Primary care is not a car to be stripped for parts

4 minute read

Task substitution is not the way to help medical and other practitioners work together for the good of the patient, top GPs warn.

Extending allied health scope of practice via task substitution is a false economy, leading GPs have warned scope of practice review chief Professor Mark Cormack. 

Speaking at an AMA webinar on Tuesday, medical association vice president Dr Danielle McMullen said there was growing concern among her fellow GPs that the review outcome would lead to fragmented care.

“GPs are really scared that we’re going to fall through the cracks and that the solution will be seen as task substitution by others, with the view that it means we’re going to [free up] GP time,” she said.

“And I think that is a flawed view.”

Instead of looking at discrete task substitution, Dr McMullen said, the reviewers should look to the examples of successful multidisciplinary teams that already exist, like nurse-led diabetes clinics.

“What we want to make sure is that we’re genuinely building models of people working collaboratively together, not just chunking up primary care into little bits and spreading them around without any collaboration,” she told The Medical Republic.

“Because there’s a risk there that you could – whether it’s GPs, pharmacists, nurses or other allied health staff – give everyone a bunch of little tasks.

“But unless you coordinate all of that, you’re going to end up with a more fragmented system, rather than a team working together for the best outcomes for patients.”

To former RACGP president Adjunct Professor Karen Price, the issue of task substitution goes to the heart of general practice.

“This whole [idea] that somehow someone focusing on one very tiny body part is of greater service to the community – the whole hierarchy is wrong, because we are all interdependent,” she told TMR.

“And we need to recognise that someone having an overall view of the system and of the body and of the person, that can also retain that person centred approach … that’s the person who can hopefully, appropriately apply the healthcare resources the country has.

“To do without that will harm patients in the long run.”

Primary care, she said, is not mechanical or linear – it can’t be broken down into parts like a car.

“I’m very happy for my patients to be treated appropriately by a physio and by a nurse practitioner and by a pharmacist, but to divide them up by condition without care coordination is a recipe for expense,” Professor Price said.

It’s a sentiment that Professor Cormack seems to have picked up on.

“The important message from this work is that we’re not talking about ad hoc extensions of scope or grab bags of tasks from one profession over to another,” he told AMA members on Tuesday.

“This is all professionals working to their full scope of practice in the context of a multidisciplinary care team in the primary healthcare setting, and I think that’s a very, very important safeguard.”

Another key topic covered in the webinar was on indemnity and whether GPs taking on a more central role in the patient journey could have expensive repercussions.

According to Professor Cormack, the review team has already had some “highly illuminating” conversations with medical indemnity insurance providers on the topic.

“The worst possible outcome would be that there’s an additional cost burden on an already stretched part of the healthcare system,” he said.

“I think that’s why we call out clinical governance, because the best way to manage insurance premiums is to have mature risk management and proactive strategies in place.”

The problem here is that, while hospitals tend to be large and well-funded enough to allow clinicians non-clinical time to focus on things like clinical governance, the same cannot be said for primary care.

“It is so vital that in the implementation of any and all of the team-based care stuff that … government understands it takes time and money to step back from direct patient care to make sure that your clinic is operating effectively and delivering best practice care,” Dr McMullen said.

Professor Cormack foreshadowed another release from the review team coming later in February.

It will look at the literature that informed its recent evidence review and is expected to specifically address some of the models of care seen overseas in places like Canada and the UK.

The Unleashing the Potential of our Health Workforce review will deliver a final report by October.

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