And the solution to global GP suffering is …

14 minute read

WONCA keynote and world-renowned GP and academic Professor Trish Greenhalgh reckons it’s marketing (to politicians). It’s not.

Sometimes for this column I don’t write what I actually think.

Sometimes I calculate that the message I’m going for will get lost in the “he’s not a GP what would he know” noise (which has a fair bit of truth to it); quite often, what I think is too confronting for anyone to say out loud (inside thoughts only, Jeremy).

This week, I’m probably going into that risk zone by taking to task the keynote speaker at this week’s WONCA, a much vaunted, loved and long-serving GP and GP academic from the UK, Professor Trish Greenhalgh.

Greenhalgh’s keynote centred on why general practice and GPs are suffering globally, and some of what she had to say resonated a lot.

For example, she referred to the work of Oxford academic Dr Michael Gill, who suggested that workers suffer when organisational control methods conflict with a person’s physical, psychological or social identity.

Put another way, GPs start to suffer when their sense of self – which often has a lot to do with the compassion around how they view and care for their patients – starts to become misaligned with organisational modes of control.

For modes of organisational control of GPs in Australia read Medicare, bulk billing, the PSR, AHPRA, rebate freezes, state payroll tax grabs, the ATO, Services Australia, MyMedicare … et al.

The other component of Gill’s theory on suffering in the workplace is when organisations start to send a lot of mixed messages to their workers, particularly ones where the formalised rules of how they are supposed to work clash with their own professional expectations of what they should be achieving at work.

GP life these days feels like the very essence of this dynamic.

TMR columnist Dr Imaan Joshi put it awfully succinctly when she compared being a GP with this piece of art: a robotic arm that leaks its own hydraulic fluid so spends more and more of its time sweeping it up and trying to put it back in its system. Depressingly, this piece of art eventually couldn’t keep up and literally broke down – it died.

If this is truly suffering, then at the very least Greenhalgh has succinctly outlined for us why GPs are suffering and the extent of their suffering – which is very deep and very serious.

But while Greenhalgh gave us all an elegant and simple insight into what is going wrong, she almost entirely skipped over how to start effectively addressing even some of the (often very obvious) problems that general practice is facing.

In doing this she spent a lot of time blaming things and people which feel like they are just unstoppable societal trends: the pharmaceutical industry, technology and technology platforms, bureaucrats who obsess over data and efficiency and who push too much prevention on GPs by over estimating risk, politicians who never get it, ever … you know the song.

Her framing of the pharmaceutical industry was at once brutal and naively simplistic: she said pharmaceutical companies represented one of the three poisons of Buddhism, greed, represented by the rooster. Her slide is below.

OK, pharma companies have been caught out doing the odd evil thing from time to time. But most other big corporations have been caught out in similar ways – Enron, Facebook, PWC and so on – which makes it more a big-organisation and human dynamic than a pharma-specific greed thing, really.

And one aspect of the pharmaceutical industry we probably shouldn’t ignore, outside of the bad behaviour and the greed, is saving billions of lives with drug development.

I’m not picking a side, but I am suggesting that singling pharma out for its own slide with greed on it when talking to 2000 GPs, most of whom have to also make a profit from the businesses they work for or run, feels a tad off track in the scheme of the issues at hand.

(Note: the majority of the revenue of medical media businesses like ours and Australian Doctor comes from pharma money, so don’t worry about writing in and pointing that out.)

Again, what Greenhalgh was describing were the (all too obvious) problems: the march of technology and its use by bureaucrats, the rise of platform providers in healthcare, the tendency for big pharma to occasionally lose its ethical way, profit driven private healthcare organisations and so on.

Most of the problems she was describing were not unique to general practice – the tech platforms and the rise of data-driven management by business and government, for instance.

They are society-wide issues that many professions and individuals are facing.

Outside the world of GPs, implying that such problems are unique to GPs does the GP brand no good at all.

Politicians and bureaucrats often assume as a result of some GPs taking this position that GPs are inward-looking and in a bubble and as such they do not have the perspective needed to truly fix the healthcare system and even their own profession.

