Scope review creating ‘McMedicine’: RACGP President

Michelle Wisbey

17/04/2024 3:49:03 PM

The investigation’s latest report left Dr Nicole Higgins ‘angry and devalued’, as it ‘trades off quality and safety for convenience’.

Doctor holding a hamburger.
The RACGP has said the Scope of Practice review appears to be trading off quality and safety for convenience.

Australia’s healthcare system is heading in a dire direction, with fears a new review will leave the already fragile sector fractured, broken, and ‘bad for people’s health’. 
That is according to RACGP President Dr Nicole Higgins, who has taken a strong position against findings in the Scope of Practice Review’s second issues paper.
The paper, released on Wednesday, proposes eight policy reform options across three themes – workforce design, development and planning; legislation and regulation; and funding and payment policy.
Summarising the challenges faced by primary healthcare professionals, the review highlighted that doctors’ skills are currently poorly recognised, there is a lack of exposure to primary care for medical students, and legislation is impeding doctors working to their full scope.
It also noted several barriers and their tangible impacts, including reduced skills portability, poor workforce retention, inadequate patient access to care in regional areas, high GP workloads, and reduced opportunity for multidisciplinary care.
However, the college is concerned about the paper’s continuous mentioning of primary care teams, despite being vague about whether that definition includes GPs.
Dr Higgins said the paper has left her feeling ‘angry and devalued’ as it appears to confirm fears about a future of task substitution and oversimplified general practice.
‘They’ve reduced medicine, they’ve reduced healthcare, to tasks and activities versus looking at the outcomes and how those outcomes are achieved,’ she told newsGP.
‘We can’t have a system that is fractured and broken into pieces, where everyone has access to the MBS and the PBS at huge costs to the taxpayer.
‘We could end up with a fragmented, inefficient healthcare system that doesn’t share information, that’s bad for people’s health, and where the onus is going to be on the patient to ask, “are you trained to treat me?”.’
Instead, the RACGP says the solution to improving access and reducing costs for patients lies in supporting more GPs to train and work in communities.
The issues paper calls for the establishment of a national skills and capability matrix, intended to clarify the abilities of all healthcare professionals.
Specifically, it calls for the development of a combined skills and capability framework, highlighting areas of shared scope and common capability and a national scope definition.
It also recommends bolstering early career and ongoing professional development, including multi-professional learnings, and national consistency in post-qualification education and training.
Other priorities include an assessment of laws and the removal of legislative barriers currently ‘restricting’ healthcare professionals from practising to their full scope, and a risk-based approach to regulating scope of practice around certain higher-risk activities.
Finally, it suggests funding and payment models to incentivise multidisciplinary care teams to work to ‘full scope of practice’, and direct referral pathways, supported by technology, to improve patient referrals.
The paper’s reform options include using block, bundled and blended funding to deliver care flexibly, complementary to fee-for-service, and a single payment rate for specified activities falling within overlapping scope.
The college says funding must be flexible and fee-for-service retained so GPs can best respond to their patients’ needs, as well as calling on the Government to commit to no capitation.
It is also advocating caution around any unintended consequences of reforms that seek to ‘cash out’ on current incentives, which are critical to the viability of general practice in delivering high-quality care.
Dr Higgins said the review has ‘completely failed to acknowledge the training, the skills, and the role GPs play in primary healthcare’. 
‘General practice can’t stand by and watch our health system be reduced to McMedicine – we can’t trade off quality and safety for convenience,’ she said.
‘It takes 11 years of training to be a GP which is very different to three years of training to become a nurse – we all have our skills and our strengths, but they’re different.’
It comes as the RACGP fears Australia’s health system is heading in the direction of the UK, where lesser-trained health professionals have missed life-threatening diagnoses.
A paper from public health thinktank The King’s Fund recently described the lack of primary care investment as one of the NHS’s most significant and long-running policy failures, resulting in hundreds of UK-trained doctors fleeing to Australia.
Dr Higgins is now urging GPs to knock on their local politician’s door and call for change.
‘I’ve already told [Federal Health and Aged Care Minister] Mark Butler that there will be 40,000 angry GPs talking with their local Member of Parliament about what this will do to general practice,’ she said.
‘It’s important that people remember that this is just a review, and reviews aren’t necessarily implemented, and if there are recommendations, they take time.’
The review was a priority recommendation of the Strengthening Medicare Taskforce Report, aimed at allowing health professionals to work to their full potential, while emphasising the need for multidisciplinary teams.
Its initial Issues Paper, released earlier this year, also clearly expressed the need for a different funding model and better coordination between specialties.
The RACGP is now seeking member feedback on the review as it begins to create its next submission.
A third phase of consultation on the review will be undertaken between July and September, before a final report is submitted to the Commonwealth in October.
­Log in below to join the consultation.

