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There is more to the GP super clinic story than you might have heard

It’s been interesting to watch how the various media outlets have been reporting on a campaign by a group of GPs against super clinics, including a protest staged in western Sydney this week.

Many of the reports, whether in the local or the national press seemed to uncritically buy the GPs’ line that super clinics will threaten the integrity of the relationships between GPs and their patients.

Even the Sydney Morning Herald editorial examined the issue as if it was only about patient care.

Only one report that I could find – and perhaps not coincidentally in a publication for doctors – acknowledged that other considerations (ie $$$s) might also be driving the opposition.

Now I am not seeking to be an apologist for the clinics. And you could argue that it’s entirely fair enough that small business people would want to defend their business.

But if we’re going to amplify the concerns of one group with a professional and financial stake at play, then perhaps we should also be reflecting the views of others involved.

Despite the silly name – GP super clinics – the facilities are aimed at promoting multidisciplinary care. So maybe we could also be hearing from the nurses, psychologists or others involved?

Even better if we could get some independent sense from the local community about how well the existing model of general practice is meeting their needs and what they think about the super clinic approach.

I’m sure there are problems around the place with the various super clinics being developed – it would be surprising if there were not, given all the logistical, bureaucratic and professional challenges that are likely to be involved in setting them up.

But the general public may not be aware that there are also some good news stories around.

From what I’ve heard, the one being developed at Shellharbour just south of Wollongong is going to be offering a terrific range of clinical and health promotion services to an otherwise under-served community. Importantly, it will also be a training hub, with postgraduate nurses, GP registrars and medical students onsite.

Those behind it hope that by developing new models of care and flexible, stimulating working environments, the Shellharbour clinic will help recruit and retain health professionals in a needy area.

There’s another good news story to be found at Gunnedah, the north-western NSW town that stakes its claim to fame as poet Mary Mackellar’s birthplace and “Koala Capital of the World”.

It’s not about how federal policy solved a local health need. It’s about how a local community came together to develop a local solutions for their problems – and then got some Federal backing to help realise it.

I wrote recently in Australian Rural Doctor about how the people of Gunnedah have been engaged in an intensive fund-raising campaign over the past 18 months in order to establish an integrated health clinic. The plan is for it to be owned by a  not-for-profit, community-owned company, run by community members, health professionals and representatives of local agencies.

The origins of the concept date back four years when a local GP, Dr Grahame Deane, acutely conscious of the perilous state of the town’s health services, began working with various agencies to develop some solutions.

The goal was to create an attractive environment to help with workforce recruitment, while also increasing the town’s chances of “growing its own” by becoming more involved in teaching and training.

But rather than impose his own vision of how to achieve this, a series of community meetings were held, to find out what the locals wanted. The response was overwhelming, with 350 people packed into one forum, and many turned away for lack of space. It turned out that the people of Gunnedah shared Deane’s vision for a community-owned venture.

Deane believes the “absolutely amazing” community support has been critical for the project’s progress. “The important thing is that it is not owned by a doctor, it’s not owned by a corporation, it’s owned by Gunnedah,” he says.

After my story went to press, it was announced that the town had won super clinic funding.  Deane rang recently to tell me how delighted he was to get the funding although he admitted that he didn’t much like the “super clinic” name.  I heartily agreed with him. Terrible name, but the concept may have more merits than some recent headlines have been suggesting.

And I tell you what – I much prefer the richness of the story out of Gunnedah than the one we’re being told out of western Sydney.

Comments 12

  1. Darren says:

    A useful contribution to the debate about changes to primary health care Melissa. The recognition by Deane that his community needed something more than medical services to sustain its health care says much about his insight. Arguably rural health practitioners are more involved in their local community than their metropolitan counterparts, and they are also much more aware of the impact of stretched service provision. The higher average densities of medical providers in the cities means a different model of care and coverage exists but Geoffrey Edelsten found a chink in the armour of the traditional GP practice when he first set-up his 24 hour clinics. The concept of providing access according to patient need rather than provider-preference challenged the usefulness of sole practice and his entreprenuership is still shaking the foundations.

    With the MBS rewarding shorter consultations there are strong financial incentives to deal with single and “simple” rather than complex chronic issues. Developing multi-disciplinary teams to deal with these issues makes sense – but the blocks are reimbursement and ownership. In other countries, such as the UK with the introduction of GP fundholding, there seemed to be less reticence to let go of the routine care to enable GPs to focus their abilities on those that most needed their high-end abilities.

    As your recent blogs have suggested if there was shift in focus away from illth and more on health then our use of resources would improve. Protection of professional silos is an issue for all health professionals but the debate needs to come back to ensuring equity of access to the type of health intervention warranted. If we shift our approach to recognise and remunerate for whoever provides the most appropriate level of health care, distinguishing that from direct access to medical care, then we could improve on our justifications for claiming a leading health care system. We would also improve our ability to sustain access within our forseeable levels of resourcing.

