In the past, one of the major rewards of working as a general practitioner in Victoria has been the opportunity to work within a community health centre. This offers not only a multi-disciplinary primary health care service, but also an organisation which works within a social health framework. 

Such a model for medical services is no longer considered possible (read financially viable) by community health centre management and government alike. This means that the concept of a neighbourhood focused, non profit, primary health care service including general practitioners is close to being abandoned. 

Victoria has demonstrated such a model of general practice within community health centres for many years. The aim of general practice community health has been to work as part of a comprehensive primary health care service that acknowledges the social, economic, cultural and gender effects on health. This has been a good model and should have been adopted or modified in other states rather than being allowed to disintegrate. 

Community health centres in Victoria have been managed (until mid 1997) by community elected committees of management that were accountable to their local community. A significant move away from local community control occurred when legislation changed and individuals on the health centre boards of management were appointed rather than elected by the community. 

Despite this Community Health Centres still have the potential to be sensitive to local community issues and to target groups with high needs. This may include groups such as refugees, newly arrived people, isolated women, people with significant mental health problems and youth at risk. A significant proportion of the work done by medical practitioners in community health centres reflected the needs of these groups. 

It is clear that certain people in our community require longer consultation time, more extensive follow-up and often liaison with other agencies. GPs involved in the care of these people need to be highly flexible and responsive in order to have an impact on the health and well being of not just the client but their family, significant others in their lives and the community as a whole. 

The current Medicare rebate is not sufficient to meet the costs associated with providing a comprehensive medical service for people with high needs. Most general practice units within community health centres in Victoria obtain revenue for health centres through the same means as a private bulk billing general practice. This revenue covers salaries of general practitioners and the unit overheads which includes a proportion of the senior management and administration staff salaries. The overheads costed to the general practice unit by health centre administration are the same or greater than private practice overheads. 

GPs working within community health are now made to feel responsible for generating sufficient Medicare revenue to ensure the unit is ‘cost neutral’. However, the GPs have little opportunity to influence the high unit overheads. 

Comments are now made by general practitioners working in community health centres that they are left feeling ‘negligent’ towards the community and the clients most at risk because they cannot provide quality care when being pressured to see more people. Some centres have even proposed employment contracts with conditions stating that GPs must meet a minimum revenue per hour. This is fraught with problems because the GP is highly unlikely to meet the set target and provide a responsible level of care. 

Current community health centre boards of management and senior administrators are also in a difficult position. State and federal governments have not seen the wisdom to better support the work done by doctors within community health centres. 

Community health centres offer the Federal and state governments an existing and successful structure in which to trial a comprehensive government funded, salaried GP scheme which does not rely on Medicare revenue. 

Community health centre general practice units would welcome the opportunity to be involved in evaluation of the work done in community health centres. Evaluation of the integrated work done by GPs and community health centre staff and the outcomes of community health programs is overdue. 

One reason the DRS supports the concept of salaried medical practitioners is because it reduces the chances of over-servicing. ‘Fast medicine’ is creeping into community health centres as the pressure to increase revenue mounts. Morale of GPs in several community health centres is falling. Salaried medical practice may allow GPs to provide a more comprehensive service to clients with high need when limited consultation time and unreasonably high client numbers are not a driving force. This has greater potential for long term, significant change for individuals and society. 

GPs interested in the concept of salaried general practice are invited to contact the DRS. 

Dr H McGrath 
DRS Victoria 
edited version published in Australian Doctor 28 August 1998