Why I Stepped Back from an Increasingly Commercialised General Practice in Australia

After more than thirty-five years in medicine across South Africa, the Netherlands, the United Kingdom and Australia, I have stepped back from regular general practice. Part of the reason is positive. Outback locum work in Indigenous communities attracts me more, with the chance to develop further skills where the need is greatest. But part of it is harder to say. In some Australian practices, I found it increasingly difficult to practise the kind of medicine I believe in: medicine grounded in communication, attitude, clinical skill and a commitment to keep learning.

Most of the GPs I have worked with try hard to do a good job. General practice is rarely straightforward. A decent income for its breadth of responsibility is fully justified, and owning or managing a practice through constant change can be a real burden. This is not an article against colleagues. It is about what the system rewards, and what good general practice requires.

What I saw

I worked in many practices, often very well equipped, with an emphasis on acute care and chronic disease management. Too often, I picked up patients whose records told me little. Past history was incomplete or missing. Medication lists were out of date. Some doctors seemed under pressure to see patients quickly, leaving the next doctor, and the next specialist, to reconstruct what was happening.

Good notes are not bureaucracy. They are communication with the patient and with every colleague who follows.

Repeat prescriptions show how structure can shape behaviour. The PBS Schedule sets medicine-specific limits for quantities and repeats; within those limits, the prescriber chooses what is clinically appropriate [1, 2]. For many chronic medicines, a month’s supply plus five repeats can provide about six months’ treatment, though the limit varies by medicine. Since 2023, some eligible medicines can be prescribed in 60-day quantities; with five repeats, that can provide up to a year’s supply for suitable patients [3].

Yet I regularly saw prescriptions with only two or three repeats and no clear reason apparent in the record. That may mean an earlier return to the practice, sometimes with another gap fee. An earlier review is right when the patient’s condition or medicine requires it. My concern is about repeat visits that seem to add little clinical value. A prescription alone cannot establish a prescriber’s motive, but the financial effect of an unnecessary visit should not be ignored.

I also encountered a disquieting contrast: clinicians describing the difficulty of keeping histories and medication lists current, while billable assessments and care-planning work still had to be fitted into the day. Those services can be valuable when they meet a patient’s needs and are done properly. The pressure arises when time is scarce and the system pays for some activities more clearly than it supports the ongoing work of listening, documenting and coordinating care.

I have seen item numbers used in ways that appeared to favour the practice over the patient. That is my observation, not a claim about general practice as a whole. The broader evidence is more mixed. The independent Philip Review estimated possible Medicare non-compliance and fraud at $1.5–3 billion a year, while noting that a significant part was likely to involve errors in a complex system rather than deliberate fraud [4]. A study of Medicare consultation-item billing found GPs more likely to undercharge than overcharge, although it examined a specific dataset and did not measure patient gap fees [5]. The payment system can create incentives; it does not establish any individual doctor’s motive.

How the system shapes practice

Australian general practice remains funded predominantly through fee-for-service. Grattan describes the system as almost entirely fee-for-service, while a government-commissioned expert panel estimated that it accounted for about 90 per cent of average practice income [6, 7]. This model pays for individual services and mostly for work delivered by GPs. It can reward volume while providing less direct support for prevention, continuity and work shared across a team.

The distinction is not that longer visits receive a lower total rebate. They generally attract a higher total payment. The problem is that the rebate per minute is higher for shorter consultations, which can make the time needed by a complex patient harder to fund [8].

Since 1 November 2025, eligible practices participating in the Bulk Billing Practice Incentive Program can receive an additional 12.5 per cent of the MBS benefit for eligible bulk-billed services. Practices and providers share that incentive, and participation has specific eligibility and registration requirements [9]. It is welcome support for bulk billing, but it remains linked to eligible services.

What other systems show

In England, where I also worked, the core GMS payment is largely based on a registered, weighted patient list. For 2026/27, the global sum is £130.07 per weighted patient [10]. That is not the whole English practice funding model: practices also receive payments through QOF, premises funding and enhanced services. NHS patients generally pay nothing for an ordinary GP consultation, and an additional routine visit does not increase the practice’s core global-sum payment. In my experience, repeat prescribing was handled in a more relaxed, patient-friendly way, alongside the substantial chronic disease work practices already had to do.

The UK approach has its own risks. The Quality and Outcomes Framework includes financial thresholds and exception reporting. York researchers examined how those incentives could affect exception reporting and other practice behaviour [11]. Exception reporting also has legitimate clinical purposes, so the lesson is not that list-based funding removes incentives. Every model needs careful design and monitoring.

Canada offers another comparison, but it has no single national model. Provincial systems differ, and fee-for-service remains important. CIHI reported that about 80 per cent of active family physicians paid through the public system received both fee-for-service and alternative payments in 2023–24. Among those receiving both, the average payment mix was about 48 per cent fee-for-service and 52 per cent alternative payments [12]. British Columbia’s Longitudinal Family Physician model, for example, combines payment for time, patient interactions and the size and complexity of a doctor’s panel [13]. Alberta has also introduced a blended model that recognises patient interactions, panel size and complexity, and time spent on direct and indirect care [14].

