You can call this a mea culpa, if you like.
General Practice Accreditation is one of several initiatives developed since the early 1990s that aimed to enhance the quality of care provided to Australians by general practitioners, and to equip the general practice sector to respond to emerging trends, challenges and opportunities as the health system evolved.
With its inception in the 1990s, and subsequent linking to government funding through the Practice Incentives Program (PIP) in 2000, the general practice accreditation system was underpinned by several key principles. These included that the process should be controlled and funded by the general practice profession; that assessments should be conducted by peers; and that to ensure equal access and affordability for small (including metropolitan) and rural and remote practices, fees should be based on a “community rating” arrangement. Under this model, accreditation for these practices would be cross-subsidised by higher fees charged for larger, and perhaps more easily serviced, practices.
Historically, in some sense, accreditation sought to define a general practice and the minimal service and quality requirements, on which the government was prepared to invest. With recent changes to the RACGP definition of general practice and to the scope of general practice over time, this definitional imperative appears to have diminished relevance. So called non-traditional practices are now accommodated under the National General Practice Accreditation Scheme (NGPA Scheme) and as such are eligible for payments under the Practice Incentives Program (PIP)
Given the significant taxpayer investment in general practice and direct payments through the PIP resulting from accreditation, it is pertinent, after twenty-five years to ask whether accreditation is achieving its desired outcomes, or indeed whether these goals might be more efficiently or effectively achieved in other ways that benefit practices and patients.
With increasing regulation under the administration of the Australian Commission on Safety and Quality in Health Care (ACSQHC), the notion of professional control is moot. While the RACGP still maintains a monopoly over the standards under the NGPA Scheme, these standards are frequently criticised by practices for their complexity, or lack of relevance to safety and quality in general practice. They can lack interpretability for consistent assessment in a number of indicators. The standards have also undergone changes over successive editions, such as removal or downgrading of requirements for after hours care and limits to the number of consultation per hour, that do not necessarily reflect community priorities with regard to access and service delivery and affordability.
Virtually all practices applying for accreditation are now certified to these minimal standards. There is thus no public discrimination between the vast majority of certified practices and no real public awareness of the standards against which practices are accredited. The ACSQHC, as empowered under legislation, has developed Primary and Community Health Care Standards, focusing on safety and quality, that could, just as readily be applied under the Scheme. Their approval for the NGPA Scheme would provide a powerful vehicle for choice, particularly for remote health services and others that provide multi-disciplinary models of primary health care.
There is also no unanimous support among practices for the contention that accreditation actually leads to better patient care. It is reported that practices see accreditation as a tick-a-box exercise and a bureaucratic hurdle to access government funding. Accreditation is taken to be a Practice Manager responsibility, rather than a whole of practice quality assurance opportunity. GPs are typically not engaged in accreditation. In fact, the first published draft 6th edition of the standards, disengages them even further from the process as the politics of payroll tax and the independent contractor model of engagement of GPs plays out.
Ongoing compliance with the standards by practices is also problematic, as again noted by the Australian National Audit Office in 2010-2011 and the 2021 mpconsulting review. Assessment is currently through a point in time assessment every three years by two surveyors, including one GP. Given that at the time of the survey visit, now over 70% of practices across all accrediting agencies do not meet all mandatory indicators, ipso facto, practices do not meet the standards across the length of the accreditation cycle.
Consistency of assessment processes and standards interpretation between agencies and surveyor teams remains a challenge and receives commentary in various general practice social media fora. Significant variation between accrediting agencies with assessment of the standards has been reported by the ANAO in 2010-2011 and differences between agencies remain in standards compliance data.
So what is the impact of accreditation on patient safety? With successive accreditation cycles the same non-conformities recur. The commonest non-conformity across all accrediting agencies, reported by the ACSQHC, relates to completion and recording of practitioner continuing professional development (including cardio-pulmonary resuscitation). With Medical Board oversight and CPD homes, this is now a requirement for medical registration. But there are other perhaps more significant areas where practice systems are not robust enough, or are not monitored through a quality assurance process within practices, and compliance at the successive assessment survey visits is problematic. These include standards relating to content of medical records, communication with patients, business continuity and information security, recall and reminder systems, infection control and vaccine storage and cold chain processes. The root cause of some of these systemic problems is clearly not being appropriately addressed by a point in time, tick-a-box accreditation system. Yet they may only come to light when a complaint is made or harm to patients occurs. Accreditation, as it currently applies, appears to have limited impact on risk management, patient complaints or incident prevention in general practice.
