Could GPs’ scope of practice change?

Most analysis of the Federal Government’s scope of practice review has so far focused on implications for pharmacists and nurse practitioners, rather than the work carried out by GPs. 
 
An announcement last week that Professor Mark Cormack, a former allied health professional and senior health official, is to lead the ‘Unleashing the potential for our health workforce review’, prompted some coverage – most of it directed away from general practice.
 
‘Nurse and pharmacy prescribing powers to be probed in new review,’ was an example headline in Nine Newspapers.
 
However, while the review has not yet published terms of reference, the Government has made it clear that the work of Professor Cormack, a former allied health professional and public policy official, is broader. It aims to help optimise Australia’s health workforce ‘across a stretched primary care sector’, Federal Health and Aged Care Minister Mark Butler’s office has said.
 
For Chris Hogan, an honorary Clinical Associate Professor with the Department of General Practice at the University of Melbourne, the potential of general practice merits a higher billing in the discussions so far.
 
‘Why is it that nurses, pharmacists or allied health professionals are expected to increase their scope of practice, but no mention is made of GPs?’ he told newsGP.
 
‘If we are looking at improving systems it is important to make sure everyone increases their scope of practice.’
 
It is a view shared by Professor Mark Morgan, Chair of RACGP Expert Committee – Quality Care (REC–QC), who sees information as one key area for review.

‘What GPs really need to enable them to work at full scope of practice are accessible, real-time sources of high-quality information and health pathways,’ he told newsGP.
 
Professor Morgan cites specific legislative barriers that hold GPs back, giving the example of prescribing Hepatitis B antivirals – an area where he believes general practice could play a greater role.
 
According to the REC–QC Chair, the college’s position statement on shared care also links to scope of practice considerations.
 
‘For those patients who have complex long term medical conditions and require specialist teams to help look after them, there’s a great scope for GPs to work more closely with those people, and be able to adjust treatments within ranges, and help make that much more efficient and patient centred,’ Professor Morgan said.  
 
‘It’s a shift towards [other specialists] really working on top of their scope, seeing new presentations that need their expertise – and not reviewing stable long-term conditions, but to allow that task to be done where it’s much more appropriate, which is with the GP.’
 
To do that, Professor Morgan believes a broader change in approach is necessary.
 
‘You do need a shift of culture, so you can ring up the specialist or get a patient in quickly if you’re managing things and they haven’t got regular reviews with a specialist,’ he said.
 
‘If you’re doing that as the GP but then a changed treatment [is required] that you’re not confident enough to manage yourself, you need to be able to send the person back quickly.
 
‘Part of the flip side of helping out with the long-term management and adjusting treatment is rapid access when it’s necessary.’
 
Professor Morgan also believes there is capacity for health professionals working within general practice to extend their scope.
 
‘I would like to imagine that practice nurses and in-house non-dispensing pharmacists and others working as part of a GP team could take appropriate roles and expand their scope of practice to fulfil roles such as running childhood immunisation clinics, for example,’ he said.
 
According to Professor Morgan, certain fee-for-service restrictions that dictate consultations need to be done face to face with the GP should also be looked at.
 
‘A revisiting of those rebates for people working within general practice, so it doesn’t have to be the GP themselves, would be a very sensible way forward,’ he said.
 
The review itself was supported by the Strengthening Medicare Taskforce, and, as the taskforce did, Associate Professor Hogan raises the very different working environment for health professionals compared to the early days of Medicare.
 
‘Patient mix has altered over the last 40 years,’ he said. ‘It used to be roughly 80% acute presentations of injury and recent infections with 20% ongoing or chronic health problems.
 
‘In modern times those proportions are reversed.’
 
Associate Professor Hogan believes allowing GPs more time is key – as is easing pressure on overworked general practice staff and ensuring remuneration is competitive with specialties.
 
‘Most allied health personnel spend at least 20 minutes for standard consultations,’ he said.
 
‘Due to the complexity of modern life our patients can easily have more than five ongoing health
issues simultaneously.
 
‘It is common enough to have management guidelines for one condition clash with those of others.
 
‘There needs to be someone to make decisions when there are difficult decisions confounded by conflicting advice. That someone is a GP – GPs are trained to deal with uncertainty and complexity.’
 
Dangers of role substitution
Professor Morgan notes the many different versions of general practice, from corporates to solo practitioners, that any changes will apply to.
 
‘We have different pressures in complex urban environments, when there are dozens of suppliers of medicine and of medical care with risks of over-servicing, right through to remote areas where GPs are flat-strapped to keep up with the necessary care,’ he said.
 
He is careful to distinguish between the changes he suggests for general practices from role substitution, which he says will fragment care – giving the North Queensland pharmacy trial as one such example.
 
The RACGP President Dr Nicole Higgins raises a similar concern.
 
‘This review must be about more than just task and role substitution,’ she said.
 
‘It’s important our health system recognises GPs are highly trained specialists with a minimum of 10 years’ training.
 
‘We work directly with patients at every stage of their healthcare, from an initial consultation, to diagnosis, to working as part of a team with other specialists and allied health professionals to deliver high-quality healthcare for all patients.
 
‘GPs are the foundation on which multidisciplinary team care rests.’
 
For the review, Minister Butler’s office has committed to be ‘extensive stakeholder engagement and collaboration with the states and territories’.
 
A final report is due in the second half of next year.
 
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general practice scope of practice