Many of the reports, whether in the local or the national press seemed to uncritically buy the GPs’ line that super clinics will threaten the integrity of the relationships between GPs and their patients.

Even the Sydney Morning Herald editorial examined the issue as if it was only about patient care.

Only one report that I could find – and perhaps not coincidentally in a publication for doctors – acknowledged that other considerations (ie $$$s) might also be driving the opposition.

Now I am not seeking to be an apologist for the clinics. And you could argue that it’s entirely fair enough that small business people would want to defend their business.

But if we’re going to amplify the concerns of one group with a professional and financial stake at play, then perhaps we should also be reflecting the views of others involved.

Despite the silly name – GP super clinics – the facilities are aimed at promoting multidisciplinary care. So maybe we could also be hearing from the nurses, psychologists or others involved?

Even better if we could get some independent sense from the local community about how well the existing model of general practice is meeting their needs and what they think about the super clinic approach.

I’m sure there are problems around the place with the various super clinics being developed – it would be surprising if there were not, given all the logistical, bureaucratic and professional challenges that are likely to be involved in setting them up.

But the general public may not be aware that there are also some good news stories around.

From what I’ve heard, the one being developed at Shellharbour just south of Wollongong is going to be offering a terrific range of clinical and health promotion services to an otherwise under-served community. Importantly, it will also be a training hub, with postgraduate nurses, GP registrars and medical students onsite.

Those behind it hope that by developing new models of care and flexible, stimulating working environments, the Shellharbour clinic will help recruit and retain health professionals in a needy area.

There’s another good news story to be found at Gunnedah, the north-western NSW town that stakes its claim to fame as poet Mary Mackellar’s birthplace and “Koala Capital of the World”.

It’s not about how federal policy solved a local health need. It’s about how a local community came together to develop a local solutions for their problems – and then got some Federal backing to help realise it.

I wrote recently in Australian Rural Doctor about how the people of Gunnedah have been engaged in an intensive fund-raising campaign over the past 18 months in order to establish an integrated health clinic. The plan is for it to be owned by a  not-for-profit, community-owned company, run by community members, health professionals and representatives of local agencies.

The origins of the concept date back four years when a local GP, Dr Grahame Deane, acutely conscious of the perilous state of the town’s health services, began working with various agencies to develop some solutions.

The goal was to create an attractive environment to help with workforce recruitment, while also increasing the town’s chances of “growing its own” by becoming more involved in teaching and training.

But rather than impose his own vision of how to achieve this, a series of community meetings were held, to find out what the locals wanted. The response was overwhelming, with 350 people packed into one forum, and many turned away for lack of space. It turned out that the people of Gunnedah shared Deane’s vision for a community-owned venture.

Deane believes the “absolutely amazing” community support has been critical for the project’s progress. “The important thing is that it is not owned by a doctor, it’s not owned by a corporation, it’s owned by Gunnedah,” he says.

After my story went to press, it was announced that the town had won super clinic funding.  Deane rang recently to tell me how delighted he was to get the funding although he admitted that he didn’t much like the “super clinic” name.  I heartily agreed with him. Terrible name, but the concept may have more merits than some recent headlines have been suggesting.

And I tell you what – I much prefer the richness of the story out of Gunnedah than the one we’re being told out of western Sydney.

“The elephant in the room that is not being spoken of or referred to in the current plethora of reports and indicated reforms in the area of Primary Health Care is: What do our General Practitioners actually do? And what is to become of them?

According to the reports released in the last six weeks, general practitioners appear to be ineffective, inefficient, have no professional identity, minimal skills, easily reproducible clinical skills and are at least obstructionist to team care if not entirely unnecessary in their current role. Reading this literature I’m not sure what they are doing or why they are doing it so badly.

Surely some of the 22 000 GP’s this country funds are doing something effective? Apparently not if you believe the literature we are being fed.

Besides this we don’t have enough of them.

Or do we in fact have too many given their total ineffectiveness? If this is the case why are we increasing their numbers? The department has believed for years that we have too many GPs per capita and the answer is apparently to reduce the numbers and replace them with allied health personnel. Is that what we are doing? The recent increase in training numbers will replace the retiring GP work force but not increase it. Have we been manoeuvred into this position where the GP shortage can be used as a reason and lever for this level of reform?

Reading the multiple submissions made in the consultation process it is apparent that general practitioners can be replaced easily by allied health personnel. This includes nursing staff that merely need to be given prescribing, pathology and referral rights to match GP skills.

The DoHA website is running a survey: “Would you be willing to see a nurse practitioner for some types of care and not a GP if it was quicker and if your quality of care was unaffected?”

