Valuing the General Practitioner in Australian Society

Introduction

In 2008, The Royal Australian College of General Practitioners (RACGP) celebrates its golden jubilee. To acknowledge its achievements, the college commissioned this historical essay, which aims to shed light on the college's place in Australian society. This essay will not focus on the roles played by some of the members whose contribution was pivotal to the success of the RACGP. Rather, it will briefly outline the impetus for the formation of the RACGP before reflecting upon its defence of the specialised role of the general practitioner and their value in Australian society.

The successes of the first 50 years of The Royal Australian College of General Practitioners (RACGP) in developing education, research and preventive medicine programs, reflect the dedicated work of many talented and enthusiastic general practitioners. The founding fathers (and they were all men!) were committed to the practical pursuit of their specialisation, as well as their commitment to the wellbeing of the Australian public.

The RACGP was founded during a post-war period that saw an increase in population and a more affluent society. In its first decade, it witnessed increasing pressure for social change, and post-war prosperity was replaced with political unease. During its second decade, in 1972, after 23 years of a Liberal-Country Party Coalition Government, the Australian Labor Party won office and began to implement its program of reform, including the introduction of the Medibank Health Scheme. In later decades, further economic, educational, social, and political reforms were implemented by successive Liberal and Labor governments amid increasing unemployment, interest rate rises, inflation and economic recession. The past decade has seen a return to prosperity and once again a succession of Liberal and Labor governments. Throughout the decades, the college has weathered these storms of change, during which its actions have emphasised the value and importance of the GP to Australian society.

Education, research, publications and preventive medicine have underpinned the activities of the college for 50 years. However, the evolving nature of general practice and, in recent years, a greater emphasis on advocacy, rural and Aboriginal health, have contributed to the broadening focus of the college and its membership. Social and political events, and public policy and their outcomes, have also impacted upon the activities of the college.

Establishing the College

When the RACGP was formed in 1958, its stated aim was to improve the health and wellbeing of all Australians by supporting GPs, as well as the 'medical education of the undergraduate, recent graduate, and those already in practice'.¹ In 2008, the primary mission of the college remains the improvement of the health and wellbeing of all Australians by supporting GPs.

In his first year as inaugural President of the Australian College of General Practitioners, William Conolly wrote in the Annual Report to members that the college aimed to ensure that the GP continue to be the family doctor who would remain as counsellor, guide and friend to his patients. It aspired to see that general practice was maintained 'on the highest plain' in Australia and 'to safeguard the health of the nation'.² Today, additional aims and objectives have expanded the college's goals to include the support of registrars, practice nurses and medical students; supplying ongoing professional development activities; developing resources and guidelines; helping GPs with issues that affect their practice; and the development of standards that general practices use as part of the accreditation process.

The Australian College of General Practitioners was established in 1958. It succeeded the state based faculties of the British College of General Practitioners; a body which had itself been formed in 1952. In Australia similar specialist bodies, such as the Royal Australasian College of Surgeons and the Royal Australasian College of Physicians, had been established in 1927 and 1938 respectively. In their desire to be associated with the British College of General Practitioners, as early as 1953, New South Wales and Queensland established their own state faculties of that organisation. Faculties were subsequently established in Western Australia (1956), Victoria (1956), Tasmania (1957) and South Australia (1958), and together with Queensland and New South Wales formed the Australian Council of the College of General Practitioners.³ The Australian Council surveyed its members in 1957 and decided that the formation of an autonomous Australian College of General Practitioners was now appropriate. A Memorandum of Association under the New South Wales Companies Act was submitted on 17 December 1957 and the Australian college was incorporated on 4 February 1958. Foundation members numbered 874.⁴

Membership of the college was open to doctors who had been graduated for at least 7 years and who had been in general practice for at least 5 years. They promised to undertake and continue approved postgraduate study while in general practice. The admission of members and associates was by invitation.⁵

The inaugural college council consisted of representatives from each state faculty and the first office bearers were elected. They were: William Arnold Conolly, Chairman; David Zacharin, Deputy-Chairman; Howard Morris Saxby, Acting Honorary Treasurer and Honorary Secretary.⁶ The first Annual General Meeting was held on 21 November 1958 but adjourned until 20 March 1959 to allow Dr Ian Dingwall Grant, President of the British College of General Practitioners, to attend.

The vital role of the GP in society was succinctly articulated by Dr Paul Hawley, Director of the American College of Surgeons. So important was its sentiment that William Conolly included this quote from Hawley in his 1959 President's message:⁷ 'Every family needs a medical adviser upon whom he can rely, whether or not such a need is recognised. The family physician is the only practitioner of medicine who can fill this role properly. He should be more than an adviser. He should be the medical manager, and if he has earned the full confidence of the family, he will occupy such a position'.⁸

Hawley's words, though now outdated in their form of expression, emphasised the importance of the GP and affirmed their value to families.

