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Private vs corporate: does it impact quality of general practice care?
Australian researchers suggest the trend towards larger corporate owned general practices may affect access and quality of patient care – but a GP expert says the evidence is lacking.
There are three components to continuity of care that go beyond seeing the same individual GP.
It’s no secret that the organisational structure of general practice in Australia has changed over the years.
The RACGP’s 2019 General Practice: Health of the Nation report shows a considerable decline in GP practice ownership, down from 35% in 2008 to 25% in 2020, with two corporate groups operating more than 400 medical centres.
Currently, 20% of full-time GPs are employed in large practices (with six or more GPs), and approximately 16% of GPs work in corporate-owned practices.
But Dr Caroline de Moel-Mandel and Professor Vijaya Sundararajan, the authors of a new Perspective published in the Medical Journal of Australia, argue this move away from privately owned practices to larger corporate models may be at the cost of patient care.
They highlight four areas in which the size and model of GP practice ownership may have an impact:
- access to care
- continuity of care
- quality of care
- health expenditure
However, Professor Mark Morgan, Chair of the RACGP Expert Committee – Quality Care (REC–QC), says while the Perspective raises some ‘interesting’ points, it fails to produce the evidence to back them up.
‘I have an issue with some of the arguments put forward because they’re basing a lot of their quality arguments on … UK research data and, of course, Australia is a very different setting,’ he told
newsGP.
‘They’re assuming that what happens overseas sheds light on what happens in Australian practice, and I actually think that’s a big assumption.
‘We have extremely highly trained professionals as GPs who’ve had a broad experience and assessment process, and then a continuing professional development (CPD) process, and the individuals are able to conduct high quality medicine in a wide variety of different settings.’
The authors claim that in larger practices ‘the “usual GP” was often replaced by “usual practice”, resulting in patients consulting GPs they had never met before’ with impacts for continuity of care.
But Professor Morgan says even though it is better to see the same individual GP, that it is only one of three components that constitute continuity of care.
‘There’s the personal component – are you seeing the same individual doctor that you saw last time? There [is] continuity of information – so are the medical records accessible, informative, and help with the next consult, even if you’re seeing a different person? And the third component is continuity of management approach – so is the same song sheet being followed at your subsequent appointments?’ he said.
‘In an ideal world you’d want all three components, but that would require a GP to be available 24/7, 365 days a year, and there are ways around the fact that that’s not going to happen.
‘You can design systems where … for example the practice nurse and part-time GPs can work together seamlessly within that system [and] from the patient perspective, the continuity is pretty good and certainly clinical outcomes can be good.’
The authors also claim that while corporate-owned practices may have more efficient management processes and longer opening hours, research suggests the quality of corporatised GP services ‘may be worse compared with care delivered by traditional providers’.
They also state that practices with co-location of allied health services ‘might be associated with the practice of over-servicing to meet income targets, or with GPs over-referring to commercially related and co-located services’.
But Professor Morgan says he is not convinced.
‘[Again] it uses UK information [and] doesn’t provide good evidence,’ he said.
‘They [also] talk about potential over-servicing and testing. But, in fact, [the evidence they cite] was somebody’s PhD, so not a peer-reviewed document at all, and the abstract of that suggests that over-servicing was not widespread.
‘So I think they’ve been quite selective with the evidence that was quoted to tell a consistent story. But it doesn’t convince me.
‘The answer is, we don’t really know whether there’s more low value care in one type of practice ownership structure or the next.’
The authors also note that access to care may be affected when smaller practices conglomerate into larger, centrally located practices, ‘especially for people residing in regional and remote areas where there are already fewer GPs per person’.
While Professor Morgan agrees that access to care, along with financial barriers, are real issues to explore, he notes that there is no Australian data at present to suggest one model of practice ownership is easier to access over another.
He says greater investment into general practice would help ensure people have access to the care they need.
‘We certainly suspect that access to care is improved by the ongoing funding of patient rebates for telehealth for follow-up care and care where face-to-face presence isn’t necessary,’ he said.
‘We’d certainly like to see a broader use of the general practice team to deliver care and patient rebates for services delivered, for example by practice nurses, [which] is woefully underfunded and fails to allow all the practice team to work at full scope of practice.
‘We would also like to have much better access to primary care data that’s collected and sitting in GP medical records with all the privacy safeguards and permissions that could be analysed in a much more in-depth way, both to explore where there’s room for improvement but also, if it … provided real-time computer decision support, then that feedback of information from the medical record would actually have an opportunity to directly improve care.’
The authors conclude that more research is vital to understand the full effects of the changes in general practice size and ownership models on patient care.
‘While there is little Australian evidence that worse clinical care is delivered in privately or corporate-owned general practices, there is also no evidence that care is better,’ they wrote.
‘Hence, if general practice in Australia is to navigate the future changes in practice size, ownership and increasingly co-located service organisation, more Australian research and potentially regulation are needed to track and control what this means for patient care in terms [of] not only patient experience, but also for health outcomes in general practice.’
Despite its apparent shortcomings, Professor Morgan says that the Perspective raises some ‘very important issues’ that should be looked at in more depth with an Australian focus.
‘It’s certainly worth exploring further what is the patient experience? What are the clinical outcomes? What is the experience of delivering care? And what are the value propositions? So the quadruple bottom line of healthcare outcomes should be compared for different practice models – that’s important,’ he said.
continuity of care corporate general practice healthcare patient outcomes
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