South Africa shows a different divide. In the tax-funded public sector, primary care is generally free at the point of use and doctors are mainly salaried. In the private sector, which serves a smaller share of the population, independent GPs are commonly paid fee-for-service through medical schemes and patient payments [15]. The National Health Insurance Act proposes contracting private GPs into multidisciplinary networks and paying them by capitation. As of November 2026, that is a proposed future model, not the current basis of GP payment. The President agreed to delay proclaiming any sections until the Constitutional Court decides the public-participation challenges heard in May 2026, and the Court reserved judgment, which has not yet been delivered [16, 17, 18].

These comparisons do not prove that one payment model produces better doctors. They show that systems can reward different activities, and that every model needs safeguards against under-service, unnecessary care and fragmented responsibility.

No payment system determines a doctor’s character. But structures shape behaviour, and they matter most when time and financial pressure make good practice harder to sustain.

Teams and ownership

The difference also shows in teams. Grattan estimates that Australia has about three nurses or other clinicians for every ten GPs, compared with about ten in Britain [19]. These are broad workforce estimates, not a direct measure of teamwork. In my own experience, only a few Australian practices functioned as real teams in which nurses had a genuine voice.

I am also concerned by practice models where commercial targets are set far from the consulting room. Large groups and non-clinician ownership are not all the same, and ownership alone does not prove poor care. Corporate practices can offer advantages to doctors and patients. But when those making financial decisions have little connection with patient care, there is a risk that commercial priorities will carry more weight than continuity, education and community need. Australian evidence about the effects of ownership remains limited, so this is a concern that deserves scrutiny, not a conclusion about every corporate practice [20].

Communication and learning

Good general practice rests on communication, attitude, clinical skill and a habit of continued learning. Communication is its cornerstone. It begins with listening before deciding, and understanding what the patient fears, expects and can manage. It means explaining in words the patient can carry home, and checking that they have understood. It continues in the record: an accurate history and current medication list are communication with every colleague who follows.

Attitude determines whether we do these things with respect and honesty. Clinical skill helps us make sound decisions. Continued learning keeps that skill alive.

My training in problem-based learning at Maastricht shaped how I see this. We began with a question, examined the problem, looked for evidence and revised our understanding as we learned more. That process belongs in everyday practice, not only in medical school. It means remaining curious about the patient in front of us, being willing to reconsider a first impression and learning from what happens next.

The evidence supports the importance of communication. A meta-analysis found a 19 per cent higher risk of non-adherence among patients whose doctors communicated poorly. In studies of communication training, the odds of adherence were 1.62 times higher for patients whose doctors had received that training [21]. Another meta-analysis of 48 studies found an association between better doctor–patient collaboration and better adherence [22]. These are findings across varied studies, not guarantees for any one consultation. They reinforce a practical point: including the patient’s perspective helps make a treatment plan one they can understand and follow.

This is why I see the FRACGP as necessary but not sufficient. It is a fine achievement, and it takes years. Qualifications and knowledge matter, but so do the attitude to listen, the skill to communicate and the discipline to keep learning. Without those, a credential can become an end in itself rather than a foundation for good care.

What good looks like

Attitude, communication and learning were also central to how I tried to teach. I have seen medical students sit silently beside their supervisor, allowed only the occasional question. My approach was different. After a proper introduction, and with the patient’s consent, students often took the driving seat from about the third day. Questions and mistakes were allowed because I was there to guide and correct them.

The learning curve was steep. After five weeks I often only observed and gave the occasional prompt. Sometimes I had to take over, and some patients preferred to see me alone, which was fair. Because we started with listening, it was usually a pleasure for students and patients alike. It often made my day.

What I would change

Australia does not need to copy the UK, Canada or South Africa. It should learn from what different systems are trying to solve. Grattan Institute and three recent government-commissioned reviews have recommended blended funding to support prevention, continuity and multidisciplinary care [6]. Grattan proposes an opt-in model combining fees for visits with a flexible budget for each enrolled patient [23].

That is the kind of structural support I would want: funding that recognises the work of practices providing good, team-based care to patients with real needs, but that struggle to make the margins work.

There is real disagreement about how reform should proceed. The RACGP’s June 2024 funding position says fee-for-service should remain the foundation, supplemented by blended funding for chronic disease. It also calls for increased government investment and multidisciplinary care [24]. Its 2026–30 Advocacy Plan calls for a 40 per cent increase to rebates for longer consultations, an independent primary care pricing authority and support for GP-led multidisciplinary, culturally safe and continuous care [25]. The College says it did not ask for the Bulk Billing Practice Incentive Program to be funded in its current form; it has argued instead for higher patient rebates, particularly for longer consultations [26].