Is this a reflection of their attitude to general practice?

According to this survey, which is “Yes Ministerish” in its directional questioning, the implication is that treatment from nurses will not affect the quality of medical care and will be quicker in delivery. It probably will be quicker until they too are buried in the bureaucratic red tape that has killed the ability of general practitioners to utilize their clinical skills or they meet their first serious problem masquerading as a simple issue. Assuming this situation is recognized as such. If it is not recognised them it will take no extra time at all.

In relation to the independent nurses working alone or in pharmacies: Will they need to work from accredited premises? Will they need to keep accurate and defensible clinical notes? Will they be able to complete Centrelink forms, disability parking permits, taxi subsidy applications, death certificates, sick certificates for 2 year olds who can’t attend their day care, obtain authority prescriptions, and complete the myriad of paperwork that surrounds work place injury? Work place injuries that they may be the first to see and treat. Or are all these bureaucratic issues solely the province of general practitioners?

This attitude of omnipotent competence not only applies to nurses but appears to include psychologists, physiotherapists, pharmacists, podiatrists and other allied health personnel all of whom are seeking direct patient access with MBS funding. Will patients or the tax payer pay for patients who see a psychologist for a year while their hypothyroidism progresses? What about the patient with the tumour receiving six months of physiotherapy with only temporary improvement.

“The need to improve the level of teamwork in primary health care, encourage greater integration and improve affordable access to a range of non-medical services is well accepted, although there is debate around where the GP sits in the team.”

Further to this debate, general practitioners apparently do their tasks so poorly that it will be necessary to develop specific and directive funding formulas to drive them to work in a manner and direction the bureaucrats, the ivory tower specialists and the authors of the multiple submissions, believe they should be working in.

Perhaps there should be some concern in relation to these developments as clinical skills applied carefully to individual illness and circumstances is replaced by pre-determined protocol applied universally to all according to a set funding formula.

So where will general practitioners go? Is there a role for them at all? Should they all specialise? Or is the development of an allied health tier in the primary health area pushing them into the realm of general practitioner specialists? If this is the case you can guarantee they won’t receive funding appropriate for this role!”

That quote actually comes from the Preventative Health Taskforce report. I thought it worth mentioning because the draft of the first national primary health care strategy (which is available here, together with a supporting report) is likely to slip off the public radar pretty quickly, more’s the pity.

The Consumers Health Forum has given the strategy a big tick. Executive director Carol Bennett issued a statement saying: “The building blocks for change identified in the draft strategy reflect consumer priorities in health care. We’re delighted to see the focus on better integration and improved access to services, as well as measuring impact and outcomes. One of the strong points in this report is the way it embraces community based service provision that is not just about clinical health or GP services.  This is particularly important for people experiencing chronic relapsing health conditions who often need a wide range of services to meet their health needs.”

But Croakey contributor Professor Gavin Mooney is not so enthusiastic. He has written this analysis for Croakey:

“The national PHC Report and Strategy are overall disappointing. Let me respond to just two aspects.

First there is no grand vision, no overarching set of principles or values. Just a listing of 10 key aspects later reduced to 4 which are “improving access and reducing inequity; better management of chronic conditions; increasing the focus on prevention; and improving quality, safety, performance and accountability.’

How these were arrived at seems to have been in some backroom with, yes, “consultation” – which means anyone or anybody who wants to is invited to write in – predominantly “experts” (like me!) or professional bodies which have a vested interest.

Where is the voice of the informed public? It is their primary health that is at stake and it is their primary health care that is at stake. They are perfectly able to think through the principles and values they want to underpin PHC.

For example the Perth GP Division – the Perth Primary Health Care Network – got me to facilitate a citizens’ jury with randomly selected but well informed citizens being asked to say what they wanted from the network. A simple cheap and effective way to consult – and interesting results – for example their suggestions under the heading of “improved quality of care” included “More holistic care; GPs running on time; better referral systems, especially for mental illness; improved doctor patient relationship (with greater transparency on a number of fronts, particularly the influence of pharmaceutical companies on GPs practice and  greater shared decision making in general).”

In another jury in South Australia in a primary health care setting, one of the very interesting issues they proposed was for the PHC facility to be a point of contact for assistance in gaining knowledge of where to go with particular problems. This was to involve establishing information about and linkages with other services (both health and non-health), identifying gaps and seeking to fill these and advocacy with other (non-health) services to be more cognisant of their potential health role.

The details of the results from these citizens’ juries perhaps do not matter in this context. What does is that people – citizens – have a pretty good idea what they want in PHC. But we will never know if we do not ask them. This national committee do not know because they never asked.

