Practices Are Getting Bigger: What Does this Mean for Doctors and Patients?

In the last year, the number of Australian medical centres with 11 or more GPs has risen by 9%. In this same period, the number of solo GP clinics has dropped by almost a third. This is an enormous shift, but is it a concern? We investigated.

When the numbers don’t match up

Getting to the bottom of just how much medical centres are changing in size is more difficult than you may think. Mostly because none of the organisations recording the data can seem to agree on the numbers. 

Take the 2019 data. RACGP, who sourced their figures from the Department of Health say there are 37,000 GPs practising in Australia. Meanwhile, Medical Board of Australia say there are 41,713 GPs. And the Australian Bureau of Statistics? Well, they stopped counting back in 2014.  

And it’s not just this year that the numbers failed to align. Even back in 2011 when the Australian Bureau of Statistics thought it was still a good idea to record the number of GPs practising in Australia, the numbers were all over the place. 

For instance, in 2011, the Australian Bureau of Statistics counted 43,400 GPs, while the Medical Board of Australia counted 26,420 GPs, and AHPRA counted 22,141 GPs. 

At this point, I gave up trying to work out the exact rate of change in average clinic size. I was hoping to show something like: in the last decade, the average clinic size has almost doubled.

For instance, according to the Australian Bureau of Statistics, the average clinic size in 2011 was 3.3 GPs (32,000 GPs / 9,600 clinics). And today, according to RACGP, the average clinic size is 5.7 GPs (37,000 GPs / 6,500 clinics). 

I would love to build a case around these figures, but, like I said, unfortunately I just don’t trust the numbers.

The numbers to watch

Instead, I decided to focus solely on RACGP’s Health of the Nation reports. This way I could compare apples with apples. 

Specifically, I looked at the percentages of 1 GP, 2-5 GP, 6-10 GP, and 11+ GP clinics between 2017-18 and 2018-19. Unfortunately, the data wasn’t recorded in 2016-17. 

The results are below:

Number of GPs 2018 2019 Change
1 GP 3% 2% ↓  1%
2-5 GPs 31% 28% ↓  3%
6-10 GPs 39% 37% ↓  2%
> 11 GPs 25% 34% ↑  9%

From the results, we can see a clear shift in practice size. Although some of the percentage changes appear small, they are certainly significant. 

The most evident change is the number of solo GP clinics dropping by a third – from 3% market share to 2%. This is a big shift, showing that fewer solo GP clinics are entering the market. 

The numbers of 2-5 GP and 6-10 GP clinics have also dropped. Perhaps it doesn’t seem to be a big shift, but when you consider that adding a second GP to a solo GP clinic bumps a clinic into the next bracket up (2-5 GPs), then it’s clear that 2-5 GP clinics are bumping up to 6-10 GP clinics faster than 1 GP clinics are becoming 2-5 GP clinics. 

The same is true for 6-10 GP clinics. These clinics are bumping up faster to 11+ GP clinics than 2-5 GP clinics are becoming 6-10 GP clinics. 

In other words, the rate of growth accelerates as clinics get larger.

And of course, the big number to watch is the increase in 11+ GP clinics. A 9% rise in just 12 months is jaw dropping. 

Above: In just 12 months, Alevia Medical Weight Loss has grown from 1 GP to 7 GPs

What is causing the average clinic size to increase?

To get to the bottom of why clinics are expanding at greater and greater pace, I talked to April Ratajczak, Director of Focus Accreditation, who has worked in healthcare for more than two decades and helped set up medical centres all over Australia. 

April says, “I haven’t seen a lot of clinics closing down, but I’ve seen clinics being bought out.” 

“I think a lot of it comes down to competition. It’s becoming increasingly easy for patients to find alternative clinics. So if they can’t get into the clinic when they want, they tend to go somewhere else.” 

“This is a distinct advantage for bigger clinics because they can accommodate more patients and work the extra hours. For instance, they don’t need to close the clinic down at Christmas, and they often can stay open later at night, or on weekends. 

