A little introspection goes a long way

Let's meet our 2 Drs from a previous blog again - SM & GT. This time they're joined by a third: HS.

SM is a GP.
HS is a hospitalist.
GT is still thinking!

Consider the cost of seeing a patient by the first 2. As a GP, SM is based in the community. Patients come to see him and he has access to unreferred patients (a big plus compared to HS).

Contractors (SM is one) typically pay the surgery owner somewhere between 25-35% of their billings to see patients. I'm told the owners in turn only make about 10-15% profit on that.
So, in order for a fully qualified, board certified specialist to see a patient in the community, he or she has to spend somewhere in the vicinity of 25% of their fee just to enable that visit. In other words, General Practice is a small business and the cost of running the service is borne by the professionals themselves.

Now consider our colleague HS. He sees patients in the hospital. Who bears the cost of facilitating that encounter? Why, us ofcourse! As tax payers.See here for typical costs incurred at hospitals
Hospitals are federally funded and essentially are a service run by the Govt.
No pretext of making profits here (not to be confused with savings). Now, you might say hospital tariffs are fixed whereas GPs can and do charge what they like.

True, but the principal difference in funding stands.
Equally, market forces rule and we know greater than 90% GP visits are Bulk Billed.

Having analysed the above, what option do you think GT went for?
Is there a 3rd way?
Food for thought dear readers

Happy New Year to you all.

Gaurav

Playing the Numbers

Lets talk about 2 Drs - GT and SM.

GT is an independent contractor. He works in a surgery and pays them 35% in Management Fee.

SM is also an Independent Contractor, but the way his contract is written, his Management Company pays him 65%.

Both work 46 weeks a year

GT's gross billings are $414K and SM's are $506K per annum


Therefore, GT would pay his management company 35% of 414K = 144.9K. Add 10%GST =159.39K
In bank = 260.61

SM's management pays him 65% plus 10% GST. So he gets (506*0.65)*1.1 = 361.79

So, >100K difference pa.

Quite a big difference in the amount each gets into their bank accounts. But, Medical Services are GST exempt. So, SM will pay back all the GST he is getting each quarter with his BAS and GT will reclaim it back. Therefore, actual earnings for them are 269.1K and 328.9K (65% of their gross billings)

Real difference is more like 60K. Lets call these figures 'A'

Both GT and SM have other deductible expenses (accountancy fees, indemnity, professional memberships, CPD events, equipment etc). These are usually fixed costs and not percentage based. Say 20k each.

To round things off lets say GT's pretax income is 250K and SM's is 310K. Let's call these figures 'B'

Now, lets look at taxation. If you put these figures into the ATO tax calculator here, you'll see that GT will pay roughly 86K in tax. This will yield him a post tax income of 164K. This is roughly 65% of B or 35% tax.
But does SM get to take home 65%  of the excess income in B? Again using the same calculator, we see that SM pays 113K in tax. Therefore take home = 197K. 
So, the 60K extra in B translates to only 33K post tax, or roughly half of the difference in B, not 65%. If you work this back all the way to the first figures or the Gross Billing, you'll see that a difference in earning of 92K (506-414) has been whittled down to just 33K or roughly 1/3rd!!

This happens because up to about 240K per annum, based on the tax slabs we are able to retain about 65% of income. But anything higher is taxed at the highest rate (currently 47%). The highest tax bracket starts at 180K but there are allowances and deductions one can make.I am unable to give an exact figure where the tide begins to turn, because that depends on many variables like number of dependents, residency status and the deductibles one may have. I have used 240K as a theoretical top end and worked the 414K and 506K backwards from these figures. I believe these to be realistic.

So, the point of this whole exercise or the lessons I learnt from this are as follows:

1) Firstly, as an Independent Contractor we are basically selling our skills and this is the single most sellable item we have, i.e we can almost certainly make the most money possible by simply plying our trade. Generating $165K per annum in post tax profit from a business isn't easy. This should be borne in mind by those hoping to open their own surgeries. 