Another issue (and it turns out to be related) in the report and strategy that concerns me is their handling of GP remuneration. The report runs through the arguments for and against different systems – and then basically stops, arguing in essence that there is not enough evidence to justify much by way of change. (There is some suggested change on chronic care and possibly prevention.) The evidence I believe is stronger than they suggest that but that is not my main concern here. We know that different remuneration systems result in different GP behaviour. The question then is: how do we want out GPs to behave? What do we want from General Practice?

Who better to address that than informed citizens! But the committee did not ask. Maybe there is still time?”

It includes more than a dozen stories of how doctors and their patients have worked together to overcome various health problems.

Stories include:

• A woman who was blind and in a wheelchair due to paralysis in her right leg, who was able to see and walk again after being helped to deal with a mental health problem that was manifesting as physical symptoms

• A woman who went from a size 26 to a size 12 within about a year, thanks to the help of a GP who set up a dedicated weight management unit

• A man who was successfully treated for heroin, crack and alcohol addiction and now helps people with alcohol-related problems

• A rheumatologist who has embraced the use of emails, texts and telephone counseling to improve the care of his patients.

Of course, it’s all a nice bit of PR for the NHS and the doctors involved. Still, the document makes an interesting read and it is refreshing to see a medical organisation promoting the notion of real partnerships between doctors and patients.

There’s a lot of talk about the importance of partnerships but we too often still hear organisations like the AMA saying they are talking for patients.

At the time, I thought it a big call which wouldn’t necessarily garner widespread support. However, you can see below that much of the feedback, from various groups and individuals, is broadly supportive. I wouldn’t be surprised though if it’s also generated some behind-the-scenes muttering, given the proliferation of promotional professionals.

Professor Garry Jennings, Director, Baker IDI Heart and Diabetes Institute, agrees with Anderson:

“I agree with Professor Anderson, especially in relation to participation in commercial advertising. In our field, if something is worth saying, it is worth doing so in the thousands of peer review journals that are published each week. The public and our peers have a right to know who is behind the scenes and whether a particular view is freely expressed or bought.

That said, a blanket ban might not be so important if there was frank and open disclosure – it’s the relationship being there and NOT being disclosed that causes the greatest problems.

In this respect, participation in commercial advertising may be less problematic than the more surreptitious alliances that are sometimes present in relation to advertorials and disease awareness programs. With advertising it is for the most part clear that the health professional and the pharmaceutical company are in league, almost certainly under a commercial arrangement which is arguably no different to a respected sports star participating in fast food advertising (and probably less harmful).

Disease awareness campaigns are more complex though, and health professionals should be very careful how they are quoted in them whether or not they are being paid. There is often not a good match between disease burden and hype and although a new treatment for a disease for which there has previously been no treatment is often worth telling people about, there are enough examples where health professionals have been manipulated by companies paying for their commentary in the cause of public awareness for us all to heed Professor Anderson’s advice to take extreme care.

I have personally experienced situations when my freely expressed and well meant views were dressed up in advertorials and surrounded by material that the casual reader might reasonably assume was mine.”

***

Medicines Australia. A spokesman, speaking on behalf of chief executive, Ian Chalmers, disagrees:

“This is a matter for judgment by the individual medical practitioner involved. There is no reason why an appropriately qualified medical specialist should not be free to impart knowledge and information about the efficacy of a medicine with which he or she is familiar.”

***

Dr Chris Mitchell, president of the Royal Australian College of General Practitioners, agrees:

“The RACGP has endorsed the AMA Code of Ethics 2006 and we believe that general practice is an ethical and honest profession. As a part of this, we have agreed that RACGP members should not participate in commercial advertising or advertorials.

The RACGP has a sponsorship policy which clearly states that any sponsorship activity should be in line with the principles of the AMA Code of Ethics.

The RACGP has agreed that college members should not be involved in/ appear in advertising of commercial products where it appears the GP is endorsing that product. The RACGP believes in the primacy of the GP/ patient relationship and believes that GPs should not enter into any arrangement that would impact on this.”

***

Dr Rosanna Capolingua, president of the AMA, agrees:

“As found in the AMA’s Code of Ethics (and supported in our Position Statement on Advertising and Public Endorsement) the AMA advises doctors:

2.2.3        Do not endorse therapeutic goods in public advertising

2.2.4        Exercise caution in endorsing non-therapeutic goods in public advertising.

Further, health care professionals are currently not allowed to undertake such endorsements, as covered in the Therapeutic Goods Advertising Code 2007, as follows:
(b) Advertisements must not contain or imply endorsement by:
(i) any government agency;
(ii) hospitals and other facilities providing healthcare services;
(iii) individual or groups of healthcare professionals, other than where
the emphasis is on the availability, which may include the price of
therapeutic goods through his/her retail business; or
(iv) by individuals, who are healthcare professionals by way of their
representation in advertisements or academic qualifications, and /
or who are likely to be known as healthcare professionals by the
reasonable person.

