John Menadue. Co-payments and the government’s attack on general practice.

Jan 17, 2015

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A strong primary health care system based on general practise is the key to a sustainable health service. Unfortunately the government is doing its best to weaken general practice.

Primary care offers the best prospect of improved quality of care and increased efficiency, particularly through new work practices. The evidence is worldwide that primary care provides

  • A greater focus on prevention and chronic care for our ageing population.
  • Care at lower cost e.g. specialist care in Australia is more than double the cost of care by a general practioner.
  • Faster medical treatment
  • Consolidated service delivery to overcome fragmentations.
  • A seamless one-stop approach
  • Consolidated history with test results
  • Better access for all.

Primary care reform is the single most important strategy for improving our health and making the health system sustainable This is true for all countries, developed and undeveloped..

Community level prevention and primary care is essential to restoring universality and efficiency in Australian healthcare. Further, health services should be delivered at the most local level possible – the principle of subsidiarity.  The dignity of patients is best safe guarded by treating patients in their homes or as close to their homes as possible.

Hospitals should be the last resort. They are very expensive. A visit to a hospital emergency department costs ten times the cost of a visit to a GP. Too often politicians, the hospital lobby and the media keep telling us that hospitals and hospital beds are the top priority. They are not.

We need to improve general practice rather than weaken it as the government is doing. At the same time we need to review the way doctors are remunerated. Fee-for-service puts up costs and discourages integrated care. The government should consider two possible changes. The first is that the MBS schedule be amended to permit private practices to remunerate a supervising general practitioner in their practices. That supervising GP would be remunerated for over-sighting the treatment and referral of patients and their records. The second is that the government should offer to negotiate contracts with practices, both corporate and non-corporate, that will commit to the delivery of integrated care. I expect that the government would be agreeably surprised at the number of GP practices that would respond because of their concern about the ‘turnstile’ nature of a lot of general practice in Australia today. Doctors should be remunerated for keeping patients healthy rather than remunerating them when their patients are sick. What a perverse incentive we have in FFS!

A related key to a sustainable heath system is health workforce reform, particularly in primary care. We have tens of thousands of health professionals whose skills are underutilised or undeveloped – nurses, allied health, pharmacists and ambulance officers. About 10% of normal births in Australia are managed by midwives. In NZ it is over 90%. We have about 400 nurse practitioners when we should have thousands. The medical colleges have disproportionate influence in controlling access to the professions.  Medical training is strongly focused on acute care in hospitals, whereas most of the work of future doctors will be with chronically ill patients in the community. Few are trained to work in team practices. Primary care is not seen as an attractive option for young doctors. Only 13% of final year students have any interest in working in primary care, and only 13% would consider working in rural areas. General practice must be made more attractive and better paid compared with specialist care, but not via fee-for-service.

Our health sector is wracked by nineteenth century work practices. It is the largest part of the Australian workforce. It is the fastest growing. We are regularly told that we need to improve the productivity of the Australian workforce. But the largest part of the Australian workforce in the health sector is not mentioned. We have seen the dramatic benefits in productivity improvements through workforce reform in many areas. But those gains are small beer compared with the potential gains with health workforce reform, leveraged by such means as wider access to MBS and making all Commonwealth health funding conditional on substantial workforce reform.

We need substantially improved health work practices to improve the efficiency of our health sector and to lower health costs. It is also necessary to expand the professional opportunism for tens of thousands of health care workers.

But workforce reform is hard because the AMA is determined to protect the territory of doctors in the name of quality and safety in health care.

The key to a sustainable health system is in primary care and general practise associated with workforce reform. But the government is undermining general practise and talks endlessly about the need for workforce reform but is not game to tackle the vested interests in the health sector.


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