2) There is no point flogging this horse beyond a certain point. After a certain threshold, for every hour you work, you only get 20 mins worth of extra income.

Up to about 240K pre-tax income, you get to keep $1 for every $1.50. Beyind that, if you want to earn an extra dollar to spend, you'll have to earn $2 in pre-tax. How much gross billings that translates to depends on the percentage fee you pay management.

3) The most important factor is lifetime income. Now look at GT's and SM's incomes again - GT can make up the difference of 33K (difference between his and SM's post tax pay) if he works 2.5 months or 10 weeks extra compared to SM. 
You might say that that is a silly suggestion - why work more?

But, if I were a betting man I'd say the chances of GT being able to work without burnout are so much higher than that of SM. If SM is off for even 10 weeks due to stress or burnout, he will have lost out an entire years' worth of extra income. I'd bet on GT! That is the second reason I've used the 400K gross billing figure. This I think is a good figure for a GP who is on the top of his game to earn working comfortably within his or her boundaries. If you're lower than this (working less hrs for example) then it makes sense to maximise income by working more (if that's what you want)

Now, instead of income or money, you could transpose the figures into other useful numbers- call them number of hours worked per week or weeks per year or patients/hour and the same principle holds.

Lastly, if you work the numbers backwards, there is actually a plus to this. So, going from gross billings to post tax income, we notice that  92K extra in billings only translated to 33K extra take home income. But, reverse that- 33K drop in income frees up working time required to generate 92K worth of billing. 1 hrs worth of wage loss frees up 3 hrs of time.

Isn't that great? If you take  3 weeks extra  holiday, you'll only lose 1 week's worth of post tax pay.
If you currently work 33 hrs (32 is very common) and find yourself taking work home or struggling to cope with blood results, letters etc., then giving yourself 1 hr per week of dedicated paperwork time, which is a 3% drop in working hours will only yield a 1% drop in income! That might just enable you to spend more time with your kids at home, get home on time each day or enjoy your weekends.

Actually, it might even make you more productive and not drop your income at all.

So, my message to all of you out there is this: look after yourselves and think long term. You owe it yourself and to your families.

Best wishes,
Gaurav

A Very Brief History of Time

Very early in my blogs I wrote about FFS (Fee for Service) vs Capitation especially comparing Australia as a model of FFS and UK as a wholly capitation based system where provision of GP services are concerned. That post and my blog in general look at this issue from a provision of service perspective- the advantages and disadvantages of one system compared to the other on a day to day level.

I would now, however, like to examine this from a completely different angle. A contractual angle. To examine the nuts and bolts of the contract(s) that underpin either system. This is very topical as Australia is now embarking on a self confessed "biggest shakeup of GP Funding". We are going to be adopting a Medical Home model and this will introduce Aussie GPs to capitation, albeit in what is being described as a 'blended system' comprising of FFS+Capitation.

For those unfamiliar with the NHS GP contract, here is a wikipedia entry on the same. I'm not sure it's entirely accurate on some assumptions it makes, but the timeline of the various changes is accurate. Have a read here.

I left the UK 2 years ago. I was a partner in a Practice. Let's examine this from a contractual perspective based on the timeline above.

I was a partner in a practice with a list size of 4200 patients. I was working Full Time (FT) by doing 9 clinical sessions a week. My partner, a female was doing 6 sessions. Remaining 3 sessions were covered by a salaried GP or long term locums. So a practice with 2 WTE Drs.

Imagine this happened in 1946. No problem for anyone concerned. Coventry would have lost a GP and the remaining GPs would have had more patients to see. As all patients paid a private fee, they would decide whom they would see. Logically many would want to see my partner as she happens to work out of the same building. My partner may have got busier (and richer) or could have carried on as usual and not taken on any new patients. There would of course have been no 'salaried' GP back then.