There may be a serious perception of a conflict of interest for doctors who publicly advertise or endorse therapeutic goods – that doctors will prescribe or recommend a medication with which they are publicly associated rather than a more effective (or cost-effective) treatment. We need to ensure that patients continue to trust their doctors to prescribe or recommend treatments in the patient’s interest (and not the doctor’s perceived self-interest).”

***

Associate Professor Merrilyn Walton, University of Sydney, agrees:

“The role of pharmaceutical companies is to make a profit – their marketing is designed to sell their drugs. Health professionals are required to put the best interests of patients first. By promoting a particular drug (in the context of little knowledge about a drug and its role in improving a particular patients health care) health professional are putting the interest of the drug companies ahead of the interests of patients. The public needs to be able to trust health professionals and their judgements about the best drug for them- if they are compromised in advertising, the perception of trust is lost. If there is a payment or advantage to the health professional there is a real conflict rather than a perceived one.”

***

Michael Roff, CEO of the Australian Private Hospitals Association, has a bob each way:

“This is an important issue and we are pleased to see the NHMRC will be fostering the debate by hosting a forum next year. As I read Professor Anderson’s comments, he is saying while his personal advice is for health professionals not to participate in such campaigns, he goes on to say if they do, there should be full and open disclosure and I think that this is the real issue. Otherwise are we saying that Professor Ian Frazer should not have been involved in promoting the benefits of Gardasil, even though he openly disclosed he received a financial benefit from the commercialisation of the vaccine?

There are complex issues involved but full disclosure of interests would appear to be a reasonable course of action. I understand that in Australia, both the pharmaceutical and medical technology industries have codes of conduct that deal with the issues of disclosure. Whether or not these mechanisms are resulting in appropriate levels of disclosure or whether their scope is adequate may require further examination.

***

The Australian Healthcare & Hospitals Association also has a bob each way:

“The AHHA recognises the high level of trust consumers place in doctors and health services and therefore supports a system of full disclosure of financial arrangements between any health professionals and health service providers and the sellers of pharmaceuticals and other health care products.

It is essential that consumers can trust that advice they receive from their health care provider is unbiased by any commercial interest and based solely on the professional opinion of the provider.

A perception of bias among health care providers can be as damaging to consumers’ trust in the health system as an actual bias. Therefore, while the AHHA does not support a ban on health professionals’ involvement in advertising and promotional activities, we do support the mandatory disclosure of thus involvement to patients.”

***

Professor Peter Brooks, Executive Dean, Health Sciences, University of Queensland, agrees – because the proposal would lead to “more transparency”.

What do you think? Join the Croakey discussion…

The recent Crikey article raising serious questions about the future of primary care is timely in view of the problems facing general practice in Australia.

We need a national approach to general practice that invests five times the current level in it: to achieve best quality care; reduce inappropriate use of hospitals; reach preventive goals; and make it an attractive career for bright medical and other health professionals. General practice should be fitted with sophisticated IT for staff to communicate with other doctors, nurses, community workers and patients and with each other.

Practices should be remodelled as part of Australia’s rediscovery of the value of investment in infrastructure. This would achieve higher levels of community satisfaction and secure the future of Australia’s health service in face of mounting pressures due to ageing and chronic illness.

Beside this rejuvenation of general practice, Australia needs to stir itself and find out what is going on around the world in the field of primary health care, which goes beyond general practice to what we might call the local politics of health.

Primary health care is about how to assist communities to achieve better health and greater equity. It overlaps with, but is not the same as, general practice. There is confusion about primary care and primary health care. We distinguished the two in a recent paper in the Medical Journal of Australia recently . Primary health care is much more comprehensive, as defined by the World Health Organisation thirty years ago, and as I used it in the paragraph above.

Towards a National Primary Health Care Strategy is a discussion paper published recently by the Australian government. Congratulations to the federal government for recognising the need for a strategy in this field. The paper called for submissions on ten ‘elements that could underpin a future primary health care system.’ The paper offers no precise definition of primary health care but generally it means general practice with add ons.

So despite the title, what we have learned from around the world about the value of primary health care, extending beyond the provision of general practice to community development, energising people to assume greater responsibility for their own health and helping shape the political and economic determinants of health, is out of range of this document although not entirely so.