  2. Doctor Whom says:

    The trouble with e the Supa Clincs is that they are half arsed attempts to bring health kicking and screaming into the late 90’s.

    Lame words about team work and ehealth don’t cut it when any serious model would be looking at big centres like the Victorians have set up at Craigeburn, Werribee and Yarra Valley. Serious attempts at integration that incorporate day surgery, GPs, allied health, Chronic health programs, screening, pathology, radiology plus car parking.

    The Feds Supa Clinics have been a feverish response by Rudd’s KPI obsessed apparatchiks to be seen to deliver some ill thought through election promises. Box 1 Tick, Box 2 Partially achieved, Box 3 exceeded expectations…..

    Drawn up on a whiteboard in Canberra (not boding well for future Fed reforms) the Supa Clinics have been plopped on marginal seats bypassing any years long local planning and evidence. Areas of need have missed out and other areas offered a Supa Clinic have scratched their head in wonderment at what this could all be about.

    By accident a few have landed where they might be appropriate and wanted but about 30% – 40% will be a waste of money and more importantly divert GPs and communities from getting on with real local health issues.

  3. Innominate says:

    I have just spent half an hour detailing how these GP super clinics are a bad idea and unfortuanately I lost my prefectly reasoned arguements.

    Basically I feel Shock and Awe

    So now as it is late a few dot POints

    Good luck to Gunnedah with your super clinic I hope you build it and that an incredibly fantastic state of the art practice is built and that the most fantastic doctors nurses and allied health practioners flock to your super clinic. Bon chance mes Braves.

    Ten milliom (at best) which is the maximum please note Maximum amount of money to establish a SUPER CLINIC has to buy the land build the clinic pay the land tax council rates title transference deeds GST and agents fees as well. Then an Architect can design your building and a kindly local builder will build it at cost because after all it is a community service. By the way 10% is automatically withheld if you read the fine print and please remember ten million is a maximum.

    Medical equipment suppliers will fall over themselves to sell the SUPER CLINIC the equipment they need a bargain basement prices so the autoclave and the ECG machine and the Vaccine fridge and the fifteen other essential Items of equipment will be provided at cost and serviced for free. So that cost won’t eat much into the budget of ten million. There is no provision for equipment and computers , so the bestwe can hope for is to sing as we go to keep our spirits up.

    Administration costs and setting up the practice paying for computers internet access software and hardware will be negligible as the local suppliers through out australia would rather stab themselves with a blunt cricket stump than make a profit on the local SUPER CLINIC.There is a tiny grant to help here, will probably cover the first four weeks pay for admin staff

    THere are no spare GPs in Australia to staff these premises. They are already in practises and mostly content. I doubt you will attract good GPs to the SUPER CLINICS. Those who work full time and provide on going chronic care to the patients that need it are the ones you need and won’t get. Their place cannot be filled by part timers and locums.

    GP SUPER CLINICS will not be super. They will be clogged up by the worried well and not especially sick kids. After hours and on week ends people will be eraged that they have to wait to see the doctor and even possibly have to pay the GAP. Stafing with DOctors will be a problem. Staffing with nurses will be worse and do we really want topull nurses out of hospitals and nursing homes to provide an inferior nine to five service. You decide but if there is at present a shortage of Doctors I can assure you the predicted shortage of nurses is very much worse.

    Brilliant Ideas from idealogues often don’t translate into reality and this is one of those cases. I wish anyone embarking on establishing a SUPERCLINIC good luck with all my heart because if they work according to government ideals they would be fantastic. I suspect they are a likely to suceed as the chance that you driving a car will never ever go over the speed limit in the next week not even by 1 Km/h.AS ever Australia tries to import the worst of UK ideas and then fails to fund them. If you want to see how popular Super clnics are in the UK just loo on the net. Start with pulsetoday.co.uk.

    If this doesn’t convince you. ASk a local businesss management consultant and get him to look at the businees plan,

    Good Luck

    Innominate

  4. Doctor Whom says:

    Innominate – there is a lot of truth in what you say.

    If the $$ floating around for SuPa clinics are any indication of how much the Commonwealth thinks health-care (and buildings) cost then we are in for a rocky few years.

    I was at one Superclinic “consultation” conducted by the Commonwealth on an unsuspecting community that thought they already had a decent enough lot of GP clinics – one lot who had just built a new clinic – and a pretty good local community health services with nurses, physios, allied health etc.

    The Feds were basically bemused that the offer of $1m wasn’t being enthusiastically embraced. One even said “what a great opportunity – If I was offered a million $ to set up a clinic I’d be very excited”

    When experienced people pointed out that $1m over 3 years for everything, buildings, staff, IT systems, supplies wasn’t much – they were treated like recalcitrant old fogies – holding back progress.