Between 1948-2004, the patients I was actively seeing before my departure would have been capitated to me. Since the capitation payment came from the Govt and not the patients, the patients and their notes (NB- the notes belong to the Govt, not the Dr) could be traded and bartered - by the govt and the remaining partner in my practice.
The Govt through its various Avatars during this period would have 'sold' this enbloc to another GP. My partner, could have advertised for a new partnership (in the building and as a trading partner) and the Govt would most likely hand the patients to whoever would choose to take the partnership. This encouraged the partnership model of General Practice. If my practice chose not to, or failed to find a new partner, the patients would be sent elsewhere, i.e no partner, no patients.
Remaining partner would have still got her own patients, but would now have higher overheads (building and staff etc).

2004 onwards however, the situation changed drastically. All the patients registered at my practice, were now registered to the practice and not the individual drs!.

This change had a profound and deeply detrimental effect on General Practice in UK. Yet, this was also the turning point for many GPs, especially single handed GPs (solo GPs with no partners). This contract allowed GPs to opt out of Out of Hours services. So, solo GPs who, believe it or not,were technically on call 24/7 throughout their working lives, were now working 8:30- 6:30pm, 5 days a week for very little drop in the capitation payments they received. This massively improved the profile of the job and profession and numbers of applicants skyrocketed. At the same time the Govt introduced something called QOF, a value added optional service, if you like. Extra payments were made to those who signed up. Everyone did, and soon QOF payments were contributing 20-25% of a surgery's gross income. So, why was this a bad thing?

Simply because it killed off partnerships. Practices had no incentive to take on partners- they could keep the patients, regardless of how many partners they had as long as they provided the services they were contractually required to. So, upon my departure in 2004, the remaining partner in the practice would have simply taken on a salaried Dr and her profit share from the surgery would have gone up dramatically. In a small practice, as a 0.7 WTE she might have opted to get a new partner as she would have struggled with the non clinical work. But, in a larger practice it became common to replace retiring partners with salaried Drs or even Nurses. ANPs, physician assistants etc all became ways for a practice to increase their profitability. So, partners got richer and partnerships became rarer.
As long as the profession was desirable and there was a steady supply of Drs and other staff, this wasn't necessarily a problem. But, it opened the gates for corporates to step in (no GP principal required to attract a capitated patient base). The Super Surgery had arrived. Owners weren't necessarily corporates; many GPs were on the hunt too.

The patients, too were starting to get  a raw deal. Imagine my practice. I leave. Remaining partner chooses to replace me with a mix of a Nurse and a salaried GP. Patients have poorer access to a Dr but the remaining partner is now earning more than she ever did. Or there is a succession of locums covering for my absence.

But, this goose did not lay golden eggs for long. Govt got it horribly wrong with QOF. They ended up paying a lot more than they anticipated. So, they froze the 'global sum'. Then, they made the QOF payments harder and harder to achieve. Since, practices owned the patients rather than individual Drs the Govt introduced more and more complicated contractual levers to monitor the practice.  Mystery shoppers, patient panels, compliance to various regulatory standards and bodies (each accompanied by a hefty fee) became the norm. Partnerships became less attractive and partners even if they earned more, were an increasingly harried lot.

Then came Andrew Lansley's White paper in 2010. This laid bare the fallacy of accepting the new contract in 2004. Since Drs no longer owned the patients, the market could be opened to "any willing provider". Clinical commissioning was the latest craze - Darzi Centres, Virgin Helath etc etc all got into the game. Recruitment and retrenchment became real issues in many parts of UK.

Compared to 2004, where my departure could have a blessing in disguise to the remaining partner, imagine I left after 2010 like I did.