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Dr Christine Colson   17/04/2024 6:58:27 PM

I can’t understand how those who are not trained as a doctor propose to do the work of a doctor. Architects, lawyers, engineers, plumbers, mechanics undergo specific training before working in their various fields. Could I set myself up, without their specific training, to work as one of them? Why would I want to do that?

I keep wondering how it is that I find my work challenging if those who are not medically trained apparently expect not to find it so.

In the midst of this scramble to hive off bits of our work (impossible as that is) lies the real devalued part of 'the team' – the poor unsuspecting patient. Life itself has become devalued in this country.

The health minister should know better.

Dr Saluay Kidson   18/04/2024 8:31:25 AM

This appears to fit with the current trend to find the supposedly cheapest way to nominally provide services whilst ignoring the overall quality of service, and with the result of massively increased costs. GPs are the most cost effective part of the entire healthcare system; the cost blowouts in the NDIS are clear evidence of this with the huge spikes in cost for therapists etc. as well as "support workers" who are often minimally trained. The governments are ticking boxes and the architects of the changes will be long gone on their generous pensions by the time the full disaster unfolds. I am fearful that the RACGP has missed the opportunity to ensure effective input at undergraduate medical training level

Dr Richard A   18/04/2024 8:52:03 AM

Universal health care has left the building, universal access in terms of price AND in training. Tripling bulk billing incentive for only part of the population, now leaving unsuspecting/uninformed to be treated by a non doctor primary care practitioner. How funny it is Labor who killed it off, irony not lost on me. Glad me and my family (I know poor grammar) will not pay the price of the shift, because at some stage some poor person will suffer from the systems change. Predictions - private health insurers will be able to sell policies for subsidising primary care, allied health performing current gp tasks /consults will be allowed to us titles like primary care Dr or physician or consultant. Oh the salt…

Dr Paul Po-Wah Hui   18/04/2024 11:50:43 AM

I’m a retired emergency physician, now works as locum GP in rural general practices and aboriginal health centres. I am a strong supporter of health teams, in particular, nurse practitioners. I am absolutely certain that well trained nurse specialists with their dedication to family medicine can contribute to our rural population as much as, if not better, than doctors recruited overseas to fill in the gap in our health system. Admittedly, the focus of these nurse are not in diagnostics but most are good in recognition of serious problems with their diligence and observations. Don’t we all learn from errors. I just come across a GP prescribing Alpha blocker as treatment for enlarged prostate of a patient with Parkinson’s disease. No postural hypotension was checked. Just imagine the consequences.
Learned lots from these nurses during my transition from hospital medicine to general practice. Of course, they aren’t those who have studied for 3 year of nursing

Dr Natalie B   18/04/2024 1:44:12 PM

I agree with Paul Hui above. I too am ex-Emerg, now locum rural/remote GP. I think NPs are great. I have found many of the nurses I work with utterly stellar. And yes, an under-prepared doctor is not going to service a community/team as well in reality as on paper.
There are at least 50 things I do in a day that could be done by other craft groups - I don't mind doing them, but I am busy and if someone wants to do those things I won't argue.
I find College's obsession with this issue (and all the other gate-keeping /GPs-must-be-the-hub-of-everything absurdities) very off-putting.

Dr Christine Colson   18/04/2024 5:25:50 PM

I fully understand where Dr Hui and Dr B are coming from. I would not work in a practice without a practice nurse. The mutual learnings are obvious but I think it's wrong to mis-characterise the concerns that are being raised about working to 'top of scope' whatever that is defined to be. The danger, as I see it, notwithstanding the diverse levels of GP skills and knowledge, is implementing a system where patients feel they can just as safely and effectively seek help for all their health issues from any health professional. We are all trained for specific jobs.

