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Australia’s peak doctor groups are highly critical of aspects of the Scope of Practice Review.
The Unleashing the Potential of our Health Workforce – Scope of Practice Review final report was delivered last week. It’s caused a stir among Australia’s peak doctor groups but has been welcomed by the nation’s nurses and midwives.
The review was led by Professor Mark Cormack who calls it an “ambitious program of work to reform our primary care workforce to deliver high quality, equitable, integrated and sustainable healthcare for Australian communities”.
The report contains 18 recommendations.
The Royal Australian College of General Practitioners (RACGP) as well as the Australian Medical Association (AMA) are urging the government to be cautious in its assessment and response to the report.
More costs, more delays
The RACGP warns that the recommendations may sound good but will create a more costly health care system, delays to care and an increase in out-of-pocket costs to patients.
“This is a report, not a plan, but its recommendations will raid Medicare and set us up for a two-tiered health system where those who can afford to see a GP will, and those who can’t, don’t,” RACGP President Dr Nicole Higgins said.
The RACGP slammed the review’s recommendation for direct referrals to specialists for “something a GP can do” and can lead to “inappropriate referrals.”
“This isn’t gatekeeping, it’s coordination of a patient’s care by a GP who knows them, their history, and who can make the link between the medical implications of different types of care and results and a patient’s health and needs,” Dr Higgins said.
“Dropping that coordination will lead to a free for all, without a GP’s oversight to ensure care is necessary and in a patient’s interest, and no doctors and other health professionals duplicating each other’s work,” she said.
“There’s also a risk of more inappropriate referrals as patients are sent to non-GP specialists in greater numbers, including specialisations already facing workforce shortages,” Dr Higgins said.
That will increase out-of-pocket costs for patients already struggling with cost-of-living pressures, and delay their care as they wait to see specialists already in short supply.”
UK comparisons
The AMA warns of adopting an NHS style approach that had “doomed primary care” in the United Kingdom.
“We have always been very supportive of enhancing collaborative multidisciplinary care and ensuring all health professionals can work to their full breadth of scope in primary care, but this requires better funding models and improvements to the many reforms currently underway in general practice, such as MyMedicare,” AMA President Dr Danielle McMullen said.
The RACGP also raised the situation in the UK.
“Rather than investing in general practice, they substituted less qualified health professionals without medical training for GPs – it was disastrous. There was not just lower quality care, but real harm, including misdiagnosis that ended with a patient’s death,” Dr Higgins said.
The nursing perspective
Not every health practitioner group criticised the review. Australia’s nurses have welcomed the findings and recommendations.
“The community benefits when the nursing profession is empowered and supported to work to its full scope of practice,” the Australian College of Nursing (ACN) CEO, Professor Kathryn Zeitz said.
“The review acknowledges and explains the restrictions, barriers, and inconsistencies across states and territories that prevent nurses, nurse practitioners and midwives from working to the full capability of their skills, education and experience,” she said.
“ACN agrees with Minister Butler when he said in releasing the final report ‘removing these barriers would make it easier for Australians to get high quality care, when and where they need it, without waiting weeks for an appointment’,” Professor Zeitz said.
Professor Zeitz said the review findings highlight that general community awareness of the scope of practice of all health professionals is limited.
Some cautious support
There was some support from the doctor groups for the review.
The RACGP conditionally supports the recommendation of a body to provide evidence-based advice on workforce innovation (as long as it’s politically independent). It also gives “cautious support” to the recommendation for the funding and introduction of a new “blended payment” to enable access to multidisciplinary health care.
The AMA supports the recommendation of greater consistency in regulation across jurisdictions.
The AMA said decisions about standards of training and clinical practice must be made by independent, profession-led bodies, not politicians as the report suggests.
“Regulation of health professionals exists to protect the community and ensure the highest standards of care for patients, and this is not something that politicians should be meddling in,” Dr McMullen said.
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Latest set of potential disasters from “empowered” pharmacists who think they know better than the GP:
– last week saw 5 patients who reported not taking prescribed medication on pharmacists advice, for up to 6 months, with neither pharmacists nor patients considering following up directly with prescribing GP
– one patient already had poorly controlled diabetes, and was advised not to take additional medication due to potential (and usually transient) side effect, which they had already been advised of – no consideration by pharmacist of potential serious complications of poorly controlled diabetes
– another with a recurrent UTI had antibiotic course shortened by pharmacist resulting in failure of treatment, further recurrence with resistant strain requiring broader spectrum antibiotics which resulted in unnecessary GI side effects
– other cases fortunately did not appear to have significant consequences, although the potential is always there
I have huge respect for pharmacists practising within their training, and calling me to clarify details if they have any concerns, but they are not doctors and should not be making treatment decisions outside the scope of their training. And given that about 40% of self diagnosed UTI’s presenting to me are not UTI, this and other pharmacy prescribing should be halted immediately on safety grounds. Politicians with no medical experience should not be deciding who has the knowledge and diagnostic skills to prescribe (including examination and investigation, which cannot happen in a pharmacy). I’ve also lost count of the cases of non-bacterial conjunctivitis which have been unsuccessfully treated with chloramphenicol since that was downgraded from S4.
Professor Mark Cormack calls it an “ambitious program … to deliver high quality, equitable, integrated and sustainable healthcare”. It is hard to see how downgrading medical care to nurses and osteopaths is “high quality”, how encouraging non-medical consultations is equitable, how fragmenting medical care to allied health practitioners is “integrated”, or how further eroding the role of the GP creates “sustainable healthcare”. These are simple platitudes and nonsense to pull the wool over the Health Ministers eyes. The report should be filed where it belongs, in the bin.
One of the major problems with our current health service is that it isn’t run by trained & experienced Healthcare Professionals. It has progressively been taken over by bureaucrats who to a large extent don’t know what they are doing, so they are totally risk averse and focused on the budget. When there’s a budget problem their answer is to appoint more bureaucrats to collect more data rather than appoint more health professionals to make things more efficient.
About two decades ago the CEO of one of the private hospitals in Brisbane told me that if you compared the ratio of true inpatient beds to non-clinical staff ( clinical staff including all doctors, nurses, allied health professionals) you would find it was 5.5 times greater in the public system than the private system. These people set hospital protocols that clinical professionals were obliged to follow for fear of administrative retribution. An example was a nurse who called an emergency alert on a patient because a patients blood pressure post-op was outside so called acceptable limits. This happened while there was a senior surgeon, surgical fellow, surgical registrar and anaesthetic fellow by the bedside. She knew it was unnecessary but was obliged to follow the protocol. What a total waste of time and resources.
This review recommends “task shifting” which occurs in low- and middle-income countries – why is Australia moving to this model?
Is this what the public want and deserve? The government is cheating the Australian public by making them pay a medicare levy as a public health insurance scheme but not using that levy to pay for medical practitioner-led care. Much as we respect the scope of allied health, the diagnostic algorithm that medical practitioners undertake with each patient cannot be “task shifted” to non-medical practitioners. This is moving medical care in Australia to what occurs in low- and middle-income countries.
And….. and politicians bothered to hear from non GP specialists whether they think this is better care and if they want to have referrals from non doctors with a very skewed scope of practice on a predefined range of conditions?
If you see the world through the lens of a hammer..