    $1m in health care or building goes nowhere – in fact anyone with only access to that much would be a seriously bad business person to consider doing anything.

    $1m might just buy you 5 allied health staff for one year – without any building, computers, cars, phones, equipment,training or ability to do anything.

    All this from a posse of (about 8 – I counted) Canberra denizens who had flown interstate, stayed overnight, hired cars – meals etc –

  5. weed says:

    These are great ideas but what about people that live say 6 hours away from any form decent doctors. I live in western queensland and I am disgusted with the medical profession. We haveo decent doctors out here. The clinic in Longreach was a great clinic but now HA. We have got a couple working for us with a sixteen month old daughter who after months of visiting the clinic in Longreach due to an itch has just been diognosed with scabies. WOW get the doctors working prpoerly now. Since the medicare system has been used the visiting times have gone down doctors are ripping it off. They say our health in Australia has gone down hill in the lasy twenty years why Medicare. Get the doctors actually doing what they are supposed to do. Ask anyone about the doctors and you will find that there are quite a few people fed up with how they are being treated or not being treatedmore like it.

    Debbie Oldfield

  6. Innominate says:

    Thank you Dr Whom

    I appreciate your support. I would urge anyone who supports SUPER CLINICS to actually look at the financials rather the the hyperbole. Sit down and work the numbers,by hand as I had to, or on a spread sheet. They are underfunded from the start and doomed to the risk of trading while insolvent (ie Must close). We’ve had previous examples Edelstone Mayne Health Symbion etc. Simply having a grant from the state and federal governmentsdoes not a clinic make. Nor does it ensure its longevity or quality of service provided. I am not brave enough to sign up as a director for a super clinic though I have run successful practices before and subsequently worked for corporates.

  7. Innominate says:

    Sorry I cut myself off. I am not sure about where you work but,local council regulations where I am require a substantial amount of parking to be provided. This is not proportional to the number of Doctors working there but to the number of health care providers working there. This includes the psychologists and social workers who require more time with patients but does not take into acccount the fact that they generate less income than a GP. I would imagine most councils have a formula to calculate the number of parking bays needed and it will be based on the number of consulting rooms and the number of practioners of all the various disciplines. Sit down with your local council and work out the minimum land area requirements for parking alone that a SUPER CLINIC plus staff doctors nurses and allied health needs.

    If the purchase cost fees conveyancing GSTand local taxes etc is less than $5 million for the land alone I would be most surprised. That leaves at maximum( minus the retained grant) a $ 5 million available to boild the practice clinc out fit it and supply all the equipment.

    Frankly the money for building the clinic will be about the same as a quality home in an affluent inner city suburb.

    If I were a failed bidder for one of the controversial Bids for SUPER CLINICS in Western Austrailia I would be thanking my lucky stars that I wasn’t committed to produce the albatross I would have gained. I feel that the following is broadly true. Localy owned and driven practices who drive their own agenda to improve health and access do it very well. Governments of any shade who try to impose agendas from the top down fail.

    The only way these clinics would work is in areas with high density populations, such as capital cities; these are no sinecure for the bush where help is generally despirately required. I cannot see that these clinics will cater for the most diffficult patients with complex needs which is going to be tough for our indigenous population and patients in nursing homes. These populations have more pathology in them but recieve little care. Julian Tudor-Heart’s inverse care law is once again revalidated

    I will continue to avidly follow the governments policy and believe it’s mantra,but only out of curiosity. I am fascinated by what they might come up with next, which is why I will follow then everywhere. I HAVE ALWAYS BEEN VERY CURIOUS.

  8. Doctor Whom says:

    Innominate – Funny you should mention it. I was going to say before that $1m wouldn’t even provide for the carpark needed let alone the land, building or staff. But I thought people might think I was being hyperbolic rather than business like. But it’s true – the car park for a decent clinic would cost more to pave and mark and fence off than $1m.

    I don’t think all the Superclinics are doomed by any means . Some have been granted around $2.5m – $5m and if they are a consortium of GPs,existing community health providers, Division and say Uni and Hospital then the chances of success are high.

    From memory some in SA have been granted around $7m to $13m clearly a different kickstart than $1m.

  9. Innominate says:

    Doctor Whom, My friend

    I agree a car park would cost more tha $1 million to build. It will cost more to buy adequate land, My concern is this. The figures don’t add up. Unless land is donated or on a peppercorn rent the cost in urban areas to purchase or rent the land at commercials rates .

