Redistributing trust: professionalism, policy and expanding scope of practice in primary care

Professionalism is about establishing and maintaining public trust. “The community trusts the medical profession,” states the Good Medical Practice guide, and “Every doctor has a responsibility to behave ethically to justify this trust.” Professionalism is often presented as an individual responsibility, but it is enabled and supported by structures and systems, including government policy and leadership.

Public health relies on public trust: it is difficult to persuade the population to adopt new health care behaviours unless there is a degree of trust in those who communicate health messages and manage health systems. This is why governments need to build trust in the health professionals they support, especially when there is a considerable change in the way health care is delivered.

The social contract between health professionals and society

There is a social contract between a professional and the community they serve. Society grants health professionals status, respect, autonomy in practice, the privilege of self-regulation, and financial rewards. In return, the community expects them to be competent, altruistic and moral, meeting the health care needs of individuals and society to the best of their ability.

At the moment, there are significant changes in the primary care sector, with health care reforms being proposed by various governments. The Scope of Practice review, the Review of General Practice Incentives, the Strengthening Medicare reforms and others are requiring the public to change the way they access health care.

Governments are readjusting their side of the social contract, changing autonomy, financial rewards and regulation, in an environment where there is already decreasing trust and respect for health professionals. In return, health professionals are assessing the other side of the social contract, and deciding whether they are still able to deliver competent, altruistic, moral care that meets the needs of their patients and their communities.

As the risks of practice rise, and the benefits decline, GPs are re-evaluating their roles and are leaving the profession at unprecedented rates. In particular, they recognise the risks of being held personally accountable for structural harms to their patients, a type of moral injury that is becoming more prevalent. Frankly, doctors describe being held ethically and legally responsible for systemic harm without the agency to counteract the personal and professional damage inflicted on themselves and their patients.

Principles underlying change

Governments clearly articulate the principles they believe underpin “good” care. All recent reforms claim to increase the accessibility, quality and efficiency of primary care, although there is also a less obvious goal to improve government access to primary care data. Strategies thought to address these goals include: 

• encouraging co-located multidisciplinary team-based care. This is often presented as introducing team-based care, but in reality, most primary care patients already access bespoke teams, that are distributed across the community;
• extending the scope of practice of primary health care professionals;
• embedding technological innovations, data collection, data linkage and data reporting; and
• involving carers and consumers in system design.

These levers are not applied equitably, which exposes other agendas not obvious in the documents. For instance, the growth in health care technological entrepreneurship is a major concern, as well as an unprecedented opportunity. Doctors are trained to recognise and distrust conflicts of interest, which feature heavily in digital products and their marketing. Technological innovation is not subject to the strict evidence base that is expected of new drugs and devices, even though it is likely to have a significant impact on clinical decision making. An example of under-regulation is digital mental health products, such as cognitive behaviour therapy tools, which are excluded from the TGA regulation requirements, meaning most digital mental health products can sidestep regulation.

There are other concerns, including that these principles of change are not applied evenly across the professions. Perhaps this is because there are unconscious biases that ground the reforms, or perhaps there may be other agendas that influence the way these strategies are applied. Regardless, the impact is that the benefits and costs of reforms are changing the workforce, increasing the roles of nurses, allied health practitioners and pharmacists, while nudging GPs out of the primary care workforce.

This reorganisation of the workforce has been enabled by governments and other agencies redistributing public trust.

Building trust in nurses, allied health practitioners and pharmacists in primary care

Since the pandemic, governments have publicly supported, endorsed and promoted nurses, midwives, allied health practitioners and pharmacists, increasing their autonomy, agency and status. Various state and federal governments have increased financial rewards for these professions and championed their roles to increase public respect. Governments have used consistent language in these communications, describing nurses, midwives, pharmacists and allied health professionals as “highly trained health professionals” working at the “top of their scope”. The “top of scope” phrase is an effective rhetorical device to disguise the extension of scope into new areas of clinical practice. There would be no need for additional training if professionals already had the skills they are now using, but clearly programs like the pharmacy UTI trials have required training.

