This report looks at the challenges, opportunities and trends for general medical practitioners (GPs).

Commentary in this report draws on a report prepared by Access Economics in 2008, which looked at GPs' contribution to Australia's gross domestic product (GDP), GPs' income and practice income, current and projected numbers of doctors practising as GPs and general trends in this field. This report also includes case studies from three GPs.

This report shows new trends facing GPs are having a significant effect on the shape of their field:

• The number of female GPs is expected to outstrip the number of male GPs by 2038. However, many female GPs will choose to work parttime to balance their work with their family life.
• Although the number of GPs is growing, increasing demand for their services - and especially the services of female GPs - means the supply of GPs to meet demand for their services is inadequate.
• GP practices in rural areas earn more than their counterparts in metropolitan and remote communities.
• GP practices in Western Australia and Queensland earn more than those based in other states. GP practices in the Northern Territory earn less than GP practices based in other states.
• Anecdotal evidence suggests doctors are starting to move away from corporatised GP groups in favour of setting up doctor-run medical practices.

The remainder of this report discusses these trends in more detail.

In 2007, GPs contributed $9.1 billion to Australia's gross domestic product (GDP), which equated to 0.87 percent of total GDP.

	NSW	VIC	Qld	SA	WA	TAS	NT	ACT	Aust
number of practices	4857	2911	1975	939	820	342	88	158	12091
total income ($m)	1652	1062	785	341	378	121	23	60	4424
average income ($)	340,000	360,000	400,000	360,000	460,000	350,000	260,000	380,000	370,000
estimated FTE income ($)	93,900	100,700	109,700	100,200	127,400	97,900	73,100	105,000	101,000

Source: ABS Census Data

males

• In 1995 there were 14,379 male GPs practising in Australia. In 2007, the number of male GPs practising was 15,213, which equates to 16,232 fulltime equivalent male GPs. In 2038 the number of male GPs practising is expected to rise to 25,168, which equates to 26,854 full-time equivalent GPs.

females

• In 1995 there were 6,658 female GPs practising in Australia. In 2007, the number of female GPs practising was 8,858, which equates to 7,692 full-time equivalent female GPs. In 2038 this figure is expected to rise to 31,079 female practising GPs, representing 26,988 full-time equivalent female GPs.

These figures indicate a significant rise in the number of female GPs, with the number of female GPs expected to overtake the number of male GPs.

The total number of female GPs will be more than the total number of male GPs by 2030, with the total number of fulltime equivalent female GPs expected to rise above the total number of full-time equivalent male GPs by 2038.

As the full-time equivalent results show, a significant proportion of female GPs will work part-time, with the assumption being many female GPs will balance their role as a doctor with family life.

According to Access Economics' data, the total number of practising GPs grew by 1.5 percent per annum between 1995 and 2005. The number of female GPs practising is expected to grow by 0.6 percent each year up to 2038, when women will make up 55 percent of the GP workforce. In 2008, female GPs made up 36.8 percent of the total GP workforce.

The total number of GPs is projected to increase from an estimated 24,071 in 2008 to 56,247 by 2038. Full-time equivalent numbers are projected to increase from 23,924 in 2008 to 53,842 in 2038. This represents a 65 percent increase for males and a 250 percent increase for females (for both headcount and full-time equivalents).

Figures indicate the overall supply of GPs is currently inadequate and will only get worse.

falling GP numbers

• 5,500 GPs are projected to retire in the decade to 2016. This is 24 percent of the 2006 workforce or an average of 2.2 percent per annum. Around 0.5 percent of GPs are also projected to leave the labour force in any given year - for example to work overseas or raise families.

rising demand for GPs

• 13,600 additional GPs to meet demand will be needed over the next decade, or 60 percent of the 2006 workforce.

One way to supplement the number of GPs working in Australia is to increase the number of migrant GPs. However, migrant GPs generally require additional training in Australia to be able to practise as a GP.

miscellaneous trends

• Access Economics reports that between 2001 and 2005 the hours GPs work fell slightly from 42 to 40 hours per week, perhaps a reflection of the increase in the number of women in the field and their desire to work part-time.
• The average GP age increased very slightly between 2001 and 2005, with the average age of a GP being mid to late 40s.
• For GPs, there is limited scope to improve throughput of patients and therefore the productivity and profitability of practices. While doctors can attempt to shorten consultation times to increase the number of patients they see and therefore the earnings and profitability of a practice, there is a ceiling on the number of patients a doctor can see without seriously compromising the quality of care.

