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NHHRC foreshadows ‘reform’ for general practice
vicdoc, October 2009
Change is coming in general practice. The National Health and Hospitals Reform Commission report provides a blueprint for the biggest shake up in general practice we’ve ever seen.
A big call? Sure. But let’s look at the evidence.
Medibank was big, as was Medicare, but both were more about payments than structure. The General Practice Strategy in the early nineties brought us the vocational register, divisions, blended payments and accreditation. Pretty big changes, but general practice could continue business as usual if it chose
The Commission report presents the potential for even bigger changes for general practice.
Prime Minister Rudd and Minister Roxon have embarked on a national listening tour and plan to visit a long list of public hospitals to hear the views of doctors, nurses, allied health providers and patients.
AMA Victoria has attended these local hospital consultations but the biggest changes proposed by the Commission will affect general practice. We and the Royal Australian College of General Practitioners (RACGP) in Victoria have invited Minister Roxon to extend her listening tour and attend a GP consultation session at AMA House to hear from GPs themselves. We are awaiting her response.
In the meantime GPs have raised concerns with me about the vision of the Commission’s report, and where it leaves their communities and their businesses. They want to know whether this report signals the end of small and solo general practice. Will voluntary enrolment become mandatory enrolment? How do we prevent fragmentation of care, reduce cost-shifting and cut red tape?
While the Commission’s report does not outline substitution of care, it fails to point to general practitioners as the centre of patient care. Instead the report says we may see ‘primary care providers’ being central — including but not limited to GPs. The importance of the rhetoric cannot be underestimated.
If the Commission has its way, our most vulnerable patients may lose their automatic right choice of doctor, in favour of voluntary enrolment. I hope they choose wisely.
I can see a scenario where aggressive and well-resourced practices will seek to maximise their enrolments. We have already seen allied health providers in Victoria offer plasma televisions to aged care facilities who sign up for EPC items with ‘their doctor’, with explicit instructions not to tell the residents’ GP. When patient enrolment funds are available to practices, we could see all sorts of behaviour as practices seek a monetary advantage.
The Divisions of General Practice — with more than 2500 staff (one for every eight GPs), and around $200 million in annual funding — have already rolled over and accepted their demise. Whether we see Divisions as serving general practitioners (their nominal sponsors) or government (their paymasters), I’ve been bitterly disappointed with their immediate acquiescence to the big-government agenda.
The Divisions expect a phoenix-like revival as Primary Healthcare Organisations, where GP control will be at the very least diluted. I’d also argue that the confidence of the 2500-plus staff that their futures will be assured with the proposed Primary Healthcare Organisations is naïve, given the performance of some of the Divisions.
Our practices will be torn apart and put back together as Comprehensive Primary Healthcare Centres. Who will own them? Who will control them? State-based primary health care will disappear. Community health centres will be under significant threat, along with a range of other employment options. GPs who do not take up the ever-decreasing options to run their own business will be at the mercy of a much smaller pool of employers.
General practice is a microcosm of the challenges in Australia’s health system. There are the typical difficulties posed by a federal health system: cost shifting, blame shifting and hoping the other level of government blinks first. There are community- and institution-based care providers, including hospitals, residential facilities and general practice, which do not communicate well.
There is an astonishing amount of red tape, process-driven care and a myriad of government and community programs that are difficult to navigate. There are armies of well-intentioned people who still have trouble connecting services to people.
There are plenty of threats outlined in the Commission report. But every threat is an opportunity. General practice is strong, if fragmented. All the evidence around the world demonstrates that quality general practice is a wonderful investment in the community’s health. General practice is efficient. We are very good at what we do.
However, it will take will and desire to turn the threats into opportunities. We can take the lead. The medical profession is in a unique position to see health problems from a variety of perspectives. We have doctors caring for patients in general practice, residential facilities and hospitals. There are doctors in research, doing home visits, and leading in public health. Medicine can, and should, provide leadership to the community. We need to marshal all of the profession’s resources to buttress and build general practice.
With all the talk of systems, it is important to remember that we are actually talking about people. That’s why we are here — to provide services to people.
It seems that for every issue that’s discussed, two more are raised. The medical profession must take a central role in these debates. There are tough and complex issues facing the profession and the community.
As a profession, general practice can sit back and wait for someone, somewhere, to come up with the answers. If we take this path, we need to hope that the solutions work, and that those solutions come on time.
If we are relying on government, then a timely solution may be a bit much to hope for.
When life gets hard, people look to general practice for help, advice and assistance. Similarly, when the public debate is difficult, the community will be looking to the medical profession to take a leadership role in encouraging public debate.
Doctors must take the lead in ensuring governments’ responses to the National Health and Hospital Reform Commission report are coordinated by general practice, team-based and underpinned by the best in patient care.
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