It would be nice to be treated as the professionals we are, and not naughty schoolchildren who won’t do as they’re told.
There has been rather a lot of green and gold waving recently, and I must say I’m afraid my suspicious little mind has been wondering what that bloated piece of plastic is hiding.
At the outset, I wanted to say that I have no intention of pitting the bulk-billing GPs against those who choose not to. However, seeing as the government is sure they can “swing the market” by flooding one side with cash, I thought I should just imagine the questions I might ask if I was behaving in a market economy, which is how I am seen.
Who is going to sweep up after the parade of shiny green and gold services have passed by and selected their patients?
We are all familiar with the phenomenon of private psychiatry, the only specialty that consistently rejects our patients because they are “too hard”.
I am not being judgy about this – I understand the need for a whole team for many complex situations – but I am also aware that the list of people too complex for private and too wrong for public seems to be growing.
I am also seeing something I’ve never seen before.
I’m used to the “when I have something simple, I go the bulk-billing clinic up the road, but when it’s really complex, I come to you” problem. However, now it’s getting … interesting.
I am getting patients who are telling me the clinic doesn’t prescribe antipsychotics. At all. Or authority scripts. We are not talking stimulants, or opiates, just … authority scripts.
If we follow market logic, I don’t blame them. It makes complete business sense to eject the hard and expensive patients in favour of those with rapid and lucrative throughput, but here’s the question.
What are we, as a nation, going to do with the patients that are rapidly becoming “uninsurable”?
What happens when no service with a green and gold logo will take them?
After all, without other specialist support, these patients are risky. We have all seen the reports to AHPRA, and the coroner, for complex psychiatric patients who saw a GP because they had nowhere else to go, and the GP found themselves with a lengthy legal process to endure. It is an enormous load on the GP’s mental wellbeing, and they could just say no, couldn’t they? Or their corporate overlords could.
If we simply use market logic, why would we put ourselves in the firing line? Especially as there is essentially a complexity tax. The harder the patient, the less Medicare pays. I find myself thinking like the psychiatrists on this one.
Do GPs have the right to protection from the psychosocial hazards caused by recent political and policy change?
Under the Safe Work Legislation, a person conducting a business or undertaking (PCBU) has a duty of care to ensure workers are not exposed to psychosocial risks. A PCBU is defined as an entity that can:
- direct or influence work carried out by a worker;
- engage or cause to engage a worker to carry out work (including through sub-contracting);
- have management or control of a workplace.
Recent changes in the primary healthcare policy environment have increased the direct influence of governments in the management, regulation, funding and control of general practice in Australia. Health ministers now exert regulatory, legal, financial and administrative controls in and around general practice, suggesting that health ministers and their various departments may have obligations under the Safe Work Act to protect the doctors they direct, influence, engage, manage and control.
While governments may or may not meet the legal definition of a PCBU, it could be argued that they have the same moral or ethical responsibilities, which means they should protect GPs from unnecessary psychosocial hazards.
It is unfortunate that most of the hazards defined in the Safe Work Legislation have been caused, directly or indirectly, by recent government policy. Here are some of them, as listed in the legislation.
- Excessive job demands;
- Low job control;
- Poor support;
- Lack of role clarity;
- Poor organisational change management;
- Inadequate reward and recognition;
- Poor organisational justice, which includes unfair decision-making, a lack of communication of important changes and a tendency to allow leaders and government agents to speak about GPs with a lack of dignity and respect. Federal health minister Mark Butler encouraging patients to “vote with their feet” and choose a GP who does what they are told, is an excellent example;
- Poor workplace relationships and interactions are evident from the language other professions are prepared to use about general practice. Being told by a nurse practitioner leader that working with us is like being in a domestic violence relationship is appalling.
Does anyone intend to address the rising gender pay gap?
This is a direct result of the different work done, on average, between male and female GPs.
Minister Ged Kearney is justly proud of her work on medical misogyny, but is there any intention of addressing recent changes to Medicare that have made the gap worse?
Or are women GPs simply seen, as one GP mentioned in my study said, as disposable and easily replaced by the feminised workforce of nursing?
Related
Why is Medicare not accountable for its own advice?
Presumably, the Medicare stewards are the final arbiter of billing rules, because they perform the audits that lead to GPs paying back incorrect claims.
So, they know what the rules are. They just seem anxious not to reveal them. AskMBS has so many disclaimers, it’s really not an advice line, it’s just … gossip.
Is there any evidence that the much-loathed CPD changes have made any difference?
I have read the evidence provided to justify the shift to audits and so on, and there are no articles less than 10 years old in the rationale. Except in orthopaedics. There was one in orthopaedics.
I remember Anne Tonkin saying she would have welcomed the opportunity to check if she were “up to scratch”.
I promise, if you can define what scratch is in my world, I’ll do my best to see if it’s possible to get “up to it”. In the meantime, we GPs are rather good at learning. Can we please just get on with it?
While we are unleashing the power of the health workforce, can we also unleash their indemnity?
I don’t want to be responsible for everyone’s indemnity and medicolegal risk.
Our MDOs are very clear that when a letter from another health professional hits our desk, we become responsible for the duty of care.
If other practitioners are just as good as I am in caring for patients, why am I expected to carry the responsibility for their decision-making? I don’t want it, and I shouldn’t be paying $12,000 a year so I can cover the run-off from everyone else who pays less than $500 a year.
I should be able to say no.
Can you imagine Qantas accepting legal responsibility for a new up and coming airline just because they send a copy of their maintenance reports to Qantas? Thought not.
Does “access” trump quality?
I am rather tired of hearing it was “essential” to allow yet another industry to do what I do with seven years less training in the name of “access”.
It’s “access” to something different. Like going out to buy a banana and being given a bread roll. Doesn’t matter how good it is, is not what you wanted or paid for.
There are nudge letters to reduce low value care, so can we GPs return the favour by pointing out equally low value administration?
We could help make the health system fair for all Australians, and reduce healthcare waste, and fulfill a lot of the rationales for the nudge letters in reverse.
And don’t get me started on low value innovation, reorganisation, optimisation, modernisation, streamlining, technological change or role substitution.
We have no idea what all this has cost. But we know the clinicians are struggling harder than ever, so whatever you’re doing, you’re not “freeing me up”.
Can we make a decision whether it is ethical or not to sell the products we recommend?
One or the other. If pharmacists can prescribe, what on earth is wrong with selling wound dressings?
And finally, we should consider that professions providing the same care in different disciplines have to meet the same standards.
The public have the right to know if they take their UTI to pharmacy, nursing or GPs that they get the same standard of care.
Shouldn’t they? And currently, they don’t. The protocols are different. The codes of conduct are different. If anyone actually measured them, I suspect we would find the outcomes were different.
Of course, none of this will trump increasingly bizarre political dances with ludicrously huge pieces of green and gold plastic.
But it would be nice, just for once, to be treated as the professionals we are, and not naughty schoolchildren who won’t do as they’re told.
Associate Professor Louise Stone is a working GP who researches the social foundations of medicine in the ANU Medical School. She tweets @GPswampwarrior.
