The former UN medical director has changed jobs again, saying general practice has become 'unsustainable'.
Dr Jillann Farmer has a unique perspective on the Australian healthcare system, having worked in it at every level, as well as on the outside looking in.
These days Dr Farmer is an emergency locum GP, but her CV includes almost eight years as UN medical director and a year as Queensland Health’s deputy director-general.
Since January 2023 she has been CEO of A Better Culture, a national project funded by the Commonwealth to improve the culture of healthcare workplaces across the country.
When we caught up with Dr Farmer, she was just about to start a shift in the emergency department of Capricorn Coast Hospital near Rockhampton.
After your stint with Queensland Health, you were working as a GP. What prompted the change to emergency locum GP?
I’ve spent a lot of time thinking about that, because there was much about general practice that I really loved.
I found there was an increasing emphasis on a need to earn a living. When I first entered practice, you didn’t have to pay attention to the billing. It took care of itself because the rebates were adequate. So, for me it was definitely in part the Medicare rebate.
Something that doesn’t get talked about a lot is that general practice can be very isolating. If you want to work in a team-based environment, general practice isn’t great for you.
Another thing is that GPs are being left holding everything that no one else in the system wants to deal with, including stuff that should be way outside our scope of practice.
And finally, something that doesn’t get talked about much is how much clinical risk GPs hold on behalf of the healthcare system.
What do you mean by that?
Every time a GP sees a patient and decides not to order the CT, not to order the x-ray, not to refer, the GP is taking that risk on to protect the healthcare system from unnecessary costs.
That is a huge, unrecognised burden and benefit that GPs carry and it never gets talked about. That gets taken for granted – more and more risk has just been being piled on to general practice.
So, the rebate structure is inadequate unless you’re prepared to have a virtually unsustainable income, you can no longer bulk bill the majority of your patients, and the gaps are getting bigger and bigger and bigger.
The turning point for me was when it became apparent that bulk billing all the people I had on pensions and disability wasn’t going to be possible.
So I went to emergency medicine, where I can treat everybody. I can give them what they need and I never have to ask them for money.
Why the central Queensland coast?
I grew up here and this little hospital agreed to help me reskill. I went to them pretty useless, and they’ve helped me over the course of a year and a bit to build those skills.
It’s still a journey. You don’t jump from medical administration to general practice to emergency medicine without some white-knuckle moments along the way.
What skills did you need to relearn? You ran the UN medical unit!
Yes, but I’d never put an ultrasound on a belly.
It wasn’t so much stuff as mindset. The approach to the same patient in an emergency department is very different [from general practice]. It would be considered unacceptable not to order that CT scan in emergency, when in general practice I might sit on it for a couple of days.
General practice protects the system from cost. The emergency department’s role is to make sure they don’t miss the life-threatening stuff that’s going to kill you within the next 24 to 48 hours.
In general practice I do that with a combination of knowing the patient, clinical judgment, and sometimes phoning a friend. In emergency departments, I’m the friend the GP phones, basically.
What do you think of the urgent care clinic model that’s grown since the last federal election?
It’s not the answer to all ED problems.
I think it’s really good the government is trying different models, but I would have designed it differently.
It would be better to give funding to existing general practices to keep a GP on standby so that they could manage their own patients with urgent care needs.
In a well set-up practice that’s well located, you do have access to imaging, you do have access to point-of-care pathology or urgent pathology. So I would probably have designed it a little differently, because I have a bias as a person who worked in and cares about general practice and my general practice colleagues.
I feel very sad that Australia seems to be moving towards a place where general practice delivered by specialist GPs looks like it’s heading the way of being something only for the rich.
Are you worried about pharmacy prescribing?
I do have concerns that governments are positioning pharmacists as GP substitutes.
I don’t have a particular issue with a prescribing trial. There is stuff that I’ve often wondered why I have to write a script. There is definitely scope to make medication access easier.
But the marketing that’s being done is saying to patients that your pharmacist is a “highly trained specialist clinician”. People are turning up to the pharmacist and they’re not reading the document that says what the pharmacist has been trained to treat.
There’s a real misunderstanding in the public mind of what the capacity is. We’ve got to get past media conferences with pharmacists wearing stethoscopes, which was just mind-blowing.
We have a federal budget next week. What are you hoping to see?
This will make me very unpopular with some of my very high-end specialist colleagues, but every time we make a decision to spend 20, 30, $40 million on a service that will operate only at a single hospital, we’re actually robbing everybody else of the basics.
People who live in cities don’t understand how much of the basics are not available [outside metropolitan hospitals]. It’s truly shocking to me. There’s a lot of human suffering in between.
I wish that our healthcare would focus not so much on being excellent, but actually on being good enough. We need to start talking about what a good enough healthcare system would be.
We need to reflect really hard on the UN’s sustainable development goal three – building good health for all. We need to recognise that rural and remote communities in Australia do not have that.
That’s something that I really would love to see addressed in the budget.
