The young mother was referred with a melanoma. She noticed the spot months earlier but was too busy to get it checked. Then, she needed a repeat prescription for The Pill, and remembered the odd spot just as she was leaving her GP.
Role substitution for GPs by nurses, pharmacists and allied health professionals has been flagged as a key feature in the proposed Medicare reforms. The implications for Australians like this woman – any of us – are therefore vitally important to understand.
Universal health care is a core Australian value, but pragmatically, governments have always sought to balance budget limitations with providing as good care to as many people as possible. Universal care has never been truly universal.
In primary care, budget strategies have included freezing Medicare rebates. But now, the politically palatable limit of what GP clinics can absorb and what Australians can pay to make up the deficit has been reached, and thus the scramble for different compromises.
Nurses, pharmacists, dentists and allied health practitioners play a vital role in our health system and patients deserve Medicare rebates for their services. But current proposals don’t seem to augment existing primary care arrangements; rather the plan is for these other clinicians to undertake parts of the work GPs have historically performed.
Like public health, great primary care is invisible. Vaccination, mental health care, health checks and screening, well child checks, the management of multiple disparate preventative, therapeutic and social issues in a single appointment – the best care you get from your GP is what you don’t see. Primary care has contributed more to rising life expectancy than the fanciest ICU or the shiniest operating robot.
Australian medical training has long built a redundancy of knowledge into every doctor’s expertise. Clinicians might largely see and treat common issues, with lay perception that the job is simple, but broad, rarely used knowledge is what helps the patient with atypical symptoms, the unrelated problem they mention as they rise to leave. GPs in particular flip between organ systems and age groups, social class and cultural background with dizzying proficiency – even while often being publicly derided for not being expert enough. Breadth of knowledge costs money, both in the training and delivery, but delivers benefits to individual patients and the health system more broadly.
Redundant expertise allowed the rapid establishment of community respiratory clinics for a novel virus, and administered a new vaccine into tens of millions of arms at pace – tasks that weren’t about taking a swab or giving a jab, but rather staying up to date with complex changing information and interpreting that for millions of individual patients with myriad co-existing needs, worries and health conditions.
Breadth of knowledge allows GPs to hold greater risk and uncertainty – allowing patients to be safely treated in the community rather than be referred to hospital. We know that where that role is substituted, non-GP services refer on to more expensive and scarce hospital care at higher rates. Role substitution may seem cheaper, while being a false economy.
If nurses, allied health practitioners and pharmacists are to maintain this level of knowledge – to really substitute them into the existing role of a GP would require them to be trained with the same breadth of knowledge as a GP. If they are only trained for a fraction of a GPs role, then a patient would need to see multiple fractional providers to achieve the care currently possible in one appointment, at greater cumulative cost.
Many non-doctors could be trained to work equivalently to GPs and other medical specialists, but it would require the same time and resources as training those specialists now. This is not about whether nurses and other clinicians have ability – they do, as evidenced by the specialised clinical roles already held by these craft groups – but about roles, training and patient expectations.
But coming back to the budget problems of a country with an aging population and collapsing primary care – a nurse trained as a GP will (and should) cost as much as a doctor trained as a GP which doesn’t solve the budget issue. So the glib assurance that this proposed role substitution is like-for-like but at lesser cost cannot be accurate.
Many countries do have a different standard to Australia for the training and breadth of experience medical specialists are required to have, including many peer countries in Europe. As a nation we could save money by training surgical technicians that perform only a couple procedures, rather than surgeons who can treat anything within a broad remit; community health workers rather than GPs. We can move to a system of piecemeal fragmented care and hope that these new training and policy settings will stretch the budget dollar. It might be safe for those with simple, straightforward, single problems, and far better than nothing, but let’s be clear that this would be a health system with different goals and standards to what we have today.
Some patients probably wouldn’t notice the difference. For others, their poorer outcomes might never show up in data or statistics, the delayed diagnoses and missed health opportunities, the greater number of appointments and higher risk of using hospital services hidden among the blunt population statistics of 26 million people.
As someone who sees so many patients, like that young mum whose melanoma was diagnosed early because her GP biopsied it on the spot, at an appointment she was irritated to attend because it was for ‘just a script’, I know all too well why role substitution of GPs demands a national conversation about the future of primary care in Australia, and not to be presented as a fait accompli.