By June 1959, membership of the college had reached 963.⁹ Standing Committees of Council for Undergraduate Education, Postgraduate Education, Research, Preventive Medicine and Publications were appointed and have largely remained the basis of the operations of the RACGP. A coat of arms was approved by college council in 1960; it was granted by the College of Arms in May 1961. The college achieved 'Royal' status in 1969 and its name was appropriately changed to The Royal Australian College of General Practitioners. Fifty years later, the college has over 35 000 members, and over 23 000 GPs participate in the RACGP Continuing Professional Development Program. It is the largest general practice representative body in Australia.

The work of the first decade of the college was dynamic - education, research and preventive medicine programs were established and the state faculties were recruiting increasing numbers of members. The profile of the GP was raised through the new specialist body. In his 1983 history of the college's first 21 years, Ronald Winton recalled that the vision of a college of GPs was a bold one when it was proposed, and the idea was received with both surprise and hostility among the medical profession.¹⁰ The idea of general practice as a collective entity seemed strange, he wrote, because, 'It made general practice a sort of specialty'.¹¹ In this way, the college distinguished itself from the (then) three royal colleges,¹² the universities and the Australian Medical Association (AMA).

In defence of general practice: the National Health Act 1970

Until the college was formed in 1958, medical practitioners had generally become members of the British Medical Association (BMA) and subsequently the AMA. The college had affiliated with the AMA in 1961; their rationale was that this would be in the interest of unity of the profession and allow the college more time to devote to its education and research programs. While the college's affiliation with the AMA was essentially complementary, a divergence of philosophy between the RACGP and the AMA became evident in the late 1960s. The 1970 debate over equitable fees and rebates, which later (in 1973) resulted in the disaffiliation of the college from the AMA, appears to have been a convergence of two issues: an election promise and the perception of the role and training of the GP and specialist.

Late in 1969, Prime Minister John Gorton, announced a revision of the National Health Scheme, a recommendation of the 1968 Nimmo Committee. The proposed revision meant that the rebate for any medical service would be the scheduled fee less $5.00. In response to this proposal, Harvard Merrington,¹³ later wrote that: 'By this one move was thus perpetrated the notion that general practitioner services were of inferior quality to those of a specialist and at the same time the cost to the patient would be the same'.¹⁴ He concluded that a patient would naturally choose to see a specialist for the same cost.¹⁵ Monty Kent Hughes, in his 1969 President's message, bemoaned the fact that: 'There are some still who need to be convinced that family medicine is a specialty discipline in its own right. This is difficult to understand because it has its own special areas requiring study, research and application'. ¹⁶

This, of course, was the very reason the college had been established. Why had the government come to their decision on differentiating GP and specialist rebates by recommending a 'common fee'? Was it simply honouring an election promise or a misunderstanding of the training, expertise and work of the GP? An historical view of the role of the GP and the specialist can add perspective.

The earliest doctors in Australia - such as William Redfern, a surgeon who was convicted and transported in 1801 - practised as a physician and surgeon, 'an appellation assumed by early GPs'.¹⁷ In the 1850s, medical education became an integral part of the newly established universities of Sydney and Melbourne - and of later universities. These medical schools taught the basic skills of medicine, surgery and other types of medical practice, as Eric Fisher notes, 'thus graduating undifferentiated doctors'.¹⁸ Specialists were recruited from the pool of GPs who then obtained higher qualifications by further training overseas. This meant that the GPs who had become specialists were also experienced in general practice and family medicine. This situation continued well into the twentieth century.¹⁹ During World War Two, many GPs joined the armed services where they were trained to become specialists. However, this meant that at the end of the war, specialists were no longer recruited from GPs. As Fisher points out: 'Suddenly GPs were referring patients to specialists who had no experience and little knowledge of general practice'.²⁰ The balance of expertise and expectation had also shifted: GPs were perceived as less specialised. At the same time, the majority of members of the BMA, and later the AMA, were specialists. General practitioners appear to have become somewhat marginalised in the immediate post-war period.

From early March 1970, the college considered Health Minister, Dr AJ Forbes's proposals regarding the 'common fee' and levels of rebate. They were appalled at the proposals. Former President, Monty Kent Hughes, instigated meetings with the AMA Executive to urge modifications to the Bill. However, he soon realised that the worst features of the Bill had been initiated by the AMA itself; they had had prior discussions with the Minister for Health in Canberra.²¹ The college was alarmed that the new Bill proposed to divide some professional services, such as surgical and obstetric, into two levels, that is, those carried out by GPs and those carried out by specialists. That this was occurring while the college was carrying out a drive to recruit young doctors to general practice, marketing it as a vocation of high satisfaction and one requiring as high a level of expertise as any other professional discipline, also disturbed the RACGP Executive.²²

The RACGP Executive, worried that some of its members would not wish to engage in a political campaign, held a plebiscite. In total, 1350 members responded to the three questions: on undertaking a political campaign, which would oppose the 'common fee' list; on differential rebates; and on the college pursuing its own independent campaign. The response was overwhelmingly affirmative, with approval ratings ranging from 77-91%. At a meeting of council on 22 March 1970, the decision was taken to campaign outside the AMA.²³ Meetings and press conferences took place from March until June 1970 and catapulted the college into the medico-political sphere - a place they did not wish to inhabit!

