Over the past few months the ACT Government and our local Medicare Local have made several press releases stating that the GP shortage in Canberra is over. That may be true for the large semi-government and corporate clinics but the constant stream of smaller stream of small two to three doctor clinics closing down shows the other side of the story.
This is our story:
Seven years ago my wife and I decided to open our own clinic – we chose an area close to our home that had also been devoid of any GPs for many years. Within a year our workload was so heavy that we had to close our books. At that stage we were leasing a portion of a suburban office building and the remaining part of the building was standing vacant. We approached a Recruitment agency, the same one who brought us to Australia in 2000, and asked them to find us a suitable candidate. A few months later a miracle seemed to happen – a perfect candidate was found. She was well qualified, well experienced and keen to migrate to Australia from South Africa. This was followed by a year of immense stress – we purchased our building, did an extensive fit-out and fought a running battle with the ACT Medical Board to get her registered – the goalposts were shifting all the time. Finally we managed to get to the stage where we had her working at the clinic – $ 50,000 later in regards to her recruitment and seven figures later in regards to getting the infrastructure in place – all borrowed from the Bank.
Things could only get better – our new doctor did her FRACGP in record time and my wife and I were looking forward to actually having a break and seeing our debts dwindle & disappear. This was not to be – shortly after receiving permanent residence our recruit gave us notice that she was reducing her hours to less than a session a week. No explanation was given (it certainly was not money as she was taking home more on her own than my wife and I were taking home combined). We thought about legal avenues but in the end this would have been a senseless exercise so we just swallowed our pride and tried to salvage what we could. We were back to it being essentially a one family practice but with hugely increased overheads and debts. To make things worse we now had all the patients that started to see our Recruit to deal with as well and once again our books were closed for new patients.
It was obvious that we would still need another fulltimer if we wanted this business (and our health) to survive. We therefore started advertising – our advertising was specifically targeted at Vocationally Registered candidates as this is obviously the ideal situation (see below).
We placed colorful (i.e expensive) adverts on-line, in printed media and hoped for the best – 3 years went by and the only responses were from people in obscure overseas locations who were not eligible to work in Australia. Even though our adverts showed the practice facilities in details, but did not stipulate income and hours, no Australian Vocationally Registered General Practitioner expressed any serious interest in the position.
Early on, even before we had recruited the doctor from South Africa, we approached the local regional training consortium to see if we could get a Registrar. For the first few years they would not give us the time of the day – we were simply ignored and when we queried this we were told that they had Practices with unfilled positions and to go away. After they publicly announced that Practices could send an expression of interest in we though we had a chance – we applied only to be told that we had to teach ANU medical students for at least a year before they would consider talking to us – the fact that we had been a rural teaching practice in South Australia for three years before moving to Canberra was deemed insufficient. Even though we were already working 10 to 12 hour days we decided to get the students on board – the fact that we love teaching and that the students love our Practice made that an easy choice.
This year we again approached the Training Consortium to see if they would consider accrediting us for a Registrar Position. During the negotiations with them it became very clear that we would be allocated a very Basic Registrar and that one of the requirements would be that we would have to dedicate a full session each week just to teaching. It was clearly stipulated that this teaching would have to happen during normal business hours and could not happen after hours or on weekends. This seemed an impossibility in a Practice where the wait for routine appointments was anything between 4 to 6 weeks so we pulled out of the process.
This left us with the option of trying to recruit a GP – the whole process of doing this can be a jungle and as I understand it the are currently several options for a Practice such as ours – what follows is how I understand things and may not be 100% correct:
The first option, and the ideal one, is to find a fully qualified Vocationally Registered doctor who is an Australian permanent resident or Citizen. This person would simply apply for a Medicare Provider Number and three weeks later start working. Their work would be rebated by Medicare at the same level as ours and we would be cruising
The second option would involve the processes that we went through with our last Recruit and in fact is what my wife and I went through 14 years ago. The successful candidate would be an overseas doctor whose GP experience would be sufficient for the Medical Board and the RACGP/ACRRM to feel that they could apply for a limited registration as a General Practitioner.In addition the Practice would also need to obtain a District of Workforce Shortage Status from the Commonwealth and Area of Need Status form ACT Health
With this information they could then be sponsored by us to come to Australia on a 457 visa and once approved they can apply for a 19AB exemption that will enable them to get a Provider Number to access rebates for their patients from Medicare. These rebates are however the so-called Non-vocationally registered rebates (more about that later) and they would need to pass the FRACGP or FACRRM examination process before they became Vocationally Registered and could access the higher rebates that we access. Their 19AB exemption allows them to have a location specific Medicare Provider Number – this restricts their location from which they can access Medicare services for a decade – after that they have the same unlimited access as an Australian Graduate.
