Let’s not kid ourselves that what’s good for the geese is good for the gander, when it comes to general practice.
There have been a lot of changes in primary care recently, and behind these changes are some important assumptions about what is “good for us” as an Australian community.
It is, of course, a government’s responsibility to set up policy so that, on average, we get good population outcomes. It’s why they invest in roads, education and infrastructure.
However, in health, I’ve noticed some inconsistencies in policy application, and that brings me to the geese. I’m sure most of you will have heard the phrase “what’s good for the goose is good for the gander” and seeing as medicine is often conflated with patriarchy, I thought we might have a look at a few core policies to see if we GP ganders are, well, missing out.
So, here are a few comparisons.
Telehealth
The goal: “The Albanese Government is committed to unlocking telehealth’s potential, while also ensuring its safety and quality for patients.” Mark Butler.
The mechanism: Regulating MBS rebates to ensure telehealth is used appropriately.
The geese: Nurse practitioners, social workers, dieticians, midwives, obstetricians, occupational therapists, psychologists and mental health nurses can access Medicare rebates for consultations over phone or video as an alternative to any face-to-face consultation.
The ganders: Some types of consultations are restricted to using video, and not telephones, because telephones aren’t safe. Sexual health is apparently fine, but not mental health treatment plans. Because for some reason it’s safe to do a psychology session over the phone, but not if you’re a GP.
And for GP ganders, governments have to be extra, extra careful.
“It is a legislative requirement that medical practitioners working in general practice must only perform a telehealth or telephone service where they have an established clinical relationship with the patient.”
That means the patient must have seen this GP within 12 months of the phone call. Because otherwise, it’s unsafe. But only for GPs (and recently, nurse practitioners). Apparently.
Score: 1-0 to the geese.
Organising subsidies for diabetes
The goal: “The Albanese government is delivering on our election commitment to give all 130,000 Australians with type 1 diabetes access to subsidised CGM products under the National Diabetes Services Scheme.” Mark Butler
The mechanism: The application form for NDSS allows patients to get a subsidy when signed by a health professional.
The geese: Diabetes educators, endocrinologist/diabetologists, nurse practitioners, physicians and paediatricians can fill out the form so their patients can obtain a subsidised continuous glucose monitor.
The ganders: GPs and nurses contaminated by working in general practice cannot fill out this form. I am reliably told by a program bureaucrat this is because “insulin is a dangerous drug”. Yes, yes it is.
Score: 2-0 to the geese.
Related
Antibiotic prescribing
The goal: “Described as a ‘silent pandemic’, antimicrobial resistance is one of the World Health Organization’s top 10 global public health threats. Common infections can become untreatable, leading to longer hospital stays and higher death rates.” — Ged Kearney, Assistant Minister for Health and Aged Care
The mechanism: Several, including a nationwide survey of antimicrobial resistance in Australia’s food supply
The geese: Pharmacists are empowered to prescribe antibiotics to consumers with symptoms that might be a UTI. The Queensland health minister triumphantly declares that the trial will “improve and support the health of Queensland women and has been incredibly successful since its commencement”. I agree if you think “incredibly successful” means 97% of these consumers received antibiotics.
The ganders: GPs were used as guinea pigs in the “nudge vs superbugs” campaign, without their consent or knowledge. Australia’s chief medical officer sent one of three personalised letters to GPs whose antibiotic prescribing rates were in the top 30% for their region to “encourage” them to have a good hard look at their antibiotic prescribing. The “trial” team then compared which letters had the most impact in driving clinical behaviour. No patient outcomes were discussed or measured. I bet none of them were prescribing 97% of the time.
Score: 3-0 to the geese.
Unleashing the geese (but not the ganders)
The goal: “Funding and regulatory arrangements should support all parts of the primary care workforce to work to their full scope of practice.” — Strengthening Medicare report
The mechanisms: Letting everyone do what they think they can do, particularly if it is (a) procedural and (b) lucrative. Aged care, disability health and other less prestigious care is apparently bottom of scope. I haven’t heard anyone scrabble to “own” top-of-scope aged care, but there is plenty of competition for endoscopy, anaesthetics, prescribing, and anything else centred on expensive technology.
