My background is in rural generalist practice in a small rural community and hospital. Obstetrics, anaesthetics, private general practice and over 38 years of getting out of bed 3 or 4 times a week and every weekend treating community acute care or highway emergencies. This was my general practice. It was the best of times. It was sometimes, perhaps, the worst of times.
When we first moved to Gundagai in 1982, there was no mandatory training, We became Fellows when Fellowship was voluntary and not taken up by many GPs. There was no Strengthening Medicare, no MyMedicare, no bulk-billing Medicare, no Medicare, no on-call allowances and a call out at night paid $12.50. The only remaining doctor in Gundagai, who had been there since the year we were born, told us nostalgically about the good old days and said that general practice wasn’t fun any more. But nostalgia is a false mistress and as the Canadian Prime Minister, Mark Carney said, it’s certainly “not a strategy”. Like it or not general practice has changed. Patients have changed, and no longer necessarily feel confined or committed to one GP. Doctors have changed and no longer necessarily have the confidence or feel a responsibility in providing continuity of care or a comprehensive range of services. The scope of general practice has changed, focus on illness has changed, training has changed, workforce has changed, funding has changed.
My experience has been that attempting to define general practice is a loser’s game, played on shifting sands. Definitions will never keep up with rapidly evolving practice or patient needs.
If we’re honest, defining general practice has always been about protecting a patch, and rent seeking. When corporate medicine was spawned with the introduction of Medicare, the definition of general practice and later accreditation standards, were articulated to protect smaller, doctor or family run practices, and indeed traditional care models, from corporate medicine. That went well didn’t it.
With accreditation, the original standards were in fact definitional. They defined the basis on which the government was prepared to invest in a general practice. Now, not only have the standards changed, not always for the better, they are no longer definitional. It seems to some the government is rewarding bulk billing more than quality.
The RACGP has recently (again), in a struggling attempt to keep up and maintain control of a primary health care agenda it is unfortunately losing, changed its definition to accommodate so called non-traditional models of general practice under the National General Practice Accreditation Scheme.
But who gets in or out is pretty arbitrary. Are general practices even general practices anymore or simply management services companies. Opening the door to non-traditional models has meant that the standards have been watered down, with many of the indicators being deemed “not applicable”. The shifting definitions have also potentially opened the door for shonky providers and practices, like what has been seen in the NDIS and elsewhere, to get involved in general practice. Now independent contractor doctors, perhaps with a special interest, while currently working in an accredited general practice, are seeking accreditation in their own right, and along with it access to their own PIP funding, with the obvious financial implications for the practices they work in.
Patients ultimately will define what a general practice is and what their care needs are. Individual doctors will ultimately decide what services they can provide. If patients choose to go to a woman’s or sexual health clinic, or a skin cancer clinic or get their flu vaccine from a pharmacist, seek advice from an after hours telephone service or urgent care clinic, then no definition will change that. If the only option for patients in a remote area is a nurse led clinic with a doctor providing support by telehealth, then a definition doesn’t change that reality.
Let’s face it. Many patients are simply seeking care from these providers because they cannot access the care they feel they need, when they need it, or feel embarrassed to seek the care they need, from their usual GP. Its not just about clever marketing. Patients in Gundagai sometimes sought after hours advice from a health hot line even though we provided 24/7 care. When asked why, they said they knew how busy we were and didn’t want to bother us unnecessarily.
The current definition decision making process has no formal right of appeal. It does not respect patient or practitioner options or choice. It has little justification based on outcomes.
If the RACGP says that a service is not a general practice and can’t be accredited, then patients seeking these services are denied assurance as to the quality and safety of those services. Don’t patients have a right to expect that when they receive a vaccine from a nurse or pharmacist that there is an audited cold chain and vaccine storage process? Or if a mole is removed from a patient in a skin cancer clinic, that the doctors have the qualifications, skills and training to perform the procedure, provide proper information to the patient and that infection control and sterilisation procedures are maintained.
Why should general practices have to be accredited to access funding, but not urgent care centres, women’s health services, sexual health clinics, urgent care clinics, nurse led clinics in rural and remote areas that are too small or isolated to get a doctor, pharmacists providing general practice advice, and after hours telehealth services?
Government has made a considerable investment in general practice. We can argue about whether this is enough. We can argue about whether this is more about politics or policy. But they are targeting access and affordability. The next step is accountability. If we exclude some sub-specialty clinics from the definition of general practice, we remove these practices from any responsibility for meeting standards that traditional general practices have to meet. We also deny these clinics access to incentive funds that improve affordability for patients and probably the quality of care that can be provided.
The worth of any service is not predicated on an arbitrary definition. Capital will follow opportunity and people will follow the money. If the definition is about what a general practice should be now, it will never keep up. If the government is prepared to fund a medical service, then the nature of this service might be subject to discussion or argument, but ultimately the funding formula will inform and drive practice. If we believe in continuity of care, then embed this in the PIP incentive algorithm, not in some definitional rhetoric.
In the past the unique market advantage GPs had was almost exclusivity with prescribing and referrals. GPs were true gate-keepers. Formalising a training pathway and being labelled a specialist was supposed to improve the quality of general practice and access for patients in rural and remote areas. It was supposed to address perceptions of general practice being a fall back option, and improve incomes. Has that really happened?
Some may say that I’m only interested in opening up accreditation to grow a market. Look again. The real advantage GPs have, and perhaps always have had, is their commitment to quality in providing for their patients. Supporting this commitment to improving patient care is what matters. Aristotle said that excellence is a habit not an act. GPs don’t need a definition to know what excellence is in their practice. Their patients already tell them.