“A clinic which is open until 11pm at night, or 7 days a week, is attractive to patients, especially when your child gets sick at 8pm at night.

“You can compare it to the big chain supermarkets like Woolworths. If the consumer can’t get into the shops when it’s convenient for them, and get the products they want, they will go elsewhere. 

“That’s why many people choose the larger chains, because there is one on every corner and customers know they have the exact brands they want. Some of them are even open 24 hours. You will rarely find a small locally owned supermarket open 24 hours.”

April says because of this advantage, “Fewer GPs are becoming interested in starting their own standalone practice, unless they have a major stand-out service or plans for growth in the first few years. The stand alone single GP clinics are simply becoming non-existent.”  

RACGP’s numbers back this up too. According to RACGP’s 2019 Health of the Nation report, the number of GPs interested in starting their own practice dropped by 5% between 2017 and 2019. In 2017, 53% of GPs said they were not interested in starting their own practice. This grew to 58% in 2019.

April says there is also often more incentive for GPs to go work for large corporates over small family practices. “Often the work-life balance is better in larger practices because it means as a solo doctor you can take time off without having to shut down the practice or restrict patient visits,” she says.

Bob, 71 years old from Perth, says this is one of the biggest benefits of visiting a large practice. “If your own doc is on holiday, sick, for whatever reason not there, normally you can still see a doctor without having to make a new appointment.”

Whereas, if Bob visited a small clinic, he may be forced to go down the road when his doctor wasn’t available.

April says, “This is often how large clinics gain new patients. For example, a patient goes to another clinic because their doctor closes over christmas. And they have a good experience. They can’t fault the new place, and it is more convenient because it’s easier to get into.”

There are other advantages to bigger clinics too, April says.

“Bigger clinics usually have a bigger budget so they can afford nicer facilities. They usually have a bigger budget for marketing too, which means doctors don’t often have to worry about their appointment book being half empty.”

“They have people who oversee their social media. They have someone who knows recruitment; who knows the wording of the advert and where to post the ad. 

“They often have a team to help with their accreditation too. They are like the large supermarkets in that they have one-stop shopping. This can be really appealing for doctors who simply want to consult and go home without the stress of owning a clinic.”

How is this increase in clinic size affecting patients?

April says this trend is ultimately a good one when considering patient health outcomes. “I think it’s good. The easier it is for patients to access care, whether its after hours or weekends, the less strain we’re putting on our emergency departments.”

“Any time that patients can access the care they need, I don’t think that’s a bad thing.”

“In regard to patient outcomes, I don’t think there is really a negative there. Bigger clinics often have the resources to provide more chronic disease management plans and support too, which helps with better life outcomes. Plus patients don’t have to go off-site to see a specialist or allied health.”

Bob, 71 years old from Perth, agrees. “Where there are multiple doctors, there is almost always multiple skills and specialties. So I don’t need as many referrals that cost extra time and money.”

Above: Patients in the waiting room at 11 GP clinic, Your Family Doctors

This said, there is of course a “family feel” being lost as clinics grow. April explains, “Some patients really like that small clinic feel – the family doctor. A lot of the older generation see these small clinics as how a doctor should be… patients feel less like a number.”

Kirsten, 37 years old from ACT, agrees with this sentiment. “I have experienced both single GP practices and multi GP medical centres, and have had good experiences with both.

“However, I have found that the personal service provided by a single GP and their staff cannot be matched by a larger practice where staff come and go more often and where they are dealing with a much larger volume of patients. 

“When my family and I chose an independent practice with one doctor, the doctor got to know us all well, knew our history without needing to consult notes, and it felt as though the care was more individual. The staff at the practice also knew us by name, as they obviously did all their other regular patients, and we knew them also.”

How is this increase in clinic size affecting GPs?

There are several advantages to GPs working in larger clinics. Many of which we covered above. But of course there are disadvantages too. 