Now, the remaining partner, even though she is only a 0.7 WTE Dr has to ensure adequate services are provided to all patients registered at the practice. So, a 0.7 WTE Dr shoulders responsibility for a patient list intended for 2 WTE Drs.
If she can't recruit a new partner to share the increasingly onerous contractual, non-clinical work, tough luck. If she can't find a salaried GP or even locums, tough! She is now legally, morally and more importantly contractually bound to provide these services. Even closing your list requires approval from the powers that be. Locums want and get higher rates. The partner is haemorrhaging money and tied up in keeping the practice running. Seeing patients is almost a distraction. Many partners emigrate or take early retirement. Some hand in their contracts. General Practice in UK is imploding. Is anyone surprised?

So, where on the timeline described above, do you think General Practice in Australia is now?
Is is gonna be boom or bust? Or is it going to a 'blend' of the two?

Think long and hard my friends

Gaurav

Let's get graphical

As doctors and indeed human beings we are often flummoxed by that most imponderable of imponderables- human nature.

Human beings by their very nature are unpredictable. So, how does one plan a business model or services that caters to Human beings and more so with their health. Lot of people have made stabs at this. There is veritable treasure trove of information available on  variation in patient numbers, peak periods, seasons, the effects of charging for services etc.

Yet, I find that no one in my practice can reliably predict what will happen to the workload during school holidays, for example. Surely, given a stable demographic and years of trading in the same spot, we should be able to say that demand will go up or down and how many Drs we should need to match it. But, never happens. We can have very quiet days and then 1 day can be extremely busy.

So, I thought perhaps Drs are not the best people to be analysing this. We are, in the thick of it and may lack the objectivity or indeed even the skills to analyse this.

At this time I came across a blog by esteemed marketing guru Nirmalya Kumar. I suggest you read this before going any further - it shouldn't take more than 5 mins:
https://nirmalyakumar.com/2016/08/07/pricing-why-make-things-worse

I would urge you to ignore the buzz phrase 'make things worse'. He is talking of products in his blog whereas we are talking about services and no one is suggesting we provide medical services that are deliberately inferior.

To stop you from having to go back and forth to the blog I'll reprint the 2 relevant graphs from the blog here

So, what is the relevance to us as General Practitioners?

I'll tackle this on 2 fronts- one at an independent Dr level and second at a Practice Level from an organisational, marketing, provision of service perspective.

As a GP wherever you are working now look at graph 1. The blue box represents your workload or income. What can you do to increase it- if that's what you wanted to do? 

In my experience, most cannot look beyond graph 1. The only way on that graph to increase your income is to shift the red line to the right, i.e provide more services, work more and thereby increase the size of the blue box. This might work on pure numbers but is it the most cost effective and efficient way to do things? 

Numerous studies link burnout to overwork exist and we as Drs are always advising patients on the value of work- life balance. Costs, go up too. If you work 6 days instead of 5, commuting costs are up. The medical indemnity may increase too. There are various clinical implications too. Will you have enough time to review results, follow up on hospital letters, telephone calls etc. if you are seeing patients all day long?

So, look instead to graph 2.  No matter where you work and how good you are, there will always be consumer surplus and deadweight loss. This is true even if you bulk bill all your services, i.e services are free to the patient. 

How can there be a consumer surplus if services are free? Well, we all have patients whom we refer to specialists for things like annual skin checks to dermatologists, for heart checks to cardiologists etc. These patients can and do pay to see the specialist, so clearly the capacity to pay more, the definition of consumer surplus exists, even in deprived areas. Apart from that there is always demand for cosmetic work. Patients who demand they be bulk billed at every consultation will willingly pay for botox injections!

And deadweight loss? If everything you provide is free, how can you go any lower to attract the deadweight loss? A product can be made cheaper, but how can you make a service cheaper than free? A bit of lateral thinking and you will realise that there is unmet demand for free services, which we routinely ignore. Isn't there a demand for Home Visits or visits to Nursing Homes? For opening at weekends or early mornings/late evenings?