A third option would involve an overseas doctor whose overseas qualifications have not been assessed as being sufficient to work as a GP. These doctors arrive here with a variety of different visas but, very importantly, are not Citizens or Permanent Residents. They have one of two options:
the first option is to apply to sit the written part of the Australian Medical Council’s exam. Once they have passed this they may or may not be able to work in some fashion within a hospital system under supervision while waiting, often for years, to get a turn at doing the clinical AMC exam. Once they have passed this they can apply to enter the GP Registrar training program (three years) and then sit the FRACGP/FACRRM exams. They would also be subject to the 19AB exemption.
A second option is to sit the written AMC component and, if the RACGP’s assessment of the overseas GP experience is favorable, find a Practice with DWS and AON status who would offer the candidate a position. The candidate can then apply to sit a clinical exam run by ACRRM known as a PESCI. If they pass this exam they can apply for a limited registration with the medical board. APHRA considers the level of skills of these candidates at Intern level yet allow them to work as GPs with limited registration (A bit of an anomaly IMHO and a medicolegal risk to the Practice). They would be able to apply for a 19AB exemption and would usually be able to apply to sit the FRACGP/FACRRM after a year or more. We have had a few candidates from exotic locations such as Somalia and Egypt approach us but in most cases we would have to also sponsor their immigration and we have understandably been a bit reluctant – once bitten, twice shy.
A final group of doctors is a large cohort of doctors who qualified overseas but are already Australian Citizens or Permanent Residents on the basis of their Spouses or some other relative being here. Through some bizarre legislation these doctors are mostly prohibited from accessing any way of registering as doctors and accessing a Medicare Provider number. They are subject to the 19AA restriction of the Healthcare Act and only a tiny portion of this group will ever be able to resume working as a doctor under one of the s-called 3GA exemption schemes. We are currently attempting to get a Sri Lancan doctor with extensive GP experience through this process. She is already residing in Canberra but the odds of us achieving a positive outcome are not looking good.
I feel it would be worthwhile explaining the concept of Vocational Registration. Most patients understand that Medicare provides a rebate that enables a patient to recover some or all of the cost of a visit to a doctor. Around 1994 it was decided that GPs needed to have a formal post-graduate qualification – at that stage the FRACGP, now also FACRRM. Doctors who had one of these qualifications, or who were grandfathered onto the system, became known as Vocationally Registered GPs.
Medicare indexes their rebates every year. This is supposed to keep track with the CPI (the fact that it does not is a story for another day) but in their wisdom Medicare has decided that non-VR doctors are not fully qualified and hence their rebates are not indexed at all. This lead to a very challenging problem for Practices who have non-VR doctors as employees or as contractors who work for a percentage of their income.
The impact at our clinic is best explained comparing a patient who sees a VR doctor and a non-VR doctor – lets assume they initially sees each of these doctors for 15min. Our standard fee is $ 75 for such a consult – if the patient had seen a VR doctor they would be able to claim the standard VR (5-20min)consult rebate of about $35 back. If they have however seen the non-VR GP the rebate is only $ 21.
Next scene – patient banging on front desk and abusing Reception staff
But wait, the plot thickens – what happens if that consult spins out to 24minutes. Our standard fee for a longer consult is $ 110. If the patient saw the VR doctor they would be entitled to a rebate for a longer consult which is about $ 69. The Medicare rebate for a non-VR GP’s standard consult is however, for a mysterious and bizarre reason, deemed to be up to 25min hence the punter would still only get $ 21 back if they saw the non-VR GP.
Next scene – both fists being banged on the front desk and staff on stress leave.
I wish I knew why the VR doctors are not interested in working in Canberra as I would love to be able to avoid all of the drama as described. the facts of life are that I am left trying to negotiate the Red Tape and hopefully find a suitable candidate before everything implodes