Feature
Expanded scope ‘for anyone except general practice’
One GP is speaking out about concerns doctors are being left behind in Australia’s healthcare system, warning of dire consequences for both the sector and wider community.
The concept of health professionals working to their ‘full scope of practice’ was first flagged in the early 2000s.
As Australia faces an ageing population and increasingly complex medical presentations, the Federal Government has emphasised the need for healthcare professionals to be empowered to work to their full scope of practice.
As well as improving access to care, there are hopes the move will help to address workforce shortages, enhance the health system’s efficiency, as well as being cost effective.
Among the initiatives introduced so far are pharmacy prescribing trials and an expansion of the role played by nurse practitioners.
But there are concerns these efforts are failing to consider GPs and the potential of their full scope of practice, leaving some doctors feeling disillusioned.
Among them is Professor Louise Stone.
A GP and medical educator who is currently working on a general practice research project, she says the only notable expansion of scope for GPs she has seen in recent years has been in the ADHD space. Otherwise, she believes doctors are facing more regulatory and administrative barriers than ever before.
‘It is an expansion of scope for anyone except general practice,’ Professor Stone told newsGP.
‘I can’t order a continuous glucose monitor, but a nurse can.
‘I can’t make a diagnosis of mental illness on a Disability Support Pension. The Department of Health is relying on me to do mental health care, but the Department of Social Services doesn’t think I know how to make a diagnosis.
‘I can’t order an MRI of the brain unless someone has a headache. So, if someone has multiple sclerosis, I’m not “empowered” – to use the Government language – to order an MRI.
‘We’ve also got more administrative barriers to us doing maternity services in rural areas.’
Healthcare professionals working to their full scope has been proposed by Australian Governments for decades.
The concept was given greater emphasis in the National Health Workforce Innovation and Reform Strategic Framework for Action 2011–15, which included promoting flexible scopes of practice to improve access and efficiency.
More recently, it has been integrated into numerous health workforce policies, including the Government’s Primary Health Care 10-Year Plan.
A controversial move has been the expansion of pharmacy prescribing trials to allow pharmacists to both diagnose and prescribe for what governments have termed ‘minor ailments’ in a bid to expand access to care, while also reducing the workload of GPs, in theory to free them up for more complex cases.
However, Professor Stone says this logic fails to make sense on multiple levels.
Firstly, she says it is a risk to place the onus on patients to recognise whether their symptoms are minor, or the sign of something more significant that requires examination and testing.
‘Patients don’t always know the difference between “big sick and little sick”. Pharmacy would dispute this, but we all have patients who have been treated as the average – because that’s what protocol-based treatment does – when they are not an average patient,’ Professor Stone said.
‘Many will come to some form of harm, and I believe that is an ethical problem.
‘If you follow a protocol, then probably 90% of patients are fine, but the other 10% aren’t. The question is, as a community, what are we going to do with that 10%? Do we just assume they don’t matter?’
Meanwhile, given healthcare workers are overseen by their own Boards, she says it is unclear whether each profession is held to account by the same standard – and whether the public is aware of this.
Regardless of this, however, the Canberra-based GP says doctors are often feeling the weight of an increasingly fractured healthcare system, and that this also presents additional pressures from a medical indemnity perspective.
‘Our medical defence organisations have told us that whenever someone sends a discharge summary, we accept duty of care, and the same happens with the nurse-led clinic that has no doctors in it,’ she explained.
‘An example is where a nurse sends me a patient and gives me a summary and it says, “the kid’s got fever, query viral infection”. If I get that from an emergency department, I know it’s gone past a doctor and probably a consultant. If I get it from a nurse, I don’t know who’s seen it.
‘So, if that kid happens to be, God forbid, the one kid with meningitis, it’s my indemnity supporting that clinical interaction. It’s a huge risk for me, and it’s a risk over which I have no control.’
Professor Stone also fears that adding more health professionals into the mix of an individual’s healthcare delivery, especially when there are multiple chronic diseases to consider, only complicates matters for patients by opening the doors to communication breakdown.
‘There’s a sort of Lego approach,’ she said.
‘I’m a holistic generalist, but you could replace me with a whole lot of Lego blocks; a little bit of pharmacy, a little bit of social work, a little bit of this and a little bit of that.
‘Every time you add someone to a team, you add communication complexity; I’ve then got to talk to five people and I’m more likely to disagree because we’ll have different opinions and different approaches. And it’s a lot more work for the carer and the consumer.’
However, one of the Governments’ arguments is that the move both enhances access to care, while also being cost effective – both difficult to argue with from a patient perspective.
But looking to the United Kingdom’s experience with the NHS, Professor Stone says she fails to see how that is the case.
‘Often there’s this idea that if you put in a cheaper worker then care will be cheaper,’ she said.
‘But that’s not true if a cheaper worker takes twice as long as me. At the moment, if you use a nurse-led clinic, it’s five times as expensive as I am. So, the economic logic doesn’t make sense to me.’
Further to that, there is concern that a changing funding landscape could place general practices in a precarious position requiring them to prioritise shorter consults or risk going broke.
‘Six-minute consultations attract $6 per minute in Medicare rebates. Forty-minute consultations attract $1.50 per minute, so there is a clear policy driver to want us to move to six-minute consults,’ Professor Stone said.
‘If pharmacy take all the short ones and we end up with the long ones, then you reduce your financial viability – and that’s particularly the case for women because women, on average, spend five minutes extra per consultation. We’ve got a 25–40% gender pay gap.’
She also believes part of the issue is the Government’s inference of ‘care’ as the provision of a product, rather than recognising the different levels of training, knowledge and experience that each profession brings to the table.
‘It doesn’t matter whether I give the flu vaccine, or the nurse gives the flu vaccine, or the pharmacist gives the flu vaccine – they’ve got the vaccine,’ Professor Stone said.
‘What’s the difference? Better access, cheaper, easier and consumer led. However, what they’re actually getting access to is the product; they’re not getting access to the diagnostic training.
‘There’s an assumption that healthcare is about delivering the right product to the right customer, and it isn’t. I have serious ethical concerns.’
But the implications of this could be more widespread beyond the individual patient.
According to the RACGP’s Health of the Nation survey, aside from reaching retirement age, the biggest drivers for leaving general practice, often prematurely, are administrative harms, lack of respect, lack of autonomy, inability to make a difference and moral distress.
Professor Stone says this is consistent with her own research findings.
‘What I’m hearing is, “I love the patients, I love my job, but I cannot survive the environment”,’ she said.
‘So, we’re losing people much, much quicker. In fact, there’s been a real precipitous drop in the number of years people stay in general practice.
‘I love my job and am still pretty motivated, but I don’t know that I’d do it again. And as a fierce advocate for general practice for over three decades, it’s all a bit sad.’
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