Advantages of larger practices

Better work-life balance 

RACGP’s 2019 Health of the Nation report found, “Working with a greater number of GPs may increase satisfaction with hours worked. GPs very satisfied with their hours of work are working in practices with an average 9.4 GPs, compared with very dissatisfied GPs working in practices with an average of 6.3 GPs.”

Dr Evan Jones, Medical Director of one of Australia’s first super clinics at Strathpine in Brisbane, says, “If there are only two doctors and someone goes away, it places an impossible load on the remaining doctor. If there are 14 doctors, though, we have the capacity to deal with that.”

Dr Rashmi Sharma, the owner of a 14 GP Canberra medical practice and Chair of the ACT Medicare Local, says, “In a larger practice, staff don’t have to worry about going on holiday and that’s important because you don’t want burnout.”

More time for “doctor stuff” 

Large practices are also more likely to have all the systems in place for doctors. As April Ratajczak from Focus Accreditation explains, “A larger corporate clinic is more likely to have all their bases covered. It means there is less admin for the doctors to do.” 

Dr. Anthony Mariampillai, who moved from a 2 GP practice to become Director of Medical Services at Australia’s first GP super clinic in Ballan, Victoria, says, “Now I can concentrate on patient care rather than administration and computers.”

Fewer hours in a working week 

GPs in large clinics are also more likely to work fewer hours in a week. In RACGP’s 2019 Health of the Nation report, just 44% of GPs in large group practice were likely to work more than 40 hours a week. In a solo practice, this rose to 69%.

While solo GP clinics are obviously not representative of all small clinics, there seems to be a logical link between fewer doctors at a clinic equating to a greater workload per doctor. 

More likely to consult with others

RACGP’s 2019 Health of the Nation report also found that “as the number of non-GP health professionals in a general practice increases, GPs become more likely to consult with others about the management of patients. 

“GPs working in larger teams are also more likely to report that formal structures are in place to encourage communication among practice staff.”

As well as being a benefit to doctors, this is certainly advantageous for patients too.

Above: 5 GP clinic, Battery Point Medical, still operates as a small “family feel” clinic

Disadvantages of larger practices

Less autonomy 

“The smaller the clinic, the more you know what’s happening,” April Ratajczak says. “With some big clinics you don’t know about the problems until they are quite large.”

Dr. Anthony Mariampillai, who moved from a 2 GP practice to become Director of Medical Services at a super clinic in Ballan, says, “What I do miss about owning my own practice was being able to make my own decisions.”

More bureaucracy

April says as clinics grow there are more hoops to jump to get something passed. “If you want to take a day off, you have to go through more channels. There are more people signing off on processes. 

“Simple things, such as the replacement of equipment, often requires a request to be submitted, and you have to wait for approval. This can be frustrating for the managers, doctors and staff who need the equipment for their day to day duties.”

Dr Rashmi Sharma, the owner of a 14-doctor Canberra medical practice and Chair of the ACT Medicare Local, agrees. “If doctors see something that needs changing but they have to go to the head office to make changes, that can lead to disengagement. The risk with a corporate-run practice is you lose the bottom-up approach.” 

Higher patient churn

While higher patient flow is healthier for the business of a clinic, “It can make patients feel like a number,” Aprils says. 

Kirsten, 37 years old from ACT, says, “At larger practices I’ve attended, I find it is hard to get to know the doctors and other staff so well. The doctors often seem to be under more pressure to get you in and out quickly, and the level of service can be quite variable even whilst adhering to acceptable practice.”

Of course, this can be a problem at any clinic, regardless of the size, but as April explains, “Some people just like the look and feel of a small clinic. To them, it’s what a medical centre should look like.”

Conclusion

The big takeaway, April says, is that things are trending in the right direction. “Anything that helps people get the care they need more easily and with more consistency has to be a good thing,” she says. 

“Of course, I feel for the small clinics trying to compete with the bigger companies, but many have a strong team and loyal patient base, which means they can still thrive. At the end of the day, we have to remember that patient outcomes are our priority. 

“Until this change of tide has a negative effect on those patient outcomes, I would say things are going in the right direction.”

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