So, if your income is the blue box in graph 1, I suggest rather than expanding that and making it bigger, a bettter option would be to tap a little bit into the consumer surplus and a bit into the deadweight. This always requires some planning and time management. The patients in box p1q1 in graph 2 for example may require more time during their appointments. They may even expect a different, posher, quieter environment. Would you have your botox injections next to the nurse's room where screaming children are having their vaccinations? Unlikely. So, a dedicated day or slot to cater to these patients when the nurse is off would be suitable. The waiting room will be quieter and the receptionists better able to handle any queries.

Opening weekends or unsocial hrs to attract the deadweight is another option. This can be done in hours too. If you are busy and there is waiting list to see you, you could dedicate a few hours a week to a walk in clinic. Patients can see you without an appointment in this clinic for simple problems like script renewals or BP checks. This will stop them from going to another Dr. If you are privately billing consults, you could Bulk Bill this clinic to capture the deadweight. So, the bigger your p1q1 portion, the less onerous your workload will be. To me this is a continuum. You start at the right early in your career at graph p2q2 and move left. Most people unfortunately get stuck in the middle portion and rarely move to the left most portion of the graph. Towards retirement, many practice exclusively in a pattern that mimics the left most portion, but they tend to be using a thinner slice of the main pq box - seeing more complex patients, spending more time with each patient and working less. They haven't truly moved to the p1q1 portion either.

So, approaching this at a practice level. From the above, it is clear what I would suggest. Rather than concentrating on making the main pq box bigger, practices should look to moving from graph 1 to 2.

Expanding the size of graph 1 is fraught with problems. You need to either work your Drs harder- work more days, longer hours or see more patients in the allocated hours. Drs are perhaps the most difficult people to work with. The more you have, the problems you face. More Drs means more support staff required. What happens if a Dr leaves or goes off sick. You now have support staff but no one generating income to support them. What happens if another centre opens up and your deadweight patients move to them. They may do so just because of shorter waiting times for example. 

In my experience, especially in Metros and outer metros of Australia there is cut throat competition in this arena. Surgeries are opening up; chasing the same market. Universal Bulk Billing (UBB) Centres are mushrooming. When services provided are free (to the end user, not to the tax payer) this also leads to what is called over servicing. A very simple example- most UBB practices I know, do not give out blood test results on the phone. So, have a blood test and then go back to get results, even if they are all normal. This is called 'churn and burn'. Pointless medical consultations purely to meet the needs of a model of service. Wouldn't it be better to charge the patient a small premium at first consult, then text them or email them to say "all ok" if results are normal? A fee of $5-$10 can easily be offset by the savings made in not traveling to and paying for transport and parking for example. This could be sold as a value added service to patients.

What of those who can't afford it? They come to your walk in clinic- simple!

The UBB model also promotes what's been described as a bums on seats model. High throughput of patients requires all drs to be present and actively seeing patients; to keeping waiting times down and to compete with other centres in the area. Hence, no one does home visits or sees patients in Nursing Homes. Some don't even do Work Cover. Continuity of care is lost and the potential for mistakes are high. Abnormal result not acted on because the patient didn't come back for a review for example.

My recommendation to anyone owning a centre is simple. Don't expand on the square pq. Go to graph 2 and look into moving into p1q1 and p2q2 instead. Employ Drs with varying skillsets and skill levels. Why would you Bulk Bill a mirena insertion for example purely because the Dr happens to work in a UBB? This service can & should attract a premium of $50-$100 minimum. 

Consultants would charge up to $300 for this. 

Remember the consumer surplus - if you don't value it, neither will the patient.

Have some Drs doing Home visits. Encourage them to do this by reducing your management fee for this service. If the Dr is out of the surgery, not using your room, electricity, receptionist etc then they pay you less management fee and thereby earn more. You gain what you might loose on management fee by expanding your patient base as opposed to trying to overservice your existing base. The latter is always unpredictable too.  It's a win- win situation. Encourage some to acquire new skills (dare I suggest even pay for courses). Having someone with an interest in dermatology performing procedures or minor surgery etc can really move you into higher margins. Bulk Billing procedures is a loss making exercise due to the complexities of Medicare.

