articles

First published: Friday, November 21, 2008

Are doctors 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 centred around funding providers – not patients, not need – is a sad reflection that patients are no longer the cornerstone of primary care.

However I think I’m correct in saying that the debate today is about how GPs and other health professionals fit into the primary health care system. Technically we’re really talking about what many call “primary care” as the term “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 GP is central to care in the majority of situations – but there are an increasing number of situations in which the role of the GP 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 and without any contact with a GP.

For those who cannot afford such access, the access to such practitioners is limited. This is so firstly because GP referral is generally required, secondly because funding is an issue, and thirdly because access to a GP can also be a problem. Thus, government currently funds one system which requires GPs to be the cornerstone and another system which bypasses GPs entirely, the difference being largely the socio-economic status of the patient. Optometry, it should be noted, is a little unusual in that government funds the bypassing of GPs for all and clearly relies on the expertise of the optometrist to recognise those conditions for which specific GP or specialist care is required.

So is there a problem with patients bypassing GPs? When AMA President Dr Rosana Capolingua addressed the National Press Club a few months ago, she raised the example of a patient with Cushings disease, a tumour of the pituitary gland which may present with obesity. Her concern was that this patient may be seen by a dietician and the diagnosis missed. Her example was raised in relation to a dietician in a Superclinic: the patient was seeing the dietician because a receptionist had suggested she didn’t need to see a GP first.

Dr Capolingua continued, “Patients directly access allied health providers now and should be able to continue to do so.” I agree. But rather than patients seeing such professionals in a fee-for-service small business environment, – if they can afford it – I think these professionals 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 GPs are the best trained health professionals 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 GPs in assessing and treating a sprained ankle. GPs 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.

What is desperately needed is a collaborative approach to the assessment and treatment of patients: “teamwork” is the buzz word. There are several requirements for teams to function optimally. 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 and avoids perverse incentives. Having all staff funded in a similar way would be a start: fee-for-service for GPs and salaried service for other providers works against fostering teamwork. Thirdly, funding for professional development is required. It would entail 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 streamline the multiple sources of funds and multiple accountability measures so that money is directed towards patients rather than programs. Finally, consumer and citizen input on how the team works and how it determines its priorities is also essential given my central proposition 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 all parties are 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 GP down the corridor.

Back to the front desk. Who should decide what to do with the patient when they arrive at a primary health care centre? 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 GPs as first contact and patients are often happy with that, it seems 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 their 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.

This is an edited version of an
address delivered by Tim Woodruff to the Victorian Healthcare Association
Annual Conference on 16^th October 2008.