Skin cancer

July 2012

Up front

Gatekeeper, shopkeeper, scientist, coach?

Volume 41, No.7, July 2012 Pages 457-457

Kees Nydam

Health Workforce Australia is proposing to further extend the list of practitioners who are eligible to prescribe to include physiotherapists, pharmacists and psychologists.

Extending the prescriber list has some potential benefits, including improved patient convenience and the potential for Medicare savings (although it is not clear how nonmedical prescribers will be remunerated or what governance processes are proposed to determine the scope of prescription practice). Despite these potential benefits, objections to the proposal have been raised by organisations representing general practitioners, including the Australian Medical Association and The Royal Australian College of General Practitioners,1 and the National Prescribing Service (NPS) has concerns about the potential risk that the proposal may fragment care.1 Certainly, patient safety is a vital issue, however, this is unlikely to improve (regardless of who prescribes) without important systemic improvements such as regular medication reconciliation and quality assured management algorithms.2

Perhaps concern from doctors about the proposal reflects a deeper tension within the healthcare system. In recent years there has been a trend toward self management of chronic disease. Reflecting this, the NPS states on their website that ‘individuals are gatekeepers of their health decisions’.3 But GPs regard themselves as best practice gatekeepers of prescription medicines. Although patients do not routinely seek preventive healthcare, the need for repeat or other prescriptions creates opportunistic GP contact: reducing this ‘enforced’ contact carries a risk and managing this risk requires assessment of the need to alter scopes of practice. To get the most out of our workforce we need innovative workforce re-engineering and collaboration between all disciplines.

While GPs define themselves as primary care providers and gatekeepers to more expensive specialist services, consumers can access primary care directly from physiotherapists, chiropractors, complementary practitioners and others; GP roles can likewise be usurped by patients attending hospital emergency departments or community health services. Reflecting this broader focus, the Commonwealth government’s healthcare reform package includes ‘the establishment of primary care organisations with a population focus and responsibilities that are broader than general practice; the small but significant move to capitation and performance funding in chronic care’.4 These territorial changes jeopardise the traditional view of GPs as having a central role in the provision of primary care.

The Australian Health Practitioner Regulatory Authority regulates this broader healthcare workforce and consists of over half a million health practitioners from 10 professional groups. Another four will join the registration and accreditation scheme midyear. Doctors comprise 17% of all present registrants,5 and less than half are GPs, comprising approximately 20 000 full time equivalent positions.6 Despite this, they receive a sizable amount of the public healthcare budget by way of fee-for-service Medicare rebates. This creates significant complexity in financial governance within Medicare.7 Under fee-for-service arrangements, GPs are sole traders, but medical care is no longer a cottage industry. General practice is changing and it is time for GPs to ride the wave of innovation if they wish to remain relevant.

Perhaps patient safety in the prescription debate is a distraction from the more critical debate on medical leadership and the core role of doctors in the delivery of primary care. Questions around scope of practice are inextricably linked to patient safety and are necessary in the pursuance of good clinical governance. Importantly, in a healthcare system with multiple players there will be early, mid and late adopters of changes in service delivery. An overarching collaborative practice framework between medical and nonmedical prescribers is now espoused by many early adopters of change.8 This should reduce risk if managed intelligently and place patient care at its centre.

The late Professor Cawte wrote, ‘the expectancy of society for those it appoints as doctors is twofold; they should wear the mantle of “coach” together with that of biological scientist. Effective is he who wears them like a reversible cape’.9 The next innovative wave should have GPs moving away from being sole traders and re-embracing the coach mantle; except this time, coaching wider multidisciplinary teams as metaclinicians. This will require true medical leadership.

Conflict of interest: none declared.

References

  1. Cresswell A. Doctors fight rival powers to prescribe, saying ‘Patients put at risk’. The Australian, National Affairs, March 5, 2012.
  2. Scott I, Jayathissa S. Quality of drug prescribing in older patients: Is there a problem and can we improve it? Intern Med J 2010;40:7–18.
  3. National Prescribing Service. About us. 2012 Available at www.nps.org.au/about_us.
  4. Hall J. Health care reform in Australia: advancing or side stepping? Health Econ 2010;19:1259–63.
  5. Flynn J. Message from the Chair, Medical Board update. 2011. Available at www.medicalboard.gov.au/News/Newsletters.aspx.
  6. Goldstein S. Foundations in Public Health and Health Care Systems. UNSW PHCM9041, 2012.
  7. Webber TD. What is wrong with Medicare? Med J Aust 2012;196:18–9.
  8. Bonney A, Farmer EA. Health care reform: can we maintain personal continuity? Aust Fam Physician 2010;39:455–6.
  9. Cawte JE. Neurosis in general practice – everyday use (or non-use) of tranquillizers. Med J Aust 1962;1049:378–9.

Correspondence afp@racgp.org.au

Yes     No

Declaration of competing interests *

Yes No

Additional Author (remove)

Yes No

    

 

 

 

 

Competing Interests: 

Your comment is being submitted, please wait

 

Download citation in RIS format (EndNote, Zotero, RefMan, RefWorks)

Download citation in BIBTEX format (RefMan)

Download citation in REFER format (EndNote, Zotero, RefMan, RefWorks)

For more information see Wikipedia: Comparison of reference management software