I have heard it said before- Drs make very poor business persons. There is a grain of truth in there.

We pride ourselves on practicing evidence based medicine (EBM). Shouldn't our business models follow evidence too?

Gaurav

Man, Incorporated

I realise now that my last post ended with the promise of a Part 2 and that was several months ago.

Well, you know what they say- time flies when you're having fun!

But, that brings me neatly to the point of this post. If you have read my previous posts, you could say that they could all be summarised thus: How to have fun. How to enjoy your working life, how to have a better work/life balance.

And, hence the pause; I was merely working on a unifying theme!

So, going back to basics. How do GPs earn money? And is there a difference between them and hospital consultants?

To my mind, in UK as an NHS GP even though we are called independent contractors, GPs are firmly tied into the health Ecosystem controlled by the Govt. Earnings may vary but the percentage spread is actually very narrow all things considered.

Working hours (core hours)  are  dictated by NHS as is prescribing & referrals. Add in the NHS pensions, retirement rules, Rent control on premises etc and you realise that you are at best a mere cog in the huge NHS wheel- toiling away and putting in your best years for the Govt Machinery.

This is true for the vast majority of people in developed countries. The carrot is Universal Health Care and good standards of living.

Contrast this with Consultants. Paradoxically, they would class themselves as NHS employees and not independent. But, most have a private practice and have much more leeway in practicing/prescribing etc atleast in their private line of work.

So, moving to Australia I have realised that this is the biggest change. I am no longer a cog in big wheel. There is no capitated patient base. There is no guaranteed income.

This could be a big pitfall. But, if you consider yourself as a GP Consultant just like an NHS Hospital Consultant, things become clearer. You can work for a 'hospital', i.e the surgery you work for (and that will earn you a steady income) but what you need to do to establish yourself is to market yourself and find your niche. Just like a hospital cardiologist for example. They all do general cardiology in hospital but in their private practice they all have special interests- one does Echos, another electrophysiology and so on.

Once, we find our groove not only in relation to our personal goals and aspirations, but also the right fit for the community we serve, we can be truly independent masters of our destinies. No one can then dictate income, retirement, working hours etc. I am still coming to grips with this and not to put too fine a point on it I consider this to be a paradigm shift in not only our thinking but ultimately in the way we practice medicine.

So, that brings me to the title of this post. If, we as GPs or Drs can choose to exercise control over our working lives in this fashion, why does it have to stop there? Is there a need to accept the convention of working your whole adult life, putting money into a pension, paying into income protection etc etc and merely existing as a 'productive unit' for someone else? Even independent contractors, like GPs in Australia are working units for the govt.

Just as we should become Consultants based in the community if we want to exercise autonomy in our working lives, we should be our own consultants for retirement planning, social security and tax planning. Do you have to put your pension fund in the country of your residence? What if you incorporated yourself as a company? Not so strange after all.

 Someone did the same back in 2013 : http://www.wired.com/2013/03/ipo-man/

What Price, Freedom?

Several things are going on in my head right now and I have the feeling I'm at the stage of realising something profound and yet simple....perhaps!

This seems like a 3 blog conundrum so I'll probably break it down in order to keep it simple.

I left UK in May 2014, having worked there as an NHS Dr for 12 years and as a GP for more than 6.

Since I left, the UK Govt has finally woken up to the workforce crisis enveloping Primary Care.

Recently, a package of measures has been announced to increase recruitment and also retention.

One of the schemes is a Golden hello and a scheme to make it easy for people like me who have left the NHS to return to the fold. I was contacted by a magazine editor for my views on this scheme as I had been quite critical of the situation before I left. The Editor asked me a simple question: "Is this package enough to tempt you back?" (Package includes a 20K Golden Hello)

My response was to actually laugh. After the interview was over, I asked myself this: What is the actual reason for my leaving? Why was I discontent there?

