Practising sustainable healthcare cannot be limited to change undertaken by individual clinicians or isolated healthcare services. A lasting and substantial change to the fundamentals of the system needs to be undertaken, one which prioritises the provision of preventative care.

Preventative care has been shown to be both economically and environmentally sustainable, and investment in prevention and early intervention has been cited by the Royal Australasian College of Physicians (RACP) as a major recommendation to protect Australians and the healthcare system from climate change.^1,2,3 Changes to social and economic determinants of health are what will fundamentally alter health outcomes and are at the heart of preventative health measures, however general practice is a major site for the delivery of preventative medicine.

Our colleagues’ critical function in the delivery of preventative medicine is multifaceted, including disease prevention (such as vaccination programs), early disease diagnosis (secondary screening), and treatment of chronic disease to limit interactions with inpatient services.

It is indisputable that our GPs are tasked with an increasingly complex and, at times, emotionally taxing job, and the demand for their services is only growing with an ageing population, cost of living crisis, and rising specialist fees.⁴

General practice has been underfunded for decades, with Medicare indexation having been woefully below annual changes in the Consumer Price Index (CPI) or frozen altogether. The Australian Medical Association (AMA) estimated in 2023 that the freeze from 2013 to 2018 alone had resulted in a loss of $3.8 billion from general practice.⁵ Alongside the widespread defunding of primary medicine, the growth of GPs has occurred inversely to the areas of greatest need – regional and remote communities.⁶

The fee for service model incentivises quick “six-minute” medicine over preventative care and that which reduces preventable hospital admissions.⁷ This model also promulgates the inverse care law – GPs are being forced to choose between providing quality care with a co-payment or shorter and fragmented care that is bulk billed, and it is communities that cannot afford the former, and also happen to bear the greater burden of chronic disease, who suffer.⁸

Our current culture in medicine is also one which devalues the role of GPs with a tacit labelling of reduced professional and clinical status. The effects of their under-prioritisation is evident with one third of GPs reporting burnout and the same proportion indicating an intention to stop practising within the next five years.^9,10 Meanwhile, the Special Commission of Inquiry into Healthcare Funding in New South Wales, whilst acknowledging the “fragmented” funding arrangements between the states and the Commonwealth, has pointed out the “greater desire for ephemeral aspiration than actually funding something that is aimed at ‘prevention and wellbeing,’ ensuring that it is done, and analysing the outcomes.”¹¹

Efforts have been made to reform the system. The tripled bulk billing incentives and Bulk Billing Practice Incentive Program (BBPIP) have improved rates of bulk billing most significantly in non-metropolitan areas.^12,13 However, the target group, mixed billing doctors who lie somewhere between being able to afford the reduced income to those who financially benefit from taking up the incentive, are faced with two choices – to continue their current length of consultations, acknowledging that Medicare benefits have a woeful history of keeping up with inflation and this gain is likely to be very quickly eroded; or make the change to shorter consultations with reduced opportunity to provide complex care, potentially undermining their communities’ health outcomes.

Both initiatives substantially benefit large, corporate owned GP clinics which provide the majority of their care through short appointments and were already bulk billing. What they do not incentivise is the provision of preventative care which often requires longer consultation times. Whether the Medicare fee for service model is even the best way to fund healthcare on a population level should also be up for a debate – preventative care is simply not prioritised, and the most recent incentives clearly do not pay this concept much notice.¹⁴

Despite its flaws, Australia’s public healthcare system and (near) universality of access is something to be commended. These gains, however, were hard fought and won. The first nationwide general strike in Australia’s history occurred in 1976, with 1.6 million of Australia’s 5.7 million workforce striking to prevent the dismantling of the Medibank scheme.¹⁵ Medicare as we know it was born out of the Prices and Incomes Accord, negotiated by the Australian Council of Trade Unions, much to the chagrin of the Australian Medical Association who tirelessly struggled to sabotage the initial development and rollout of a universal healthcare system.¹⁶

The erosion of our claim to “universal healthcare” is something which must be grappled with in solidarity with our GP colleagues. They and their patients deserve the opportunity to provide best care and to be adequately supported to do so. I urge us all to be more informed, critical, and political, both within and outside of electoral politics. We need to advocate for and show solidarity with our colleagues, especially when they are being targeted by politicians and the public for making the difficult decision to privately bill in a system which gives a financial disincentive to the provision of quality care.^17,18

Ideally, collective action will one day achieve material benefits for our GP colleagues comparable to specialists, but on an individual level, we need to consider how we can best support and learn from our colleagues despite the universally exasperating experience which is working in healthcare. That the care GPs provide is economically and environmentally sustainable is just the icing on top – the care we provide as specialists in women’s health is enhanced and dependent on the work they do.