Dr Angela Maree Roche   19/04/2024 12:13:27 AM

“I am a strong supporter of health teams , in particular, nurse practitioners.” So is General Practice. General Practice wants to keep the legislation that encourages “ collaborative arrangements” with Nurse Practitioners, the very essence of what comments here are espousing. It is Government and Nursing Bodies that want to sever it, risking the production of 2 parallel, disconnected primary care streams - silos in healthcare , fragmented care that “ reduce cost of efficiency, impact the quality of care and lead to the duplication of services “. ( Silos in healthcare are bad for us. Here’s the cure. Global Health. Nov 14.2020). These issues are not about what 2 doctor’s experiences were working with a nurse practitioner. These issues are about Government Reform for role substitution in Primary Care and the effects that that will have on the Australian Healthcare System as a whole.

Dr Angela Maree Roche   19/04/2024 12:35:21 AM

“ must-be-the-hub-of-everything absurdities “ is called Continuity of Care - a foundational element of primary care, recognised as a key component in highly functional primary care systems and is associated with improved patient satisfaction, increased health outcomes and decreased total cost of care. ( “ Measuring continuity in primary care: how it is done and why it matters.” Family Practice, Vol 41, Issue 1. Feb 2024). Health systems that have deliberately fragmented care with role substitution, like the UK, are now in crisis. (Nine major challenges facing health and care in England. 3/11/23. The Health Foundation. ). Wondering why there might be an “ obsession with this issue” demonstrates a complete lack of comprehension with the matters at hand . We do not need to and must not repeat the failures of those whose evidence is so plainly available for us to see.

Dr Suzette Julie Finch   20/04/2024 1:24:39 PM

I've attempted to remain calm & so delayed answering the StrawMan comments of Paul & Natalie, our esteemed ED doctors.
This is exactly the arrogant tertiary centre thinking that misrepresents GP work & trivialises it, resulting in devalued Primary Health Care. PHC investment has a significant on a country's 'life expectancy ' & I don't believe shiny ED departments have the same nationwide impact.
Paul we can ALL give examples of mis-prescribing by GPs, Specialists & even the esteemed & all-knowing ED docs. I try not to subject my poor patients to the wisdom of ED doctors if at all possible given the current debacle of emergency care.
Natalie for we poor schmucks stuck in the usual GP contract work - not the financial cosiness of a salaried rural locum, where you move on before the chronic disease congregates, we appreciate the vaccine check between the vicarious trauma of end-stage MS, cycling DV, undiagnosable abdominal pain, existential pain etc etc, financially & mentally.

Dr Suzette Julie Finch   20/04/2024 1:54:27 PM

If you don't understand a central profession is critical to each individual patient's care, who easily manages 75% of each of the complex patient's >5 clinical problems, you aren't involved in Primary Health Care. Rural locums are likely to be ED-lite semi-urgent problems, not the complex chronic care patients waiting for "their GP" to return. If you understand a central professional with a reasonable knowledge of most clinical conditions & pathophysiology to improvise management compromise & experienced in boundaries of NON-generalist assistance but don't believe it's a GP role, then who would be best? I too have worked in regional centres where super rural nurses attend the after-hours PHC urgencies. I have mentored NP students & nurses of varying skills. They will never have the skills 6 years of med school, 2-3 years of hospital training & either the RACGP or ACRRM gives. Compromising PHC standards compromises the Nation's health- a fact not an opinion.

Dr Peter James Strickland   22/04/2024 11:45:24 AM

It all relates around 'dollars', and has nothing to do with patient care quality and freedom when it comes to government reviews. The correct argument is that hospital care as inpatients and outpatients is expensive, and seeing the GP is relatively cheap. Nurse practitioners ONLY complement GPs in areas of scarcity, and cannot be expected to be the same diagnosticians --it is every thing to do with training and expected responsibilities according to that training, and priority MUST always be to get GPs to areas, and have the complementary availability of nurse practitioners who can refer to their local GP when required.