Was it money- I earned enough

Was it the weather- I had lived there happily for many years

If not these oft quoted reasons by everyone who leaves, what else could it be?

This is Part 1 of what I think the answer maybe. I say maybe because this amounts psychoanalysing myself!

In the end I think it boils down to Freedom, autonomy or call it what you will.

I think the GP contracts in UK are completely at odds with the concept of Autonomy.

By Freedom here I don't mean something like being able to choose your own working hours or working part time (though these are hard enough themselves). By freedom I mean clinical freedom. Freedom to practice medicine according to your skills and levels of expertise, to grow and sustain an interest in the field. When I went to India I met a friend of my sister in law. She has lived in UK and Australia and now lives in Mumbai, India. She summed it up beautifully for me. She said life in Mumbai is hard, but life in UK is a drudgery. This is exactly how I felt like working for the NHS as a GP in my last few months if not years.

Let me give you an example: I went on a Minor Surgery and Joint Injection Course organised by the RCGP and it had an exit exam which I passed. This allowed me to get a certificate which I could pass on to the Primary Care Trust (PCT) which then theoretically allowed me to carry out these procedures. I had been carrying out these procedures for more than 6 years already but the PCT demanded the piece of paper. So, what happened after I got the certificate? Well, the very procedures we were taught to do were procedures the PCT had banned under the so called LPP (Low Priority Procedures) Policy- things like lipomas, cysts etc. So, now I had the training and the certificate but no way of doing them. In UK, if you suspect a cancer you are of course explicitly forbidden from doing any biopsies/excisions etc.

So, if you see a lesion where you are not certain, you cannot utilise your skills to carry out an excision. If it is benign, and the patient wants removal, your referral to tertiary care is rejected by the Referral Management Centre as a LPP. 

If the differential diagnosis includes a cancer you have to refer the patient to the Dermatology Department under the so called Two Week Wait (TWW) Referral System.

About 2 weeks after obtaining the Certificate, I went to a skin club meeting called the Skin Forum. This was organised by the Local Hospital and had an interactive format with real patients and quizzes etc. The keynote speech was by the Dermatology Cancer Lead. He said he considered any TWW referral by GPs which subsequently turned out to be non cancer as 'inappropriate'. He then went on to show us graphs and figures of how this number was rising and literally swamping the Department with work. His proposal was to 'educate GPs'. So, in essence- if you vaguely suspect a skin cancer, you cannot biopsy or refer to a normal skin clinic. If you refer to the cancer clinic and it turns out to be non cancer you need to be educated!

I realised at this point in time that this was a farce worthy of Monty Python! 

What kind of society are we living in where highly trained professionals are first made to undergo training only to be told they can't use their training. What kind of health system discourages a physician from ruling out a sinister pathology by carrying out a simple test but then blames him for referring too many people with said suspicious lesion- surely you want a system where only a very few lesions suspected of being cancer turn out to be cancer.

You might say for something as serious as cancer, surely its right to have strict guidelines. I'd say you're right. But, then to call referrals as inappropriate?

You might think this kind of idiocy is limited to cancer only, but its not. It pervades all fields. Contrast this with Australia. You are free to biopsy any suspicious lesion. Not only do you do bunch biopsies to diagnose, once the biopsy shows say a Basal Cell Carcinoma (BCC) you are free to do an excision. If you excise you get paid. And if you achieve clearance you get paid more. Equally, at the first stage itself if you don't have the skill to do a punch biopsy, you are free to refer the patient. Or, if you do do the punch biopsy but then don't feel confident about carrying out an excision, you could refer the patient at that stage. Consequently, almost every GP surgery in Australia has a skin clinic. A colleague in my current practice is now up skilling himself and will soon be able to do complicated skin flaps- in primary care!