    Fortunately our rural colleagues do not have this problem and it seems that Gunnedah has engaged and energised its local population to raise additional funds that they will most certainly need. I am impressed and pleased that the local population has worked with doctors and other health professionals to hopefully produce a community owned and operated Clinic I am absolutely sure the local coucil will have been most helpful that fees and taxes may have been waived. Local business will have stepped in to provide cheap or free labour. Rural people know that if the Doctor goes the Bank goes and the dentist and the other businesses stuggle as the population declines. Ensuring a good multi-disciplinary practice is great with in its town virtually ensures that they will suck in patients and residents to that town. Fabulous. Bush people finally getting the service they deserve. And a community that prooves it is a succces.

    Great News Great headlines Fabulous opportunities for photo ops for local Politicians even federl leaders. A real success story. 24 hour care and almost hospital grade facilities and what is more built and owned by the community.

    W

  10. Innominate says:

    OOPS

    Cut myself off. Never been a good typist.

    The W when I cut myself off is: What is the down side? How can there possibly be a downside? This is a dream solution. Isn’t it?

    Except for the nearby towns Burburgate, Orange Grove, Meermaul, and Mary’s Mount. I don’t know if there are GP practices there. There may be none. Even so there will be other Doctor’s practices in the area that they have built and paid for with their own money and labour and 24 hour commitment who now see their investment become worthless and their income non existant.

    Patients flock to the SUPERCLINIC that they helped build with their own money or labour or free goods. Fantastic.

    Don’t believe me?

    Take this example of a practice that I worked in open on Sunday mornings. Never a big profit maker but a service to our patients and helped achieve certain PIP standards. Typical Day: 22 patients at $50. $ 500 to pay staff overtime rent electricity etc $ 600 to pay the Doctor. Profit zero but got extra payments via PIP
    so broke even no loss and made practice more attractive to patients. Also kept some patients out of Emergency Departments.

    Now a local Bulk billing SUPERCLINIC opens and has extended hours and was built by the local community and is totally awesome. Let’s pretend the loss of patient numbers is only 10% , two patients . Staff costs are the same $ 500 Pay to GP declines to $ 540 ( about which he/she is delighted). Net loss $ 60 per day and a disgruntled GP.

    Please remember that a company being it a massive bank or small GP practice is required by law to declare itself bankrupt/insolvent and cease trading if it makes a loss. (yes I know about the exeptions),

    End result closed sunday. Lost PIP payment for extended hours and so closed saturday afternoons and after 6 pm on weekdays when used to be open till 8pm.
    Not an increase of availability and access. However the SUPERCLINIC will mop up the extras if, of course, they aren’t old,really ill, or crippled or have no transport/money. The Supeclinic will show increasing numbers of patients each year and of course publish surveys of customer satisfaction and ringing endorsements.

    Eg “My Doctor closed his practice on Sunday so I had to come to the SUPERCLINIC with my child who had tonsillitis caused by the Epstein-Barr virus and the nurse checked with the doctor and gave him Amoxil which cured him but he got this rash which is ok said the Nurse “cos now we know he is allergic to penicillin”. Any way they were really great, and spent half an hour checking him for other allergies and we don’t eat nuts or dairy but he did break his arm playing footy later and the Doctor said his bones were weak.”

    Doctors who read this know that Epstein-Barr virus isn’t cured by antibiotics as it is a virus . 70 % of patients with EBV get a rash which is quite characteristic,if they are treated with amoxil and this is not an allergy but it will remain with him for life in his records. Finally the dairy allergy leads to not drinking milk or eating calcium rich foods so he becomes osteoporotic and more prone to fractures.
    And the weekend practice at their local GP who knew them well. Was shut. And is less profitable. And can’t get staff. And closes, but, by God, we were lucky and had the foresight to build a SUPERCLINIC in case this happened.
    It is sure to be great.

    Never underestimate the numbers of quite intellegent people who have ears but are hard of hearing. Never underestimate the number of people proud of their intellect who are hard of thinking.
    I could go on and introduce exmples from Germany in the forties Russia in the fifties and more recently in the UK. I have had enough of waxing lyrical, or is that waxing cynical?

    What happens will happen and I reckon personally I am going to be free of government influence for at least three and more probably 6-8years. and even in ten years time the “Tsunami” of new GPs will be a trickle for what is needed in an aging population.

    Explanations and analysis may help guide government but I feel this government has made up it’s mind already.

    I will be pleased as punch if a local SUPERCLINIC provides and excellent service but I will still take my children to see our usual GP.

    Thank you for bearing with my ranting

    Innominate

  11. fith says:

    A quick look at the supa clinic locations shows that in urban areas they heavily in bulk-billing country. The clinics will be barely viable with regular consults so I just pity the poor docs who work there being forced to do care plan after care plan to refer patients to the co-located allied health (so called vertical integration). Even a 6 doctor practice in one of Australia’s richest areas running full steam only grosses $2 million a year before expenses. The local Supa Cheap Auto does much better than that.

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