Increasing demand for the services GPs provide - and in particular high demand for female GPs - is just one of the trends impacting general practitioners, according to Perth-based GP Dr Dhammika Perera. But despite the growing demand for female GPs, bureaucratic processes make it hard for women to practise as doctors.

"There are lots of opportunities for GPs, and especially female doctors given the trend for people to want to see female GPs regardless of their sex," says Dr Perera.

"Demand for GPs' services is also growing as specialists increasingly expect GPs to do their groundwork to help cut down waiting times for specialist appointments," she adds.

According to Dr Perera, specialists now prefer GPs to undertake the minor procedures they once undertook. Some of the procedures hospitals have traditionally performed, for example administering intravenous antibiotics and wound dressing, are also now a routine part of a GP's work.

"This creates additional pressure on GPs," says Dr Perera, who says this increased workload is tricky to manage given government restrictions on the number of GPs who are allowed to practise has not changed. She says this is a difficult situation that does not take into account population increases and the fact people are now living longer lives.

accreditation

Another key challenge in the GP field is meeting ongoing accreditation requirements. "Accreditation is a good idea, but the cost and time involved in the accreditation process makes it hard to practise medicine at the grass roots level. A consequence of this is that some doctors are turned off being GPs because it's easier to work as a specialist in the hospital system than continually have to go through rigorous accreditation procedures as a GP," Dr Perera explains.

"The accreditation process is also costly and can chew up much of what you make; the enormous overheads are one reason why there are so few solo GPs," says Dr Perera, who also points out the Medicare rebate doctors receive has not changed to reflect the increasing cost of practising as a GP. "Solo practices may be simpler to run, but the logistics of working as a sole GP makes it difficult to work in this way," she says.

These factors mean many GPs now practise in groups, which, says Dr Perera, also makes it easier to apply for government grants. "Grants are weighted toward group practices; the more doctors in a practice, the bigger the grant will be, which is one reason why it's more effective to work in a group," she says.

But meeting accreditation requirements is difficult for female GPs, many of whom work part-time so they can balance work and family life. This dynamic means despite the high demand for female GPs, group GP practices are dominated by men, who work full-time and can more easily meet accreditation requirements.

In addition, GPs who take more than 12 months off work are no longer able to be registered as GPs, which is a particularly difficult aspect of the accreditation process or female GPs who want to take time off to have children.

corporatisation

Dr Perera has mixed feelings about the prevalence of corporatised groups of GPs and thinks their popularity - and profitability - is starting to wane. "Selling your surgery to a corporate group used to be a good way to make something out of your practice, given it's difficult to sell a GP practice. It was also a way of handing over administrative tasks like staffing and training; and there's no doubt amalgamating practices improves running costs and helps maximise the value of grants," she says.

"But medical practices can only achieve a certain level of profit because there are only so many patients a doctor can see in one day."

"Government restrictions on the number of doctors that are able to practise also limit profits. These factors, as well as the increasing cost of overheads, have affected the profit margins of the corporate groups. So in a corporate group there's underlying pressure on doctors to see more patients, which can equal a drop in the quality of the services doctors can provide."

Dr Perera says these factors mean many doctors are now leaving corporate groups and setting up groups of their own.

"There is a trend for doctors that have come out of a contract with a corporate group to team up and set up on their own. So we're starting to see a shift away from corporate groups," she says.

Another conundrum Dr Perera is witnessing is the need for patients to pay more for the healthcare they receive, despite public expectation of free medical care. "Although the majority of patients expect free medical care, some do realise it's necessary to pay for medical services. But it's hard to judge how much this viewpoint is penetrating the community given the current economic crisis. People might understand the need to pay for medical services but it's becoming much more difficult for them to do that," she says.

Meeting strict accreditation requirements as well as rigid government controls on GPs, despite increasing demand for GP services, mean GPs are under increasing pressure. Unfortunately, this will discourage doctors from becoming GPs and will ultimately decrease the quality of patient care.

Dr Naomi Harris works as a GP in Aboriginal health services in Warrnambool in country Victoria. She says one of the biggest challenges for the GP sector is "the ageing rural GP workforce."

"I work in Victoria where the average age of a GP is 59. There are not enough young GPs who want to settle permanently in rural areas," Dr Harris says.

"This is a massive challenge, as is the workforce issue in general. There is a real deficit in the number of GPs we need compared to the number of GPs working," she explains.

Dr Harris has had first-hand experience of this problem, having worked in a rural practice - by herself - with 8,000 patients on the books. "I was only contracted to do one day a week and it became an extremely stressful situation. I had to resign because of burnout from working in that situation," Dr Harris says.

