Faculty, Royal Australian College of General Practitioners.