The geese: Oh, where to start?If we consider the good, the bad and the ugly, I think we’ve all heard quite enough of the marvels of top of scope. As usual, the capable and competent innovators that we all respect lead, but they are always followed by the overconfident, the entrepreneurial and the deeply unsafe.
So, let’s think through potential consequences of under-governance and overconfidence:
- Midwives doing home birthing, supported with Commonwealth funded medical indemnity;
- Pharmacists managing elder abuse, sexual violence and postnatal depression, and ordering and interpreting laboratory tests;
- Nurse practitioners prescribing cannabis over telehealth;
- Rapid online weight-loss drug prescription;
- Cosmetic injectables.
What could possibly go wrong?
The ganders: Not to harp on, or anything, but I can’t organise a continuous glucose monitor for my patients. Or organise a brain MRI for a patient with MS (unless I can convince them they have a chronic headache). Or deliver a baby, admit a patient, choose the mental health treatment I think my patient needs (without using a non-evidence based “tool”), make a diagnosis on a disability support pension form or convince anyone in mental health that a patient needs to be seen.
My top of scope is apparently collapsing.
Verdict: 4-0 to the expanding geese
Making each goose an independent goose
Working independently is a good thing, unless it isn’t.
Mechanism: Removing the requirement for nurses and midwives to work with a doctor and at the same time insisting every GP should work with a nurse.
The geese: Health minister Mark Butler and assistant health minister Ged Kearney removed collaborative arrangements for nurse practitioners and midwives, to open up the doors for endorsed midwives and nurse practitioners to operate independently, to set up their own small businesses, to provide very best care to the community.
Incidentally, the head pharmacy goose, Trent Twomey, made his opinion on collaborative arrangements very clear. Thinking pharmacists should need to work with GPs is “bloody insulting” he said.
The ganders: The review of practice incentives indicated that future funding will depend on “a minimum ratio of 1:1 GPs to other health and care professionals in multidisciplinary teams”. So, while nurses are emancipated from doctors, it seems GPs are being tied to nurses and/or other allied health professionals.
Verdict: 5-0 to the empowered geese.
Unleashing the flock
This one is a master of doublespeak. Multidisciplinary care with everyone working at the very top of their scope, and (this is important) co-located, is apparently “a good thing”.
“We need to put coordinated multidisciplinary team-based care at the heart of patient care, harnessing the full strengths and skills of the diverse health workforce.” — Mark Butler
Do we? Do we really? After all, we have been using bespoke multidisciplinary teams that aren’t co-located for, well, ever.
The mechanisms: Incentives, change in financing arrangements, governance shifts and other “nudges”.
The geese: There are no requirements in the review of practice incentives, or the Strengthening Medicare taskforce report that requires any particular business model of nurse practitioners, physiotherapists, psychologists, dieticians, occupational therapists etc.
Frankly, they can work with anyone or no-one. Minister Kearney is even more enthusiastic about new arrangements to emancipate nurses from their medical overlords.
“It really opens up the doors for endorsed midwives and nurse practitioners to operate independently, to set up their own small businesses, to provide very best care to the community that we possibly can.”
Pharmacists agree, of course. The 8th community pharmacy agreement includes the standard clause protecting pharmacists from having to work anywhere near each other.
The ganders: The review of practice incentives tells us that future funding should “require general practices and patients to participate in MyMedicare” and require co-located multidisciplinary teams.
They also talk about introducing specialist physicians into general practice. We can see the future here. General practice with no GPs in it. Bonus.
Interestingly, after reading the whole document, and the Strengthening Medicare report, there is this little hidden statement at the bottom:
“Remuneration for GPs may not change substantially and may still be primarily from fee-for-service payments, augmented by top-ups for involvement in care coordination, teaching and other roles.”
So, in other words, general practices will need to substantially reform, employ multiple multidisciplinary team members, commit to extensive measurements of data and outcomes, and increase their research and teaching, but there will be no financial benefit for the GPs. All the new money goes to … the geese.
That is a very impressive leash, tightened around our necks.
So, the total score?
I think we are watching the demise of the gander. Which is fine, as long as it’s honest. But let’s not kid ourselves and say anyone believes that what’s good for the geese is good for the gander.
Associate Professor Louise Stone is a working GP who researches the social foundations of medicine in the ANU Medical School. She tweets @GPswampwarrior.
