Decline in status of general practice 'a disaster' for healthcare

The Strengthening Medicare Taskforce report was released a few weeks ago. I must say, I was disappointed, not by what it did address, but by what it did not. The report is more an aspirational concept plan – let’s call it an architect’s sketch – for the redesign of primary care, than a detailed plan for significant health care system reform.

Despite this confusion between the content and the title, the report correctly identifies that strong and effective primary care is essential.

In retrospect, the flaws of the funding model that were structured into Medicare at its inception are obvious to me and I have written about them before (here and here).

Since the introduction of the Medicare freeze, it was inevitable that our primary care system would find itself in the state that it is today: disrespected, demoralised, underfunded, and loss-making.

Given what we know about the behaviour of complex systems, we should then not be surprised by the unravelling of Australian primary care in “two ways. Gradually, then suddenly” (to quote Ernest Hemingway from The sun also rises).

Although the reforms proposed in the report are worthy and necessary, they are only the most urgent part of a much larger reform process.

It is hard to imagine how, given interconnectedness of its parts, strengthening the whole of Medicare is possible without addressing the full range of its shortcomings.

These are my core concerns:

• The declining viability of primary care is founded in the imbalance in the perceived value of, and the resources distributed between, primary and secondary/tertiary care. Attempts to revive Medicare will not succeed if we do not create recognition and provide resources that prove that high quality primary care is accepted as vitally important for our health care system and the wellbeing of our community.

• The progressive commercialisation of health care and the growing focus on profits has seen increasingly large quantities of money being extracted from patients, some health care workers, and taxpayers. The result is that less money is available for patient care and poses a threat to the viability of complex health care systems.

• The report gives little consideration to the growing gap between the resources available and the promises that are being made across the full spectrum of health care. I believe there has been almost no purposeful discussion in Australia about how we might undertake ethical and equitable resource allocation of finite resources to meet this challenge.

GPs specialise as our community’s medical point of first contact with the health system, other than in emergencies.

GP training is designed to equip doctors to identify and prioritise the needs of patients who may present with any illness, to manage those illnesses for which they have the necessary knowledge and skills, and to recognise the boundaries of their knowledge and capabilities by referring on those patients whose illnesses are outside their personal scope of practice.

They are the coordinators of the complex multidimensional whole person care for which disease and organ-based specialists are seldom equipped and generally avoid.

As the complexity of health care has escalated over recent decades, the vital contribution of other health care workers who bring skills that complement those of GPs has increasingly been recognised and welcomed by most doctors.

The Strengthening Medicare Taskforce report appropriately identifies the benefits that derive from integrating these health care workers into the primary care team and remunerating them for some of the tasks that GPs have traditionally undertaken themselves.

All health care workers have exclusive sets of skills, or combinations of skills, but always there are overlaps, and some tasks can also be undertaken by health care workers other than GPs (eg, cervical cytology, some routine health checks, some repeat prescriptions and the management of some minor injuries and ailments).

GP training equips doctors with the knowledge and skills to take overall responsibility for assessment, diagnosis, treatment, and for ongoing care and oversight of multidimensional problems.

This role cannot be assumed by other health care workers (without training them as doctors) and cannot be removed from the responsibility of GPs.

Sadly, established GPs are quitting general practice and newly minted doctors deciding to pursue careers in other fields (here and here).

Why would a junior doctor choose general practice when they see their peers (who, as they know from their time studying and working together, are not cleverer, wiser, more dextrous or better doctors than them) become specialists who are well respected and have secure incomes that are often at least several multiples of what they could ever earn as GPs?

Unless we are careful, our system founded on primary care medical assessment and appropriate referral to (non-primary care) specialist practice will grind to a halt. Alternative means of referral will be necessary, or self-referral accepted with the result that non-GP specialists will be engaging in primary assessment, a task for which they are not equipped and do not want.

The most important victims of the collapse of general practice are patients. They are losing the opportunity for a long term, perhaps lifelong, relationship with the one doctor who can know them and their family.