To address this, Dr Harris says:

"Training numbers need to increase. At the moment there are 675 registrars and next year this will increase to 700 registrars. But it's still grossly inadequate compared to what's needed."

Dr Harris says a serious related problem is the "lack of infrastructure to allow an increase in training numbers. There needs to be an increase in the number of training places for registrars and medical students."

There also needs to be better incentives for GP practices to take on trainees, given that it costs practices money to train new GPs as doctors can not always be seeing patients when training new GPs.

Aboriginal health issues

Dr Harris works in Aboriginal health and says there are particular and acute problems with this area of the health services. "Health outcomes are still terrible for the indigenous population, who have significantly lower life expectancy and find it much more difficult to access healthcare services."

"Where I work it can be difficult getting patients to see a doctor and take medication, which comes back to socioeconomic issues. There's also a shortage of people who want to work in Aboriginal health services because it's not financially attractive…you take a big pay cut to work in Aboriginal medicine," she says.

positives

Although Dr Harris recognises the particular problems in her field, she does acknowledge certain benefits of working as a GP. "Working as a female GP gives you the flexibility to incorporate family life with your career; you can even train part-time, which is unlike many other medical specialties."

"There is also a lot of reform going on in the primary health care field which makes it an exciting time to be a GP. We're also being asked for our opinion and for input into the reform process. It's great to be able to offer advice, rather than be dictated to," says Dr Harris.

"There is also a variety of ways to work as a GP; I hold three or four different roles that are all completely different and that I perform concurrently; it's not just about sitting in a room and seeing patients," she says.

At the start of her internship at Royal Perth Hospital in 1987 as a sole, financiallypressed, time-poor parent, Dr Janet Campbell never thought she'd go on to build her own general practice and thriving business and later work in rural general practice with hospital call and night work duties. Dr Campbell has now come full circle to work back at a busy rural practice in Western Australia's Mount Pleasant, where she works part time and also has a role as one of the external clinical teachers for Rural Health West.

"As a mature age medical student with two young sons, there were not many others in my situation. At that time 34 was the age limit for a mature age student. Now postgraduate students in the new curriculum, for example, at Notre Dame University, have included a 52 year old,"

says Dr Campbell

who helped with teaching in Notre Dame's start up year. "It follows that juggling of relationship and family commitments during student years are a wider issue now," she says.

Having worked in rural areas, Dr Campbell recognises the challenges of being a country doctor. "Students now have assignments to rural areas in their first year, creating early links and insights to promote future rural retention of doctors. My experience as a locum GP for the South East NSW Division of General Practice for 12 months in 2006, followed by rural locum work in NSW and WA, has revealed to me the hardships and joys for rural doctors. Many of the hardworking full time doctors in towns such as Yass, Cooma, Bombala and Young, in NSW and Albany, Pemberton, Dongara, Tom Price and Beverley in WA, have long hours of work augmented in many instances by on-call hospital or obstetric work."

"Twenty-four hour on-call work frequently continues for several days or even weeks. It is noticeable that doctors are pulling out of visiting medical officer (VMO) work owing to its effects on personal health and family life, especially when their children reach high school age. The older doctors who worked until their 80s and gave their all to their work are there but in a part time day work capacity. I've observed wonderful rural GPs soldiering on into their 60s with high stress levels, but with the feeling of responsibility for their townsfolk, keeping them working at a higher level of work than normal is healthy."

A particular challenge Dr Campbell recognises is that delivery of anaesthetics and obstetric services have been ceased at many rural hospitals and these hospitals are running on impossibly tight budgets. "Many rural doctors no longer work at their local hospital and I suspect their time is taken up with the increased medico-legal imperatives of general practice, greater bureaucratic demands, and reluctance to work in under-funded hospitals with pressure to fill in on under-doctored roster systems, personal issues or with depression," she says.

"In teaching overseas trained doctors to communicate with and manage health in a manner appropriate to our society I have noticed their keenness to learn but also difficulties in coming from a more authoritarian culture in which patients have didactic instructions - that is, a doctor-centred model for consultation. Though many of these doctors have bonded with their country townsfolk and are indispensable there may be an attrition rate as they too, find the demands of country practice onerous and filter gradually into city practice or into specialty training. Certainly rural Western Australia would have an even more serious rural doctor shortage if not for the overseastrained doctors," she says.