This dynamic is a particularly dangerous and nasty one for general practice and it’s certainly in play in Australia today: GPs don’t have the perspective we have so although we see they are suffering and we even feel for them we need to force change upon them and later they will realise we did the right thing by them and their patients.

Which is why simply pointing to problems and being simplistic in describing the problems is at the end of the day lazy leadership.

One thing I love about a lot of GPs I run into is that they don’t abide much by the “inside thoughts only” rule when they are confronted with something they simply don’t agree with.

When they want to say something they generally do, no matter what.

An example would be the GP who, in the Q&A after the keynote, put up their hand to vehemently disagree with the godlike and universally revered speaker.

The GP questioned one of Greenhalgh’s big bugbears: that GPs were being forced into doing a whole lot of (apparently unnecessary) work around prevention because the bureaucrats were getting carried away, obsessed even, by the issue of risk.

This was creating significant extra work for GPs according to Greenhalgh, who said she thought that this time would be better spent on treating people who were actually sick.

The GP simply said prevention was surely one of the biggest roles of general practice and doing a lot of work on people who weren’t sick was probably a pretty good strategy for any healthcare system, whether it was overdone or not.

Greenhalgh retracted immediately (and awkwardly) saying she would never suggest that prevention wasn’t a vital part of what GPs did – but she sort of had done just that.

Greenhalgh, a world-renowned general practice researcher, probably has some data that goes to the point she was trying to make.

The problem is, it was pointing at problems, not trying to frame them in any way that might lead to some meaningful approach to solving them.

Eventually someone in the audience asked the obvious question: with all these seemingly very big and expanding problems flying around, why can’t GPs convince anyone in power that this is actually a crisis that might end in the collapse of the most efficient and important hub of care in most healthcare systems in the developed world?

It was pretty telling that Greenhalgh had to stop and think for a bit on the question. Surely she should have had a tome of well thought through, impressive strategies she could have reeled out which went directly to a lot of issues she was describing.


Greenhalgh answered, with some hesitation, that she thought that GPs “had a marketing problem”, in particular with politicians.

If Greenhalgh thinks that GPs’ major issue is marketing (to politicians) and she really is a global leader in general practice, then almost certainly one other problem for general practice is GP leadership.

After more than a decade of these problems emerging and aligning, if GPs had a marketing problem, and they haven’t sorted that by now, then they’re never going to sort out anything using marketing.

GP leadership is not that incompetent, mercifully.

The problem is a lot more complex and nuanced than “we need to be better at marketing”.

Besides, a good proportion of marketing is the art and science of bullshitting people (have you watched The Gruen Transfer?).

To return to the causes of suffering, I don’t think that bullshitting, as useful as it can often be in getting people to do what you want, would align with the “self” of most GPs and their leaders.

It would almost certainly lead to more suffering.

A giant GP strength and weakness is that in their profession they are constantly conflicted by the purpose of guiding and helping their patients and the necessity to make enough money to live.

Most other professions don’t view their clients in this light and therefore don’t have quite the same problem.

This is something reasonably unique to general practice.

So, if not marketing, what are some possible ideas to slow the ever-expanding crisis facing general practice?

A smart reader might point out here that like Greenhalgh, I’m just pointing to problems, namely that Greenhalgh isn’t really doing a great job of being a leader in a crisis here.

After the keynote, which was the end of that day’s proceedings, I wandered off to get a drink at the exhibitor reception – I needed one.

I was pretty annoyed with the session and I didn’t quite know why, but not being a GP I decided I’d ask any GPs I could find what they thought about the session.

Fun fact: half the GPs I asked hadn’t been to the session, which adds up because there are apparently 4500 GPs attending this week’s WONCA and in the room I counted just over 2000 attending the session.

Of those who had attended, none were overwhelmed or energised by the keynote, but not many were actually annoyed in any way, like me, either.

Later that night I went to a tech vendor launch function to keep drinking for free.

(As a quick sidenote, the launch was pretty interesting and relevant as it was for an app that the vendor promises will sort out quite a few of the issues facing GPs in payroll tax money flows – that story in Money & Medicine next week, bet you can’t wait).

