National health reform - good news, but …

The Royal Australian College of General Practitioners (RACGP) believes it is good news that federal and state governments have reached agreement on the establishment of the National Health and Hospital Network - however there remain reservations by many GPs about how it is to be implemented.

A recent general practice conference in Queensland (53rd Gold Coast Clinical Update Weekend: Postcards from General Practice) raised plenty of questions about how the proposed reforms might affect the delivery of primary health care in Queensland. The assembled GPs voiced concerns about how the plan will be implemented at a local level and the implications for general practice.

The consensus was that reforms, which support team work, collaboration and communication, should improve the care our patients receive. Similarly, reforms which assist in the provision of primary health care by improving access to allied health services in general practice and in the community are to be encouraged.

Seen as more contentious though are proposals to introduce a set fee for enrolled diabetic patients, the fragmentation of general practice by increasing the role of nurse practitioners, GP shortages in rural Queensland and the ‘corporatisation’ of health care.

The proposed registration of diabetic patients with capitation fees means GPs will be paid a fixed sum for all that patient's care for the year, regardless of how severe or mild their illness or their needs for care.

The college supports initiatives that improve comprehensive and co-ordinated care provision by GPs and in the case of a diabetic patient this includes access to educators, podiatrists, dieticians, and physiotherapists for individually tailored care.

Not supported is a poorly thought through system of capitation that could reward practices signing up low care need diabetics and profiting from their low cost/care needs. Doctors don’t want a two tier service for high need diabetic patients. Diabetics should be able to access co-ordinated care and the services they need through their GP. We know it will be much harder for these patients if they are only able to access care by referral to other services like hospitals or endocrinologists. Without effective case management by a general practitioner, they will be disadvantaged.

The current “fee for service” system of payment for GPs and other specialist services helps keep both sides honest and engaged. Patients value the service GPs provide and, to put it bluntly, expect a return on their investment or, even if they are bulk billed; have some sense of the cost for the service. Our patients want a continuing relationship with a doctor they trust, and they need a doctor to act as an advocate to help them get the best care within our fragmented health care system.

Concerns about the fragmentation of primary health care services by using separate nurse care outside GP teams, GP shortages and the advent of “super clinics” were also raised at the conference. At issue are fears of reduced patient safety and the danger of creating a second level, second rate health care model.

The RACGP strongly supports a stronger role for nurses in general practice, including an expanded role for nurse practitioners working in general practice teams, enhancing the range and quality of care provided to patients in general practice.

However, what is not supported is the concept of an independent nurse practitioner working in parallel rather than as part of general practice teams. No health professional should work in isolation; all should be part of a team or network with appropriate supervision and clinical governance. Employing nurses to deliver independent primary health care services will fragment care, may reduce patient safety, increase "silos", and undermine the patient-doctor relationship. Nurses, nurse practitioners, dieticians, social workers, pharmacists, psychologists and physiotherapists are all vital to the delivery of a valued range of services. They will all have role to play in the expansion of available primary care services for general practice patients. This will help to address unmet needs as we move from a hospital based to a community based system. They are not a substitute for GPs.

Nurses and doctors are far more effective when working together as part of a general practice team. Clearly, where there are no GPs the use of independent nurse practitioners has a place but is not to be preferred over the provision of general practice care. We need to ensure that potentially isolated health practitioners, such as community midwives and nurse practitioners, are also connected to teams, continuing quality improvement, and professional support networks. Without collaboration and consultation, patient care and the health care system as a whole are put at risk. Patient care must remain the number one priority.