Give GPs problems to solve, not election promises

This is not about money or profit or turf. It’s about making sure that we do not conduct experiments – such as the North Queensland Pharmacy Trial – that could have life-long consequences.

IN the 1990s, I worked for the Medical Board of Queensland. There was an occasion when a matter that I was managing ended up before a single Justice of the High Court in an application for Leave to Appeal. It was an instructive experience. I don’t remember much of the hearing, but one memory has stuck with me forever. I don’t recall the exact details, but I do recall a moment when the learned Justice repudiated the evidence given by doctors, with a statement along the lines of “well, that’s not how my doctor operates” or words to that effect. I remember this moment so clearly because I realised that, in this instance, a person (a highly intelligent, educated person) placed their experience of attending a GP as a patient on par with the expert advice about the conduct of medical practice. It was one of those lightbulb moments that illuminated my career.

Everyone in the country has an opinion about general practice because everyone has attended a GP for something at some time in their life. GPs are accessible – we are experts largely on tap (albeit with increasing waiting times to book in). There are days when I have felt the weight of this, of being perhaps the most educated person that someone in a tough situation has access to. Our position at the coalface, that ability to walk with patients in the deepest realities of their lives, is what makes the specialty unique.

However, that very accessibility, and the fact that everyone has been to see a GP, may just be our greatest vulnerability. Everyone thinks that they know what GPs do because they have been there. They have seen us, have experienced the care. This is not to dismiss the importance of the consumer experience, but rather to acknowledge that watching a footy match, even attending it in person, doesn’t make you an elite player.  Good reforms come when technical expertise and consumer experience meld.

When something looks simple, it can deceptively create a sense that the work is simple. Simone Biles makes ridiculous complexity on the vault look simple. Does that mean it is? It means she has trained and trained and trained and is an expert in every sense of the word. Experts make the impossible look easy. The ease with which health professionals exercise heuristic skills (here and here) to rapidly synthesise patient demographic and social circumstances, comorbid conditions, pathology and epidemiology and arrive at a diagnosis and treatment choice make that expertise largely invisible.

That has likely contributed to an overall perception that most of what GPs do is simple and can be safely and appropriately done by alterative health professionals with significantly less training and experience. Some of the work GPs do absolutely can be done by others. But the health system needs those decisions to be informed by actual expert practitioners.

Let’s take the example of a couple of recent issues in Queensland.

The North Queensland pharmacy trial was an election promise of the Palaszczuk government. It followed on the urinary tract infection (UTI) treatment trial/pilot which allowed patients to present to a pharmacy and be dispensed antibiotics for a UTI. Most notably, empiric prescribing without any testing is consistent with the standards set out in current clinical guidelines – in this case, the trial (and now program) at least followed an established protocol. There have been significant concerns expressed about the diagnostic acumen of pharmacists in this space, but that program is consistent with clinical guidelines – prescribing based on symptoms alone. GPs do the same if we treat a UTI by telehealth, but for most, that is the exception, not the standard.

The UTI program seems to have emboldened the Queensland Government, and the North Queensland Pharmacy Trial was born. The proposal could cut doctors (not just GPs, but all doctors) out of decisions to diagnose and initiate prescription medicines of some pretty significant diseases. Hypertension and diabetes were on the original list where pharmacists would be able to diagnose and prescribe. The details of the proposals are not public domain, but within current funding frameworks, it seems almost impossible that pharmacists would be able to implement current guidelines for appropriate care to the same standard as doctors.

Let’s take, for example, a diagnosis of diabetes and the prescribing of medication to treat it.

Diagnosis of diabetes is more than just a finger-prick test. It requires an assessment of symptoms, laboratory measurement, and in some cases, a second round of laboratory tests to confirm a diagnosis. It certainly requires laboratory monitoring to determine the need for and type of medications, and to evaluate the efficacy of those. Pharmacists cannot deliver that standard of care.

In the early stages, many patients can be managed with diet and lifestyle modification. At this stage, mobilising a GP Chronic Disease Management Plan and Team Care arrangement can have profound benefits, giving patients access to dietetics, diabetes educators, exercise physiology, and podiatry to name a few. Pharmacists cannot deliver that standard of care.

Current guidance also requires all of these as part of an annual evidence-based cycle of care for patients with diabetes. It seems contradictory that GPs have a target of an annual cycle of care for patients with diabetes and the Queensland Government sought to establish policy that directly devalued that, focusing only on access to medication.

It is of particular concern that the trial was proposed for a region of Queensland where Aboriginal and Torres Strait Islander people are a significant proportion of the population. So we target an already disadvantaged population and substitute care that cuts them off from recommended diagnostic and management capabilities. It is no wonder that NACCHO expressed opposition to the trial.

The trial itself may now be dead (at least, postponed) and, ultimately, conditions such as diabetes and hypertension may be excluded. Further argument is redundant, but it is useful to try to understand it as a case study from the government decision-maker perspective, as a symptom of an issue, rather than further prosecute the merits of the issue itself.

That the Queensland Government was even willing to contemplate this suggests that they have fallen into a trap with three strands. They have grossly underestimated the clinical complexity and value of general practice — they aren’t alone there. They have succumbed to lobbying and political donations, and they appear to have been advised by people who don’t know how the funding and regulatory arrangements around general practice work, evidenced by recent repudiation of the trial by the Director of the Professional Services Review.

Those three strands are recurring themes that keep biting the policy reform interface between state health care and general practice. They are what led to this trial being announced as an election promise, making what should be a technical clinical issue instead a political one.

State health systems have very little working knowledge of general practice, and very, very few specialist GPs among their advisors. By contrast, every other health profession and specialty group have career paths within health departments that can result in nurses, allied health, medical administrators and other medical clinical specialists being appointed to advisor roles. GP advisors, when employed, sit deep in departmental structures and their job may be more focused on advising GPs about the department’s view, rather than the other way round. When former GPs do rise to leadership positions in health departments, this is usually not compatible with continuing to work as a GP. External (practising) GPs are viewed as stakeholders, not advisors. This is a vitally important difference.

It is manifestly clear that governments by and large do not understand the work that general practice does, but they think they do, perhaps because like the 1990s High Court Justice, they and their advisers have been customers of general practice. When GPs try to explain this, we are greeted with claims of turf protection (here and here). We are advocating for good patient care, just like nurses are when they argue for appropriate nurse to patient ratios.

This is not about money or profit or turf. It’s about making sure that we do not conduct experiments – such as the North Queensland Pharmacy Trial – that could have life-long consequences.

There is an old saying: “Familiarity breeds contempt”. Sometimes if feels that our political and policy leaders are so familiar with general practice that they hold our specialty in contempt.

The first step in breaking the cycle is for state health departments and ministers to acknowledge their knowledge gap about general practice. General practice has been a blind spot of state governments for a long time, simply because of the state/federal divide, and it seems that the Queensland Government is an outlier even among their peers nationally. If state governments want reform, then engage the experts, engage GPs and consumers in the codesign of models that safely and appropriately harness the expertise of the full range of health professions.

Give us problems to solve, not election promises to implement no matter the human cost. GPs can be responsive to change, while also being responsible stewards of patient safety where that is necessary.

Dr Jillann Farmer is a Brisbane-based GP and former Medical Director of the United Nations.

The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.

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