General Practice has faced some stiff political winds and there is more to come in 2017. Dr Frank Jones says GPs must be prepared and agile to meet the challenge.
When Mandurah GP Dr Frank Jones took up the presidency of the RACGP in September 2014, general practice was in the midst of a political storm created by the Federal Budget just four months earlier. There was a ‘non-negotiable’ co-payment introduced by the then Minister Peter Dutton which threatened to unstitch Medicare. The air was so charged it could ignite.
The co-payment and the minister were dumped a few weeks later and replaced by a Medicare freeze and a new health minister in Sussan Ley. Fast forward to 2017 and the script in Canberra is repeating itself, while Frank, now immediate past president, is back in his Mandurah surgery.
Frank took up the presidency in an atmosphere of hostility, at least on the part of the bean counters. He was elected with a mandate to advocate for GPs who had had enough of being the forgotten branch of the profession, particularly rankling as government rhetoric would have general practice central to its policy of keeping people out of hospital. It remains the ultimate irony – a government pursuing a policy of blatant disinvestment in the very machinery that will save it billions.
Ministerial merry-go-round
Frank reflected on his two years in the College hot seat in an interview with Medical Forum just before Christmas. In hindsight, it was the calm before yet another storm front, with the resignation of Minister Sussan Ley and the installation Greg Hunt to the role.
While the past two years have been hectic, Frank said he was privileged to advocate for his GP colleagues and believed the Government was better informed about the views of GPs. Was the Government listening?
“Yes, there’s no question about that – they might not like what we’re saying but they are certainly listening, but in the end Health is being hogtied by Treasury,” he said.
Presuming Mr Hunt has no magic bullet, the issues for the profession remain unchanged.
The College has produced significant policy documents (available on the College website) to match every twist and turn of government – the MBS review and freeze, Health Care Homes, revalidation, eHealth, research and After Hours.
“As an academic College it is our role to advise government with policies based on good evidence and disinvesting in general practice will give poor overall health outcomes and be cost inefficient,” he said.
The College has also taken its advocacy role direct to consumers with its high-profile (and expensive) Good GP campaign, which Frank said was money well spent.
Versatile skills and roles
“It raises the profile of General Practice reflecting the multiple skills that generalists provide to our patients and communities,” he said .
This marketing of GPs’ versatility not only as health professionals but patient’s advocates in a system with its eye on the numbers is being watched and emulated by other Colleges.
“The surgeons and physicians now use words that we have always used such as ‘having conversations’ with patients rather than ‘consultations’. Our specialist colleagues are now openly acknowledging the importance of general practice and that real life happens outside hospitals.”
While the community perception is changing, frontline GPs are struggling to meet the demands at multiple levels.
Health Care Homes
“Our 2015 paper position paper took a forward view – how to provide the best care in General Practice in the 21st century, reflecting the dramatic changes in health demography and demand. It was a good paper and suggested parameters as to how a GP-led medical home would work to improve the patient journey, especially for those with chronic conditions,” Frank said.
“The disappointment for us was that it has been twisted to fit a government agenda and focusing mainly on one parameter, reducing hospital admission rates. There has also been a subtle change in terminology from a ‘trial’ to ‘implementation’ and this is of major concern.
“A trial has defined parameters including a control group and an evaluation process so that we can see what works and what doesn’t. An implementation presumes it will work and be put into effect.”
“In addition, the dollars input is woefully inadequate and it looks as if the Government is setting it up to fail.”
MBS and the Freeze
In December, the government had to clarify its bulk billing figures – the oft-quoted political justification for the freeze/co-payment of about 80% when, in reality, it’s about 65%, depending on which area was in the spotlight. It was the worst-kept secret but it was finally an admission and a sign that figures can be rubbery when politics required it. Though the announcement came months after the Federal election, the College’s ‘Targeted’ election campaign bit deep in the opinion polls.
“That campaign reminded politicians that people’s health is at the top of their priority list. There is no wealth without health.
“General Practice is struggling with the ongoing freeze and providing optimum quality care is proving increasingly difficult. Medicare rebates just do not cover the real cost of a consult in general practice and many more patients will be have to bear out of pocket costs: what then of our disadvantaged groups? Delayed presentation, more unwell, potentially more admissions to our expensive hospital system.”
“Something has to give: I’m optimistic that there will some shift in the political perception,”
PLAN & Revalidation
“Evidence for a revalidation process improving patient outcomes is very thin on the ground, however, there is obviously public and political pressure on the Medical Board to look at it,” Frank said.
“I have been to multiple meetings on the issue and if it becomes within the province of lawyers and legislators it will be an absolute disaster.”
“The philosophy of the College is that we should be ahead of the game and start to have formal reflections on what we do in our work – actively measuring and assessing what is working and making changes to clinical practice if necessary.”
“The College has been working on various concepts that re-enforce reflective learning for many years and the Planned Activity Learning and Need (PLAN) has been assessed as the best way forward.”
PLAN caused a kerfuffle among the membership in October when it was released, mostly due to its compulsory nature, and angst for some education providers because the course would be delivered by the College in-house.
Frank defended PLAN as an important mechanism for GPs “to explore where the gaps in your knowledge are”.
“GPs don’t be like being told what to do and this is a compulsory College activity but I believe once they take a dispassionate look at it and reflect on it, most GPs will see this as the way to go forward. And while it is not tied to revalidation argument, we are trying to keep ahead of that as well and I think the Medical Board will also see PLAN as a major step forward which may put revalidation to the side for a year or two.”
Where to now
Frank’s hope for the future is an enthusiastic, resilient general practice that is central and sensitive to its patients’ needs.
“I think there will be a trend towards amalgamating smaller practices because of cost efficiencies and possibly even better patient outcomes through better continuity. It would be a great shame if private general practice ceased to exist in Australia. While we have good corporate practices, they are answerable to their shareholders.”
Along with all the other pressures private general practice faced, Frank cited the proposed changes to pathology leasing arrangements as a real threat to those smaller businesses.
“A lot of young GPs who have started their own private business depend on pathology rentals to sustain their business model. If the Minister changes that under pressure from the pathologists, those general practices will have to close and then who comes along to buy them out … the corporates. That would be a tragedy.”