Many of these issues could be addressed through a more rigorous and perhaps more punitive but unwelcome, accreditation system that meets higher standards for assessment integrity; or one where there is a process for surveillance and improved practice support. But such an approach might not provide the necessary leverage with all practices to improve patient care, when there is an expectation and systemic pressure that all practices ultimately become certified. General practice has significant corporate investment with some very large market players. Discounting to gain a greater share of this more lucrative market (namely larger practices or groups) is a business strategy used by some agencies. This discounting breaks down the fundamental principle of cross subsidisation, initially established for accreditation, namely that there be no financial or other disincentives for smaller or rural and remote practices. With price becoming negotiable to attract market share, what else is potentially exposed?
Alternatives to a point in time accreditation are available. Use of information technology and AI systems could have a role. If accreditation is removed as the entry point for PIP or other funding, for example, other quality measures from data sources relating to patient safety and quality might apply and be used for funding.
Funding might also be based on demonstrated ongoing compliance with the reporting of evidence based activities which have a high predictive level for patient safety and quality care.
Using a mix of available data and a targeted audit approach, the current point in time accreditation scheme could be replaced by individualised certification of operational and clinical systems that perhaps more directly relate to patient safety and quality.
A layered approach to funding based on meeting specific metrics or quality benchmarks might reinforce behaviour and service delivery. Baseline funding could be provided through a continuity index which provides a metric to assess the comprehensive and continuing care aspect of general practice. This funding would reward practices, for example, where patients are usually seen and followed up by the same practitioner, an indicator that was previously, but no longer included in the standards.
Other performance measures might include centralised:
- regular content reviews and clinical audits of medical records, perhaps AI driven, which would be more detailed than current accreditation based medical records audits;
- online, realtime, every time, patient feedback systems;
- online reporting of vaccine storage and cold chain monitoring and breaches;
- systems for receipt and management of complaints to which practices might subscribe, and
- nationwide incident reporting systems by practices and patients to which practices might subscribe.
Practices would then be paid based on completion of activities and performance in meeting defined standards metrics and demonstrated improvement through every day practice.
Summary –
General practices should not be corralled into a system that has inherent inconsistencies with interpretation of standards or assessment processes and which does not represent a transparent indication quality for patients. Ultimately the system and all stakeholders, including accrediting agencies, need to be accountable to patients and taxpayers.
Does the current system of accreditation support general practices in a time of uncertainty, help secure the future of general practice or provide ongoing assurance as to patient safety and quality of care? If not, accreditation needs to be fixed or replaced with a more dynamic, flexible and evidence based approach. Practices, patients and taxpayers deserve better. The focus needs to shift from a point in time, tick-a-box accreditation, to one where a systems based approach to quality assurance is embedded in every day practice and supported by ongoing monitoring and with quality better recognised.
Accreditation could still be a feature of the general practice landscape, but one which has its intent in providing a public recognition of a practice prepared to go beyond minimal standards to adopt a whole of practice, whole of cycle approach to quality assurance, improvement and risk management.
This would not necessarily be a requirement for funding through the PIP or other grant arrangements which would be modified using modern technologies to address evidence based activities that support quality improvement and enhanced patient care and safety.
The viability and centrality of general practice in the health system requires policy stability and a focus on patient needs. The Government is addressing affordability through significant increased investment in general practice; improving access through the roll out of Medicare Urgent Care Clinics, 1800 Medicare and a push towards funding for multidisciplinary and chronic disease care models. The scope of these initiatives will be subject to debate and there will always be calls that more is needed. However, successive reviews, stakeholder feedback and compliance data have demonstrated that a more robust quality assurance foundation is required to underpin these initiatives, provide general practices with more certainty and ensure greater accountability for the investment made by taxpayers.
About the author
Dr Paul Mara AM FACRRM FRACGP FAMA is a procedural rural practitioner, closer to retirement than registration. He has a long term interest in medico-politics, workforce and quality in general and rural practice, negotiated much of the 90’s reforms in general practice and coordinated the original local demonstration trials of standards and accreditation in general practices in the 1990s.
He is Founder and current Managing Director of Quality Practice Accreditation, an independent quality assurance, risk management and accreditation agency approved by the ACSQHC under the NGPA Scheme.
1 The PIP and associated payments are around 8-10% of payments to GPs through Medicare.
2 Review of General Practice Accreditation Arrangements, mpconsulting Oct 2021
3 Australian Commission on Safety and Quality in Health Care published data
4 Review of General Practice Accreditation Arrangements, mpconsulting Oct 2021
5 Australian National Audit Office (Performance Audit Report No 5 2010-2011 into the PIP)
6 Through Strengthening Medicare initiatives and increased incentives