One GP I ran into at this function, who hadn’t been to the keynote either, nonetheless said something to me that immediately resonated. I asked if they thought GPs had a marketing problem.

This GP recoiled at the idea and said abruptly: “Marketing problem? We don’t have a marketing problem, we have a fiscal problem.”

If this GP had had an inside thought bubble hovering over their head it would have probably then read, “…idiot”.

It was a focussing comment.

A conversation ensued.

Politicians aren’t ever going to listen to GPs , not even if you managed to hire David Ogilvy to do your marketing campaign. (David Ogilvy is generally recognised as the greatest ad man of all time – Don Draper in Mad Men was part modelled on him. He’s dead now so no one can ask him what he might have made of Greenhalgh’s marketing comment).

Politicians and bureaucrats will do what they will do, as tech companies will, and there will be very little that anyone can do to convince them otherwise. They operate in deep and systemic ecosystems which contextually are in a parallel universe to your typical GP and are very hard to perturb.

See climate change for an example of how hard it is to convince the powers that be of the bleeding obvious. Also, it’s nearly always not just logic or common sense in play: other more pernickety forces like money and people’s careers always make up part of these problems.

Right now politicians and bureaucrats love the power of technology and data to help shape efficiency in markets, and there is probably no way anyone is going to stop anyone in the Department of Health and Aged Care or the various state government health departments having a good crack at testing their theories on efficiency, tech and data on general practice.   

They’ll probably call it “digital transformation” or something like that.

This may go well or not, but very probably not if you think about things like the rank waste that the My Health Record became, the $17 million specialist Medical Costs Finder portal, or what the NSW government did to TAFE (destroyed it in no time) with all good intention to make it much more cost-effective for taxpayers.

Given where GPs sit today, which is pretty much on a precipice of near-term extinction, and given that we know the government is going to push ahead with its plans regardless because that’s how government and politicians roll, GPs might have to ask themselves a lot more seriously what they are going to do about it and not be satisfied with “we need to get better at marketing” as an answer.

Of course, I still haven’t come up with anything, have I?

Two things: this is one hot mess of a complex problem and I’m not a GP.

That GP I talked to at the magical payroll tax app launch pointed to one pretty powerful and interesting strategy, and it’s one, interestingly, that recent RACGP leadership came up with: start mixed-billing your brains out.

This is no simple fix and it’s causing some GPs suffering because it’s that conflict of self and self-preservation, but it is going to cause some interesting things to happen.

In fact, it already has.

Associate Professor Karen Price’s call to all GPs in her term as RACGP president a couple of years back to stop universal bulk billing set a ball rolling that has already caused quite a bit of political disruption.

Bulk billing rates have dropped. Not a lot and possibly nothing to do with GPs shifting to mixed billing yet  – GPs are very reluctant to shift on bulk billing for reasons of patient preservation – but enough for the shit to hit the fan in Canberra around the idea that the public might cotton on to the idea that healthcare isn’t free like it used to be and blame it on the current government (aren’t GPs a free government service?).

Calling on GPs to reduce bulk billing probably has ended the concept of free healthcare as there’s no going back for any GP or practice that starts mixed billing and even if the government starts paying GPs properly again, it probably won’t result in any improvement in patient access now (which is one reason the government won’t start paying GPs a lot more).

The horse has bolted. It’s a new world.

At least the new world was started by GPs. That’s at least some control taken back of your self and destiny, and hopefully a little less suffering.

Very often what practices are seeing when they do change their billing is that a lot of their patients who they thought could not afford to pay can afford to pay.

Sure, it’s a blunt instrument and there are going to be some patient casualties, and this may add to GP suffering.

But it’s working at the political level.

I wonder what else GPs can come up with which might change the playing field like this idea has while at the same time adding a little more agency in terms of the profession clawing back more control of its own destiny?

GPs are well and truly into rock-and-hard-place territory here.

The hard place is non-existence.

GP leadership and many GPs ultimately understand that would mean catastrophic suffering for their patients and the community, even if no one else does yet.

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