“The Queen is Dead. God Save the King.”
As the end of 2022 approaches Australia is emerging from nearly three years of COVID-19 pandemic, a period which placed the healthcare profession generally under significant siege. Long hours with few breaks for holidays in an environment severely constrained by the medical regulations of COVID-19 containment affected both patients and doctors well being and the impacts are still being felt.
The long years of partial indexation of GP rebates and increased expectations from patients and governments is starting to bite. Many older GPs say they have had enough and are going to retire in the near future, while new graduates are no longer attracted to general practice, believing the demands and expectations are unsustainable and the specialty has been generally devalued and deskilled.
The GP drought will hit hardest in rural and regional areas. The chief executive of the NSW Rural Doctors Network, Richard Colbran has said that, “For every general practitioner that leaves the workforce there will need to be three to replace them to keep up with demand. After COVID-19, floods and bushfires, GPs have never felt a time when the system is in such a perilous state. They are exhausted.”
The Australian government has a fiduciary duty to the nation. It aims to deliver the highest quality and number of medical services at the lowest price. All political parties espouse this principle. For nearly 40 years the government has progressively reduced the proportion of fee for service it will reimburse.
In response to the changes in supply and demand for medical services the environment has evolved over time and the journey from private billing to bulk billing and back again has been succinctly summarised by Dr Tibor Konkoly in his personal journey.
The scope of general practice has also changed over time. GPs are rarely seen in hospitals now. The days of the obstetric or anaesthetic GP are long gone. The increasing numbers of specialists has seen routine management for many conditions move from primary to secondary care.
Skin cancer, women’s health, men’s health, mental health, telehealth and tele-mental-health have arisen from the evolving medical, technical and administrative reforms. These days you can even get a medical certificate for your ‘sickie’ without even bothering to get out of bed.
Pharmacy also has evolved over the years in response to the same pressures of cost, convenience and speed. The corporate model has boomed in recent years, sometimes at the cost of the pharmacist/doctor relationship. In seeking to “optimise efficiency” the Pharmacy Guild has argued for a greater independent role for pharmacists.
The North Queensland Community Pharmacy Scope of Practice Pilot is due to start shortly. It follows on from the Urinary Tract Infection Pharmacy Pilot (UTIPP-Q) which has been deemed a success by the Queensland Health Minister, Yvette D’Ath and is soon to be extended throughout the state. The pilot aims to replicate a similar program from Alberta, Canada.
The trial will allow accredited pharmacists the right to prescribe for up to 23 simple or chronic conditions including “reflux, acute nausea, oral health screening, allergies, hay fever, asthma, hypertension, type 2 diabetes, and oral contraception”. According to independent research commissioned by The Pharmacy Guild of Australia, Queensland Branch, and carried out by research firm Insightfully, patient satisfaction is said to be high, particularly with the one-stop-shop approach, where medication can be dispensed at the same time as the consultation.
General practitioners are not convinced of the wisdom of this approach. They note the conflict of interest that arises from both prescribing and dispensing and which they are prohibited from providing. Others have also raised the medicolegal risk of prescribing, particularly in an environment where comprehensive record keeping is not the norm.
There is also concern that “simple conditions” are not always as simple as they first appear and may signify more serious problems, particularly in older patients and those with chronic disease. The pharmacy-only model and associated loss of continuity of care in these patients may prove detrimental in the long term.
The RACGP and the AMA are also concerned about the influence of the Pharmacy Guild on government decision making at the State level. The AMAQ has complained to the Coaldrake Review into Queensland's public sector culture and accountability about the Guild's undue influence through political donations and the use of paid lobbyists.
The slanging match between doctors and pharmacists has continued most of the year with medical insurers, AMSes and even health economist, Dr Stephen Duckett siding with the doctors, and the Queensland and Federal Health Departments with the pharmacists.
The tension came to a head in March when the newly elected President of the RACGP, Dr Nicole Higgins, and the other GP member, Dr Toni Weller, resigned from the Board of the North Queensland PHN. The secrecy and delay in releasing the UTIPP-Q report, along with potential conflicts for other Board members, led to resignations.
Dr Higgins revealed the other PHN members at the time included four local hospital and health services and the pharmacy owner’s lobby group, the Pharmacy Guild of Australia’s Queensland branch. An application by the RACGP to join the NQPHN had, despite repeated requests, stalled for 18 months.
Dr Higgins said the PHN was failing to support GPs even though they represented the biggest group of primary care providers in the region and more than 200 GPs had come together to form the North Queensland Doctors Guild in protest over the expanded pharmacy prescribing scheme.
As the new Labor government mulls over its future plans for general practice the architect of the long standing mental health initiative, the Better Access program, Ian Hickie has argued that the investment in the program via general practice has not paid off. He holds that the current program is provider, not patient, oriented and that communication between treating clinicians is poor. He also holds that there is inadequate review of the patient’s progress and as such outcomes cannot be measured. Prof Hickie states that the management of Australia's mental health system would be better organised if run by multi-disciplinary teams in institutional settings underpinned by using modern artificial intelligence and communication technologies.
The profession has hit back stating that claims for mental health item numbers do not reflect the amount or value that GPs provide to their patient’s mental health. They argue that the long standing doctor/patient relationship is superior to a team-based model for the majority of common mental health issues. The GP is best placed to manage the complex interplay between physical, psychological and environmental factors that affect patients’ wellbeing.
If the conditions treated by general practitioners are to be reduced across a number of domains due to cost and outcomes measures it will be hard to see a role for them in the future. If patients and domain specific practitioners can manage the complex health and medical problems that arise in modern life the general practitioner will be redundant.
Australian medical practice may come to look more like American style medicine but with an increased role for governmental monitoring and cost containment. That is an interesting proposition.