Yet the future of general practice and allied community support services is very important in its own right. General practice is currently maldistributed – too many practices in cities, too few in the country, too few in ethnically diverse settings – and this is the first of the ten issues raised in the discussion paper. It is the first of three practical, understand-what-you-mean issues considered in it.

The other seven issues are interesting but require changes in health policy that go further than general practice. They may appear remote and theoretical to a general practitioner looking for evidence that his or her plight is taken seriously.

The second point has to do with making primary care more patient-centred and friendly. The third point calls for more support for prevention in general practice, especially that variety that has a clinical component to it – assessing risk factors for example. Good idea, but who pays, and where does the time for it come from in a busy practice with a waiting list?

The fourth point argues for better integration with other community health services, the fifth with assuring greater quality, the sixth (another good practical one) with the use of IT. The seventh seeks more and stronger relations between general practice and the communities in which they operate, a tilt to primary health care as discussed above. The eighth, a crucially important one, concerns how to make the primary care setting more attractive for practitioners. The ninth is about education and the tenth is expressed in econojargon – and calls for fiscally sustainable and cost-efficient care.

What is happening elsewhere? In August, The New England Journal of Medicine ran a perspective paper entitled “Primary Care – Will it Survive?” from Dr Thomas Bodenehimer at UCSF. It is superbly written, with powerful word pictures of what is happening in general practice in America, with its patient and practitioner dissatisfaction, growing expectations of primary care as the tide of chronic illness rises and as the number of preventive services that people expect in general practice grows.

Meanwhile, more clinical practice guidelines are recommended, brightly telling practitioners how to do everything from managing a lump in the breast to treating blood pressure. The similarities with Australia are striking.

Everyone wants general practitioners to do everything according to their specified rules for no more money and many more forms to complete. General practitioners are encouraged to be coordinators for people with chronic illness, but as Bodenheimer points out in an earlier paper, “the number of coordination relationships can multiply geometrically in the not-unusual case of three different provider organisations (with several caregivers in each organisation) having to interact with a patient plus three distinct family members” making care coordination an industry in its own right..

Assuming about 2,500 patients are on the books of one practitioner, Bodenehimer says, it would take that doctor 10.6 hours a working day to deliver the care for those with chronic illness according to guidelines, plus 7.4 hours a day to provide evidence-based preventive services to those who pass through his or her surgery!

No wonder that with the practitioner under such pressure half the patients with hypertension, diabetes and chronic conditions leave the physician’s office not having understood what the doctor said.

All is not bleak in the U/S., especially within general practice itself, rather than the organisation that supports it. Bodenheimer points to reform in larger group practices that now work well with other health professionals in caring for people with chronic illness. His arguments for the value of reformed general practice are supported by data that demonstrate how good general practice improves both the quality of care of patients and decreases hospitalisation costs in American states where it is adequately supported.

But much of general practice, operating in small premises, is unreconstructed. He argues for reform both within and beyond general practice, lamenting the lack of a national primary care policy in the U.S. that covers reimbursement: the fortunes of general practice, he says, are dictated by a ‘specialty-rich, quantity-based reimbursement system.’

Until we come to terms with reimbursement for general practice and infrastructure renewal, vague idealism will be like a cotton bud soaked in lignocaine jammed into an aching tooth.

To reform, it will cost more, not less, to provide an excellent national general practice service. The investment may be worth it in the long term, and ‘fiscal sustainability’ might be reached eventually, but not until we have invested heavily.

An investment strategy is needed now. We need to identify the attributes of the form of general practice we need for the future and then do the hard yards of facility building, continuing education and support, recruitment, infrastructure development, IT, continuing education, human resource management, monitoring, research and evaluation. This is the way to buy in doctors and others of quality for the future and assure excellent service.

For Bodenheimer, the contract between the present and the future is this: the general practitioner of the present may come to work in the morning and say, “OK. I have 30 15 minute consultations to complete before I go home tonight.”

In the future the general practitioner will walk into his or her office and say,” With my team I am going to spend my day trying to make my panel of patients as healthy as possible.” This means using the phone, using other health professionals to do home visits, using email, Skyping, running groups, following up people overdue for Pap smears in a sophisticated, IT-enabled practice. In this way the physician may reduce his or her direct consultations to ten a day, reserved for the most complicated patients who really require the skills of their physician for their problem resolution.

Alongside more roads, more train lines, and more ports, Mr Rudd and colleagues should consider opportunities for spend, spend, spend in health infrastructure. Public hospitals could soak up several billion dollars in long-overdue refits. A parallel investment in primary care infrastructure, way beyond the few dozen Super Clinics in the vast expanse of general practice in Australia, should fund general practice refurbishment that restores patient confidence and practitioner satisfaction in general practice Australia wide.