These are concrete advocacy positions, and they matter. In my view, the RACGP should now help design and advocate for a voluntary, adequately funded blended option alongside fee-for-service. It should involve GPs, patients and Aboriginal Community Controlled Health Organisations in the design, adjust payments for complexity and need, and insist on independent evaluation and safeguards for access, continuity and under-service. Defending fee-for-service should not prevent the College from helping test a safe and workable alternative.

The Time-Tiered Primary Care Working Group’s draft report recommends that MBS benefits support appropriate and varied consultation lengths. In discussing how to achieve this, it identifies increasing Level C–E fees as the option that could be implemented fastest. The report does not specify new rebate amounts, and its recommendations remain subject to further MRAC and Government consideration [27].

The Health Care Homes experience shows why implementation and evaluation matter. A later matched study found improved access and care processes, but also higher emergency-department presentations and emergency admissions in the first year; it found no improvement in diabetes outcomes, most other hospital-use measures or mortality [28]. The broader evaluation concluded that bundled payments could be implemented, but could not establish their long-term value. Some Aboriginal Community Controlled Health Services reported that bundled payment was more viable and appropriate for their team-based settings [29]. That mixed experience should inform better design, not close down the discussion.

Any reform must be designed with GPs, patients and communities. It must also protect against the risks of capitation: too little care, restricted access or incentives to avoid patients with greater needs.

I have stepped back, but I have not stopped caring about general practice. Funding can be reformed and structures improved, and they should be. Communication remains the cornerstone; attitude, clinical skill and continued learning help make it real. A good system can support those things or wear them down. In the consulting room, we still have to bring them ourselves.

Paul Wolf

References

1. Services Australia. Increased quantities and repeats for PBS items. URL⁠
2. Australian Government. National Health (Listing of Pharmaceutical Benefits) Instrument 2024 (PBS Schedule). URL⁠
3. Department of Health, Disability and Ageing. 60-day prescriptions: dispensing FAQs. URL⁠
4. Department of Health, Disability and Ageing. Independent Review of Medicare Integrity and Compliance – Final report. URL⁠
5. Harrison C, Gordon J, Henderson J, Miller G, Britt H. Under or over? General practitioner charging of Medicare. AJGP. 2023. URL⁠
6. Grattan Institute. The perfect blend: Getting flexible GP funding right (2026). URL⁠
7. Australian Government Expert Advisory Panel. Review of General Practice Incentives: Final Report (2024). URL⁠
8. Grattan Institute. GPs are struggling: Here are 5 lessons from overseas to reform the funding system. URL⁠
9. Services Australia. About the Bulk Billing Practice Incentive Program. URL⁠
10. NHS England. Implementing the 2026/27 GP contract changes. URL⁠
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12. Canadian Institute for Health Information. Health workforce, 2024: Recruitment and retention. URL⁠
13. Province of British Columbia. Longitudinal Family Physician Payment Model. URL⁠
14. Government of Alberta. Primary care physician compensation model. URL⁠
15. South African Medical Journal. Health sector reforms in South Africa: Evaluating financing models for universal health coverage in the post-apartheid era (2026). URL⁠
16. South African National Department of Health. NHI FAQs. URL⁠
17. The Presidency of South Africa; Constitutional Court of South Africa. NHI Act litigation statement (2026); recent-hearings list for CCT 251/25 and CCT 269/25. Presidency statement⁠; Constitutional Court recent-hearings list⁠
18. EWN. ConCourt reserves judgment in NHI challenge (7 May 2026). URL⁠; Rateweb. NHI in November 2026: status report (1 November 2026). URL⁠
19. Inside Story. Medicare’s forty-year update (citing Grattan Institute). URL⁠
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22. Arbuthnott A, Sharpe D. The effect of physician–patient collaboration on patient adherence in non-psychiatric medicine. Patient Education and Counseling. 2009;77(1):60–67. URL⁠
23. Grattan Institute. A better Medicare: How to reform GP funding (2026). URL⁠
24. RACGP. Funding Priorities: Position statement (June 2024). URL⁠
25. RACGP. Advocacy Plan 2026–30. URL⁠
26. RACGP. Medicare: Resources for practices and GPs (BBPIP position). URL⁠
27. MBS Review Advisory Committee, Time-Tiered Primary Care Working Group. Draft Final Report (September 2026), available through the official Australian Government consultation page⁠; see also Medical Republic, “MRAC recommends higher rebates for long consults”⁠.
28. Tran DT, Falster MO, Pearse J, et al. The Australian Health Care Homes trial: quality of care and patient outcomes. Medical Journal of Australia. 2024;220(7):372–378. URL⁠
29. Department of Health, Disability and Ageing. Evaluation of the Health Care Homes trial – Final evaluation report (2022). URL⁠