This is a system that a)respects the skills of its highly qualified assets and b) pays them for their time and skills.

Here, I think I can work in an environment of clinical freedom. If I have an interest in mental health I can go on courses and upon completing level 1 training obtain higher rebates. Upon obtaining Level 2 training I can start doing counselling on my patients and obtain even higher rebates, or I can choose to refer them. Contrast that with UK- the minor surgery certificate allowed me to do what? If I did carry out more excisions, I'd pay higher Indemnity, probably get sued more often and the PCT and local hospital wouldn't support me if even 1 of my biopsies was reported as a BCC or god forbid an SCC. I'd be up the creek without a paddle! So why would I want to waste my time going on courses? Such a system can only breed mediocrity. And I didn't become a Dr to be mediocre. Time and again in meetings we were told to target the mean- in prescribing, in referral rates,investigation rates etc. Not once were we asked to emulate a practice that spent more  on prescribing for diabetics for example, but achieved better outcomes. The target was always the average. In Medicine you want to target excellence not mediocrity. This is lost on the current NHS management. 

So, that's why I left the NHS and UK- I think! I want to excel. Excel in a few things maybe, but not to be mediocre in everything.

And that concludes Part 1.

What's in Part 2? Even I am not sure. But, I think I see some dark clouds here in Oz too. More on this in my next.

Blog From The Future

10/01/2018 Extract from report published in General Practitioner:

Alarming shortage of GPs- an analysis by RACGP

In 2015 the ToeKnee Abbutt Govt introduced what it called Medicare Plus with much fanfare. This was a blended payment scheme to replace the Fee For Service (FFS) that had served Australians so well till then. Analysis reveals that this has had some alarming consequences on training and retaining of GPs.

As money was pored into capitation to improve health outcomes GP principals suddenly saw their incomes jump. Those on the verge of retiring decided to stay on longer. Those that did retire were replaced not by other GPs but by Nurses and other members of staff as capitation now allowed nurses to provide a source of income to practices. There are now close to 500 ECPs (extended scope practitioners) and 700 Physicians' Assistants. Newly qualified GPs were offered salaried positions only and often not very well paid ones.A large portion of medical graduates are choosing hospital specialities or emigrating.

The RACGP is calling for urgent boost in numbers of GP training posts as a work force crisis looms.....

08/04/2019: Report by Institute of Chartered Accountants

Amongst the highest paid professionals were GPs. They also bucked the national trend with a rise in income over last 5 years that was significantly higher than inflation rate.

A typical GP income is now $487,000...

02/12/2019: Mike Munro reporting from somewhere in the Yemen

Coalition forces are engaged in fierce battle with the local militia groups. As casualties mount on both sides, the demands from Australia's allies to commit ground forces intensifies. It seems only a matter of time...

12/12/2019: Shadow Health Secretary Pamela Murdoch-Andersen on the steps of Parliament

A typical Aussie soldier who lays down his life for his fellow Australians in the Sahara desert in Yemen earns less than fifty thousand dollars. Yet the ToeKnee government has seen it fit to rob Australians and plunder the health budget at the expense of our nations defence. Our troops fight with nothing more than bayonets as our greedy GPs get richer. I say NO MORE TOEKNEE! (loud cheers from the crowds)

12/12/2019: Interview of Dr Laver in his plush 188th Floor Apartment in the Emirate of Fujeirah Published in The Australian

Interviewer: Looks like you're living the dream here. Any regrets?

Dr: smiles and points to the window- You must be joking! I love it here

Interviewer: You've been here 10 months. Ever thought of going back?

Dr: No way! Why would I want to go back? No one respects what we do there. We are everyone's favourite whipping boys and the profession is in tatters. Here, we are appreciated for our skills and the salaries reflect our years of hard work and dedication. There are more than 300 Ozzie GPs here and I understand the number in the UAE is closer to the 1000 mark...

By,

Dr Itol YouSo