Fragmentation of care (and medical records) compromises routine assessment of the progress of children, disease prevention, the management of chronic disease, disability care, and transitions across the lifespan including childhood and adolescence, sexuality, parenthood, ageing and aged care, advance care planning and end of life care. Not to mention the routine support for better mental health and dealing with the inevitable and normal stresses of relationships, study, careers, work, unemployment, illnesses and family bereavement.

Reversing the decline will require very loud signals that general practice is a vital and equally important component of health care as specialist and procedural medicine. Not just pronouncements, but a funding model, perhaps with salaries in line with hospital specialist rates, that remunerate careers in general practice that are as attractive as other fields of medicine. In the absence of a massive injection of new funding for GPs, this probably means a redistribution of Medicare funds from non-GP procedural specialist practice to primary care.

The Strengthening Medicare Taskforce report failed to address the potential threats posed by the escalating commercialisation of health care businesses, including the exploitative fees charged by some procedural doctors. The Australian Government has a duty to ensure that the regulation of Medicare supports the efficiency, invention and imaginative change that business-like processes can bring without patients being financially exploited.

Although there is not enough space here to discuss the evolutionary origins and nature of human behaviour and their impact on health care (perhaps the topic of my next opinion piece), it is worth thinking about how such matters have shaped the disaster that is the United States health care system.

Surely we do not want to go too far down the US road, which has them spending about twice as much per capita on health care (including profits) as most other affluent societies, and yet having a shorter life expectancy (the US is 66th in the world at 78.203 years, Australia is 13th with 83.579 years [here and here]).

It has been reported women have been charged for having skin contact with their newly delivered babies, and 41% of the US population is saddled with health care debt. I recommend an article from JAMA, Salve lucrum: the existential threat of greed in US health care.

Even though Australia is not yet subject to the eyewatering greed of some US health care businesses, Australians should not feel too complacent – a US study found that 30% of women of reproductive age in Australia have problems paying medical bills (US 52%), and 32% of women of reproductive age in Australia skipped or delayed health care because of the cost, second only to the US on 49%.

In dealing with this issue, it is most important to consider carefully what we should expect of our health care system – designed to take advantage of the benefits of being run in an efficient business-like manner while maintaining its predominant focus on health care as a service to the community that offers high quality care for patients and proportionate benefits for those who work in it. Perhaps in doing so we would be applying the rumination in Australia’s Treasurer Jim Chalmers’ summer essay to the design of the marketplace of health care.

Finally, human curiosity and inventiveness have prolonged our lives by improving the quality of care, creating therapeutic possibilities and designing best practice standards, all of which the Australian community are told that we have the right to receive. However, applied across the board, they would cost far more than we could ever afford to provide, either as expensive technology or the health care workers required to deliver them. We are already struggling with the high charges for some patented medications, face the extraordinary long term expense of novel and effective treatments for rare inherited diseases and personalised therapies, and are daunted by the costs of providing care for those whose lives have been prolonged or enhanced by our successes.

I recently wrote that the immediate challenges for health care in Australia should be prompting careful consideration of the outcomes we are trying to achieve with our health system – Perfect as the enemy of good. While it is appropriate to set high standards for health care, it is important for the community and the wellbeing of health care workers that they are not set so high as to be unattainable. As discussed recently in The New York Times, our community should not be led to expect that we will receive health care that we cannot afford, and that clinicians should not feel that they are failing because their efforts are spread thinly across too many patients.

If we accept that there is not enough money to do everything that we would like to do, and remembering that when we allow considerable, sometimes excessive, profits to be extracted from health care, less is available to provide such care, then we must adjust our expectations and decide which goals we will pursue and how we can share the benefits and the shortfalls in an equitable manner.

Dealing with the complex ethical issues of resource allocation will require government and community leadership of a candid and broad community consultation if we are to agree on compromises that minimise ongoing conflict.

I had expected far more of the Strengthening Medicare Taskforce report. I hoped that it would have at least identified the broader threats to Medicare, and that it would have reassessed and reasserted Medicare’s values and goals. By identifying the voids in the report, we can engage with our community to agree a plan that strengthens the whole of Medicare.

Dr Will Cairns OAM is Consultant Emeritus at Townsville University Hospital and an Associate Professor, James Cook University.

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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