GPs who are dissatisfied with current or planned changes within the NHS, may find a comparison with the Australian Medicare-based system encouraging.
The Australian Medicare is often conceptualised as the ‘antipodean NHS’ but there are quite a few major philosophical and practical differences between the two systems. The biggest practical difference is in GP payments: under the Medicare system, doctors are paid per consultation, as opposed to the NHS system of capitation payments. The other major differences are:
In very broad strokes, Medicare gives more freedom both to doctors and patients. Medicare’s fee-for-service model, in particular, allows doctors to give extra care to patients as necessary, being appropriately compensated for doing so, and without then having to work longer hours to try to see the rest of the patients in their catchment. The difference in the remuneration system in Medicare compared to the NHS is the most significant structural difference, and gives both doctors and patients greater flexibility. Anecdotally, both Australian GPs and Australian patients seem to be much more satisfied with Medicare than with the NHS (certainly true if online practice reviews are anything to go by!).
Ultimately, the difference between Medicare and the NHS in practical terms comes down to respect: respect for doctors’ time and training, and respect for patient autonomy and their desire to choose their own GP.
There is a large and growing community of expat GPs in Australia, due in no small part to ongoing and increasing frustrations with the NHS. If you are interested in practising in Australia, or considering the move, you may be interested in reading some comments from some of the GPs we’ve placed over the years. We also post vacancies on this blog, for example see here for listings for current jobs in Melbourne, Sydney, Perth, and Brisbane.
For more information on the differences between the NHS and Medicare, read on.
Unlike the NHS, Medicare pays practices themselves very little, and instead pays GPs directly per patient visit, with the amount dependent on the type of service provided. The practice then takes a percentage of the GP income (usually 35%) to cover running costs. The most common “item number” (the code associated with a particular service per the Medicare Benefits Schedule, or MBS) is an Item 23: a standard 15 minute consultation. GPs may choose either to charge for consultations by “bulk-billing” or privately billing the patient. Bulk-billing involves sending the bill directly to Medicare and accepting the Medicare-determined schedule payment as the total fee for service. On the other hand, privately billing consultations involves collecting a fee from the patient, generally determined by the practice (with GP-input), with the patient collecting the Medicare contribution directly from Medicare as partial reimbursement. Currently, Medicare is paying $36.30 for an Item 23, and many practices are charging private billing patients approximately $70 for the same (figures correct as at April, 2014). There are both mixed- and bulk-billing practices in Australia.
Medicare’s fee-for-service approach encourages a more entrepreneurial approach from GPs who, on the one hand, may earn very little if they see very few patients, but who, on the other hand, may significantly increase their earnings by seeing more patients, and performing more complex services such as creating Health Plans or doing excisions. There are billing incentives attached to preventive health checks, as well as the management of chronic disease.
Conversely, the NHS system of capitation payments is quite involved and complex — one Department of Health report on the system of weighted capitation payments and the formulas for the same came in at 107 pages! In broad terms, however, the NHS pays practices according to the number of patients on their list, and the number of patients in their catchment. There is a capped amount on the number of visits for which a practice may be paid per patient per year, and most NHS GPs are on salaries, with or without incentive payments. For patients, there is no fee-for-service charge.
Because Medicare has adopted a fee-for-service model, there is no obligation for GPs to provide out of hours care, and no financial disincentives should they choose not to. Some MBS items, such as those for home and nursing-home visits, as well as visits after 8pm, do attract a higher Medicare payment rate, if GPs choose to perform them. Similarly, the overwhelming majority of patients in Australia do not expect their doctor to be available in the late evenings, or on Sundays and public holidays, although many practices do open on Saturday morning, and generally request that their doctors work on a rotating roster for those Saturday morning sessions.
Most after-hours primary care in Australia is handled by independent after-hours locum organisations whose doctors send through visit notes to the patient’s nominated primary GP after their consultation.
On the other hand, in the NHS, GPs’ salaries are calculated according to whether or not they have opted out of the provision of after-hours services. It has also been traditional in the UK, and is still the case for some GPs, that GPs are personally responsible for providing care to all patients on their list, 24 hours per day, 7 days per week, all year round. There can also be something of an expectation on the part of the public that patients’ GPs be personally available to them regardless of the day or time. Dr Eric Rose has done an excellent write-up of the history of after-hours under the NHS here, and Dr Peter Holden has responded to increasingly burdensome patient expectations of his availability and rate of pay here.
GPs in Australia are not required to see any patient they do not wish to, discriminatory practices in patient and appointment selection withstanding. So, while under the NHS GPs have an obligation to take on any patient within their catchment, and to become singularly responsible for the year-round healthcare of that patient, in Australia doctors may choose their patients, and may see as many or as few patients per year as they deem appropriate. Although Australia, like the rest of the industrialised world, has a fairly tightly regulated medical field, and increasing government oversight, UK GPs who have moved to Australia have conveyed to us a feeling that Medicare is less prescriptive with treatment practices and grants more autonomy to GPs.
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