DOCTORS REFORM SOCIETY

Address to the Victorian Healthcare Association Annual Conference
Thursday 16th October. Melbourne
Debate:
That doctors are the cornerstones of primary healthcare.
Dr Tim Woodruff,
President, Doctors Reform Society

Thank you for asking me to address the proposition that ‘doctors are the cornerstones of primary health care’

If they are currently, they shouldn’t be. Patients should be. The fact that we have in this country a health system which uses a funding system for primary care which is centred around funding providers, not patients, not need, ie the Medicare and PBS, is a sad reflection that patients are not the cornerstone of primary care.

However I think I’m correct in saying that this debate today is about how General Practitioners and other health professionals fit into the primary health care system. Technically we’re really talking about what many call primary care as primary health care is often used to mean the broader picture including population health over which primary care professionals have little impact.

The current situation is such that the General Practitioner is central to the care in the majority of situations but there are an increasing number of situations in which the General Practitioner is not central. For example, patients with clearly traumatic musculoskeletal problems will visit a physiotherapist, chiropractor, osteopath, or podiatrist, those with weight problems visit a dietician or exercise physiologist, and those with psychological problems visit psychologist and counsellors. If a patient can afford to access private allied health or dental care, then this occurs with taxpayer support without any contact with a General Practitioner.

For those who cannot afford such access, the access to such practitioners is much more limited, firstly because General Practitioner referral is generally required, secondly because funding is an issue, and thirdly because in many situations access to a General Practitioner is an issue. Thus, government currently funds one system which requires General Practitioners to be the cornerstone and another system which bypasses the General Practitioners, the difference being largely the socio-economic status of the patient. Optometry is a little unusual in that government funds the bypassing of the General Practitioner for all and clearly relies on the expertise of the optometrist to recognise those conditions for which specific General Practitioner or specialist care are required.

So is there an issue with patients bypassing General Practitioners? A patient with Cushing’s disease, a tumour of the pituitary gland which may present with obesity, and may be seen by a dietician and the diagnosis may be missed. This was the concern of the AMA president which she detailed in her address to the National Press Club a few months ago, but it was in relation to a dietician in a Superclinic, and the patient was seeing the dietician because a receptionist had suggested she didn’t need to see the General Practitioner first. But Dr Capolingua went on to say ‘Patients directly access allied health providers now and should be able to continue to do so.’ I agree. But rather than seeing such professionals in a fee for service small business environment if they can afford it, I think they should be seen in an integrated primary health centre where finance is not a barrier to access and where it is much more likely that whoever they see will easily and comfortably ask formally or informally for input from other members of the team as necessary.

There is no doubt in my mind that General Practitioners are the best trained health professional to perform a detailed assessment and diagnosis of a patient with a complex medical problem. There is also no doubt in my mind that a physiotherapist may be better than many General Practitioners in assessing and treating a sprained ankle. General Practitioners in my view have possibly the most difficult task in medicine, certainly much more difficult than a specialist. They are expected to know enough about everything to enable them to know when they are out of their depth and need further advice and to provide treatment for almost any problem. A specialist, whether medical, or a physiotherapist, or a psychologist, is expected to know all there is to know about their much narrower area of expertise.

So, given that patients are actually the cornerstone of primary care, how best is it that we can move forward with the different health professionals to get the best possible outcome for patients?

Patients will have their own thoughts on who is best suited to their needs. They are constrained in making choices now by barriers including financial and geographic. But there remains a general tendency for patients to seek a General Practitioners opinion if there is a concern that something serious is wrong.

What is desperately needed is a collaborative approach to both assessment and treatment of patients. Teamwork is the buzz word. The barriers to teamwork are multiple. They include a lack of capacity to talk to other members of the team both formally and informally, different funding mechanisms for different professionals, demands of fee for service to deliver an adequate income, lack of professional development, and consumer input into what are the priorities. Of course there exists across Australia some examples of first class teams working together despite all the barriers. They are not the norm and they need to be.

What is needed is a model which promotes teamwork.  There are several requirements for optimal functioning of a team. Firstly, co-location, as in the Victorian community health centre model or the Superclinic model must make teamwork more likely. It’s often more convenient for patients. But geography and numbers may make it impractical. Secondly, the funding model needs to be one which promotes co-operation between members and avoids perverse incentives. Having all the staff funded in a similar way would be a start. Fee for service for General Practitioners and salaried service for the rest works against fostering teamwork. It does not make it impossible. Salaried service has its problems. On a salary, there is the possibility of not working so hard. But being part of a team can counteract that as all are striving for the same goals under similar conditions. Thirdly funding for professional development is required. It necessarily would have all the relevant members of the team learning together rather than have doctors learning at a drug company funded dinner whilst allied health professionals go to their own less salubrious meeting. Fourthly, simplifying the funding is necessary to reduce the multiple sources of funds and multiple accountability measures and to get money directed tp patients rather than programs. Consumer and citizen input in how the team works and how it determines its priorities is also essential given my first proposition ie that patients are the cornerstone of primary health care.

When such a team is the norm, the likelihood of referral to the most appropriate person will increase because they are all used to working together. Those patients who self refer to a dietician with their obesity will see a professional who will be much more likely to pick something not quite right about the patient and refer to the General Practitioner down the corridor.

Who should decide what to do with the patient at the front desk? A receptionist, a nurse practitioner, or should they all go to the doctor? That’s something which needs ongoing assessment as different models of triaging are implemented. Appropriate training is the key to the most efficient method of triaging. Where patients aren’t all seen by the doctor, it’s imperative that the outcome of such practice is assessed, given the many different possible models. But given that we already have a system which allows and indeed finances patients to see professionals other than General Practitioners as first contact and patients are often happy with that, it seems somewhat conservative to suggest we can’t improve on that rather than waste the time of the most highly trained professional seeing patients that don’t require his/ her expertise.

Nurse practitioner lead clinics in the UK have had mixed results, with reports of better patient satisfaction but increased costs because more patients end up seeing both a nurse practitioner and a doctor. But nurse practitioners working with increased responsibility in a team with a doctor, permitting the doctor to concentrate on the most highly skilled aspects of care would seem to be a sensible option. The scope for such an option is limited however, by the workforce shortage which affects all health professionals. In places of doctor shortage in Australia other health professionals are the first contact, and sometimes the only contact for the patient. There is nothing optimal about that. Better training for such people is appropriate but it is second best to having adequate distribution of doctors who remain the most highly trained health professional on the frontline of primary care.