Examples of increasing government trust include:

Midwives, who are now indemnified by the federal government for home births and intrapartum care. Importantly, Minister Butler has removed the requirement that these births be classified as low risk, endorsing a midwife’s capacity to make that decision independently.

Midwives and nurses are now able to prescribe without the oversight of a doctor. The language of this announcement is important. “This is about supporting a workforce that is almost exclusively women”, states Assistant Minister Kearney “to empower them to become small business owners, to build their own practices and run their own clinics, so that more people get the care they need.” Minister Butler is even more frank. “Since gaining access to Medicare in 2010, nurse practitioners and endorsed midwives were the only health professionals required by law to establish an arrangement with a doctor in order to provide Medicare services," Minister Butler states, “we can now see that this requirement has become a glass ceiling holding back our highly educated and highly valued nurses and midwives.”

By using the language of patriarchy and systemic misogyny, both Ministers simultaneously increase trust in nurses and midwives, while implying they have been “held back” by, presumably, the medical profession’s regulatory power and patriarchal attitudes.

Pharmacists are probably the profession that has benefited the most from these reforms, being funded and supported to deliver a range of extended services. Again, Minister Butler has endorsed, promoted and supported an increase in public trust for these initiatives and for the pharmacy profession as a whole. The language of “empowerment”, “top of scope”, “relieving the pressure on GPs and emergency departments” remains similar across these initiatives.

Decreasing trust in GPs

Table 1 demonstrates how governments, through current and planned reforms, reduce trust in GPs, and redistribute that trust to other primary care professionals. The policy levers are the same, but operate in the opposite direction, with decreased autonomy and financial reward, increased regulation and decreased respect. Frankly, the social contract for GPs is becoming untenable.

It is to be expected that highly trained professionals value their autonomy. Being unable to support patients, despite having the skills to do so, is the cause of moral injury, burnout and distress, and decimates the workforce, which partly explains the loss of GPs to practice in recent years.

 Unconscious bias

Despite the language of empowerment and respect, there are less obvious ways to diminish trust. In the ACT, there has been a sense that GPs have been sidelined in state government initiatives. To examine this, I undertook a study of ACT Health documents, analysing 430 000 words of ACT Health communications over a variety of media, including reports, social media posts, websites and Hansards. I then extracted the words used to describe the professions, and presented these in word clouds (see below). The results are disturbing, and demonstrate a system bias the redistributes government and public trust away from general practice. This may explain why ACT GP registrars experience twice the rates of bullying and harassment from the public and other professions than the national average.

Conclusion

At present, despite the rhetoric, there are clear signals that governments lack trust in the GP workforce. Without this trust, it is impossible for GPs to sustain the effective and efficient health care they are currently providing for the Australian community, which, in my view, is an extraordinary waste of a highly capable, efficient and effective workforce. There has been a sustained drop in investment in general practice year on year, and a clear redistribution of public trust, driven by government reform.

Perhaps it is time to analyse more carefully why reforms have been so uneven. We have long known the role of the social determinants of health in driving inequitable health care outcomes. With costs rising, and equity falling, it is important that all Australians consider the political determinants of health that also drive inequity.

Political determinants of health “involve the systematic process of structuring relationships, distributing resources, and administering power, operating simultaneously in ways that mutually reinforce or influence one another to shape opportunities” (Dawes, 2020). Manipulating public trust is one mechanism by which governments ensure a redistribution of relationships, resources and power. Using this lens, it is important to consider whether current reforms will achieve better outcomes, or whether the collapse of general practice will, in fact, cause considerable public harm.

Dr Louise Stone is a Canberra GP with clinical, research, teaching and policy expertise in mental health. She is an associate professor in the Social Foundations of Medicine group, Australian National University Medical School.