The Australian press followed the debate closely as this was a novel event. Headlines about the 'dissident doctors' and their argument against the Bill were featured on the front pages of the Melbourne Age and the Australian, in the letters to the editor section and in weekly editorials. Protest and dissidence was more usually instigated by radical groups - doctors and nurses, the carers and nurturers of society, did not participate in such tactics. But on this occasion they did. On 23 March, The Australian reported, with front page headlines that, 'Doctors split with AMA: Group votes for negotiations on health plan'. It reported accurately that RACGP members were strongly opposed to the scheme's $5 maximum charge and that, 'They insist this will encourage patients to ignore the 'family doctor' in favour of specialists'.²⁴ The article also observed that the college was 'normally a conservative body' - yet it had decided that if anomalies were not removed from the scheme it would not co-operate in any way with the mechanics of the scheme. Dr David Game, Chairman of RACGP Council, also pointed out that under the $5 maximum plan, 'a patient could receive a heart transplant for $5 but it would cost him $6 for five home visits'. The college did not support the scheme.²⁵

The campaign continued. Week after week the papers were filled with front page headlines, letters, speculation and reporting of the argument between the Australian Government, the AMA and the RACGP. By 8 April, the Melbourne Age, under the provocative heading 'Political doctors' editorialised, in a surprised tone, that, 'Suddenly a significant minority within the medical profession is behaving like a real live pressure group'.²⁶ The editorial, however, saw justification in the college's argument and wrote: 'First, the GPs are doing nothing more than seeking to protect their perceived interests in a conflict with the Commonwealth government and the Australian Medical Association... Second, the Commonwealth's proposed health insurance scheme (which has created the conflict) is of vital interest to the entire community'.²⁷

It rightly observed that 'concern over the actions of the GPs springs mainly from the fact that their behaviour is uncharacteristic' and that the rift between the GPs and the specialist dominated AMA was 'neither surprising nor disturbing'. In essence, it concluded that it was the government's responsibility to establish a workable consensus within the profession in which to base medical benefits and to meet the needs of patients and taxpayers alike.²⁸

After a series of meetings and visits to Canberra where agreement with the AMA could not be reached, the Bill was passed by both Houses of Parliament and became the National Health Act, 1970, effective 1 July 1970. Members of the college were justifiably angered by the decision. In his President's message of 1970, Monty Kent Hughes wrote that: 'The conflict... is now past history and from it we have all emerged somewhat battered and bruised'.²⁹ However, the message that was made clear during the campaign was that specialist training and ongoing education was undertaken by doctors in general practice. It was not simply a matter of money. That was, and remains, the main aim and objective of the RACGP.

Conclusion: A question of value

The 'crisis of 1970' brought to light the 'cleavage which had been allowed to develop' within the medical profession.³⁰ That is, greater communication was required for generalists and specialists to understand each other. It also illustrated that ongoing relationships with government and other organisations required further work. While leaving the college 'battered and bruised' by the experience, the support by the general public reaffirmed the importance and value GPs represented to their patients. The debate also emphasised that the need for specialist training for GPs was being met by the college and that standards in general practice should not be any different from the standards in other branches of medicine. When comparing the specialist to the GP, Kent Hughes used the analogy that, 'the GP was the infantry, officers and men who need supporting troops of all specialist categories to assist them'.³¹

The health debate of 1970 and its outcome highlighted the vital work of the GP, whose initial and ongoing training and professional development was threatened with, in medical terms, becoming a second class citizen to the specialist. This is far from the case today where the GP is recognised as a valued specialist in his or her own right. The RACGP continues to build close working relationships with the AMA and the Australian Government Department of Health and Ageing. It also builds strong relationships with rural doctors, the General Practice Registrars Association, the Australian Medical Students Association, and many other organisations.³²

As Australia has changed in the past 50 years, so too have the aims and objectives of the college evolved to better reflect Australian society and its needs. For example, the RACGP now represents more rural GPs than any other general practice organisation in Australia. The college has also witnessed major developments in its education, research and preventive medicine programs, making them available to enthusiastic GPs using the latest innovative technology. Education, research, publications and preventive medicine have underpinned the activities of the college for 50 years and continue to do so. The college continues to champion the diverse skills of GPs and believes that generalist skills are the foundation of the profession. The aim of the RACGP founding fathers was to ensure that the GP continued to be the family doctor who would remain as counsellor, guide and friend to his patients. The RACGP, its membership and its activities ensure that general practice is maintained 'on the highest plain' in Australia while GPs continue to safeguard the health of the nation.