"To improve their lifestyle I've observed GPs in both rural and urban practice opting for variety in their work, for example country GPs who leave their town one day a week to run a city drug clinic and city GPs who conduct fewer GP sessions and work in a specialised clinic, teach, or assist in medical or voluntary organisations. My impression is that both male and female GPs are searching for a balance in their work that is difficult to achieve with full time general practice sessions," she says.

Dr Campbell observes the paternalistic general practice style of 40 years ago, where little was said, scant records kept, and up to 80 patients seen daily has morphed into a complex, at times energysapping beast, which requires multitasking to the max.

"My experience relates to non-corporate medicine, and colleagues who have practice ownership now have an enormous task separate from the patient commitment, ensuring that staffing, finances, IT, risk management and health insurance requirements including audits are attended to. This necessitates a multilayered advisory team and much after hours work," Dr Campbell says.

Says Dr Campbell: "a medical career is still to be valued by young aspiring students, despite my insights suggesting the wonderful, fascinating medical world of the human being is shadowed by a dominant non-clinical matrix."

Dr Khaled El-Sheikh runs 24 GP practices in rural areas around Victoria and NSW. He says "the high demand for your services from patients, as well as the growing administrative burden facing doctors are two of the key challenges facing general practice doctors."

"The administrative burden of maintaining your GP accreditation is not getting any easier and considerably adds to a doctor's workload," Dr El-Sheik says.

A related pressure is the growing shortage of the support services doctors require, for example podiatry and counseling services. "There's never enough of these services and patients find these services hard to access, which means it falls back on the doctor to provide this support," Dr El-Sheik says.

financial pressure

One of the most difficult challenges facing doctors, says Dr El-Sheikh, is the financial aspect of running a general practice. "Sole GPs find it difficult to handle accreditation, as well as new technologies and equipment, which cost a lot to purchase, maintain and upgrade. The payments GPs receive haven't caught up to reflect these expenses," he says.

opportunities

Although the cost of being a GP is increasing, Dr El-Sheikh says this presents opportunities for groups of doctors to get together and share the burden of running a GP practice.

"Groups of doctors can come together under one umbrella and make running a number of GP practices financially viable," he says, adding that "there is an opportunity for people with medical and business experience to make the numbers work."

"But the tricky part is that, because the margins are not high, it doesn't take much for one aspect of a practice to slip, which affects the smooth running of a practice," Dr El-Sheikh adds.

challenges in rural areas

Dr El-Sheikh says there are particular challenges facing rural doctors that city doctors don't have to face. "Rural doctors have to perform many extra roles city doctors don't have to, for example emergency, obstetrics and counseling roles, on top of their role as a physician, which really adds to the workload. And in a small town there are limited resources, which makes it very difficult to practice," says Dr El-Sheik.

"And in a small town there is usually only one doctor, so if he or she falls sick, you've lost one hundred percent of your workforce, which means the pressure on rural doctors is much greater than in the city."

Addressing challenges

To address these concerns, Dr El-Sheik says it's important to identify the factors that are leading to doctors in rural areas burning out. "It comes back to education and training, as well as making sure you're still part of the outside world. Making sure doctors take breaks and holidays is also important."

Says Dr El-Sheikh: "doctors need a buffer to protect them from administrative burdens and help so they can maintain a healthy lifestyle and a reasonable income."

This report is designed to shine a light on current practices of general practitioners in Australia.

Most of the data contained in this report was prepared by Access Economics in 2008, which was commissioned by NAB Health to:

• Estimate the value in dollars and as a share of GDP GPs contribute to the economy.
• Estimate the current number of GPs and full-time equivalents by gender in the workforces of medical specialists out to 2038.
• Estimate changes in average income among GPs.

Case study data was also obtained from Dr Dhammika Perera, Dr Naomi Harris, Dr Janet Campbell and Dr Khaled El-Sheikh.

Thanks to Dhammika, Naomi, Janet and Khaled for contributing to this report.

more information

For more information speak with your NAB Health financial specialist or contact:

• Craig Anderson, Managing Partner Victoria
  +61(0)3 9630 9405 or Craig.A.Anderson@nab.com.au
• James Carter, Managing Partner New South Wales
  +61(0)2 9433 1922 or James.M.Carter@nab.com.au
• David Backhurst, Managing Partner Queensland
  +61(0)7 3234 5205 or David.J.Backhurst@nab.com.au
• Les Ryan, Managing Partner South Australia
  +61(0)8 8291 3440 or Les.J.Ryan@nab.com.au
• Mike Beckingham, Managing Partner Western Australia
  +61(0)8 9214 6534 or Mike.P.Beckingham@nab.com.au

visit nab.com.au/health

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