Does the English system of general practice set the bar internationally?

If familiarity breeds contempt, then distance lends perspective. This much I learned – or remembered – on a recent visit to Australia.

Invited to give the keynote address at the Australian General Practice Network National Forum 2010 in Perth, I was reminded of the strengths of general practice in the NHS. Registration with a practice; a blended payment system based on capitation and rewards for quality; team working; and the absence of co-payments mean that general practice in the NHS is rightly admired throughout the world. Contrast this with patients shopping around for doctors in Australia – where a fee-for-service reimbursement rewards GPs for contacts with patients rather than continuity, and there is a lack of incentives for quality and team work – and the advantages of the UK model are plain to see.

This was brought home in a fascinating presentation by a GP who had left England to practise in Australia two years ago. His story of working as part of a team in England, relying heavily on nurses and allied health professionals, was a salutary reminder of things we often take for granted. Unlike in Australia, the NHS payment system offers no incentive to maximise patient contacts to increase income, and encourages GPs to use other members of the primary care team as much as possible.

In Australia, by contrast, doctors' income is based on the work they perform directly, thereby encouraging over-investigation and discouraging the use of other clinicians. The result is that doctors undertake work that could be better done by others because financial incentives may trump professional judgement about the best way of providing care. Resistance by some GPs to moves by the government to provide public funding for nurse practitioners in primary care illustrates the strength of medical protectionism in Australia.

The other insight from this presentation was the impact of differences in employment arrangements in the two countries. GPs in England, who are the owner-managers of their practices, are able to see the financial and other benefits of delivering high-quality care and have a direct stake in so doing. Salaried employment for many family doctors in Australia creates a different mentality, with GPs facing weaker incentives to continuously improve performance. There is a clear warning here as more salaried GPs are employed in the NHS.

I was invited to speak at the conference about the experience of primary care trusts at a time when Australia is introducing organisations known as 'medicare locals' to support the further development of general practice at a population level. The minority Labour government, elected in Australia in August, has invited expressions of interest from general practices to become medicare locals with the aim of establishing around 15 from July 2011. Health Minister Nicola Roxon emphasised that it was up to GPs to come forward with proposals for moving in this direction, on the basis that GP ownership and commitment would be fundamental to success.

The principal purpose of medicare locals is to achieve closer integration between GPs and between GPs and other staff working in the community, as well as to improve access to care. The aim is to move away from the cornershop model of general practice towards a more organised and population-based approach to health care provision. There is no suggestion that medicare locals should become the principal commissioners of care, underlining how unusual England is in expecting GPs to take on this role in the future.

The benefit of distance is that it reminds us what a precious asset we have in primary care, notwithstanding the need to tackle unwarranted variations in quality. At its best, NHS general practice sets the bar for others to follow. If we could heed Nye Bevan’s injunction to universalise the best, then we could be confident in having a health service fit for the future.

This blog is also featured on the British Medical Journal website.

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Comments

#260 Paul

"where a fee-for-service reimbursement rewards GPs for contacts with patients rather than continuity"

What is this continuity thing that seems to be mentioned so often when NHS general practice is discussed?

The only way that I get continuity in my care is by demanding that I see the same GP when I make an appointment. This makes getting an appointment difficult because of the way that the practice manages appointments. Are you saying that I should be getting this continuity automatically? Or are you living in some idealised world that isn't available to us ordinary mortals?

#265 John
Staff Obstetrician
South East Sydney Area Health

Chris Ham seems to be implying that Australian Genral Practice is still of "the corner shop" variety. If the phrase were not so demeaning I might say, "and what's wrong with that". It sounds as though Prof Ham would think an epidemiologist cum well connected bureaucrat a better recruit to General Practice than any clinician. And he has formulated his doctrine on the weighty experience of attending one conference located in a city! The strength of Australian General Practice lies in the rural areas where G.P.s not infrequently run the local hospital as well as their own separately located practice. They do things that others could do as well partly for commmercial reasons - undertaking long difficult consultations exclusively will not keep the practice financially viable and it will attract the unwelcome attention of the government Medical Benefit Scheme - and, almost certainly but rarely admitted, with an eye to medical litigation and complaints. They do not spend their lives in anxiety over achieving targets or the appropriateness of delegation. There are not that many persons to whom one can delegate anyhow. Local pharmacists are valued. Other ancillary practitioners who give good value and attempt local solutions are likewise embraced. Those who provide an unseemly number of referrals to "somewhere else" are not.
Over investigation is as much a UK problem as it is Australian. Rural patients here pay hefty charges because the provider is usually a commercial lab and they will challenge the need for repeat testing.
No, Prof Ham, you took too much for granted: this analysis is a lazy one. Many UK graduates here came to get away from the "GP as administrator" role to which you and other members of the UK medical cognoscenti are wedded.

#266 john cooper
retired

I worked in Australia during the seventies and eighties. It is true that over-servicing by both general and specialist practitioners was a major concern for health care managers. However the much higher numbers of doctors to population was as important a factor as fee for service, as more interestingly (if anecdotally) was the influence of Australian medical educators on what was considered best practice. A case can certainly be made that the reverse side of the coin of over-investigation and intervention in a fee for service environment, is under investigation and unwillingness to intervene appropriately in a capitation environment. Why is failure of early diagnosis of life threatening illness, of which I also have personal experience, such a significant issue in Britain ? Maybe our model general practice plays a part. As one of your other correspondents remarks Australian models respond to Australian circumstances, although certainly no more ideal than our own. Robert Maxwell observed (more or less) that nearly every country in the developed world believes they have the best health care arrangements, and are fiercely attached to them. In fact people have arrangements that reflect their own history. cultural expectations, circumstances, and which suit them. There is really nothing much wrong with that. One just has to make the best of the strengths and weaknesses of the system you have.

#351 Tricia Woodhead
quality improvement fellow
NHS

One natural human instinct is to see the best in what is on offer and not the worst. We may all be missing the point. Today’s imperative is ‘how well a system will continue to do the best for patients at the same time as delivering improved population health’. I am currently on a fellowship in the US and as part of this I have looked at how well the US system is improving ‘population health’. As a result it is clear that further clarity about the purpose of any system is needed rather than calling it Medicare Local (Australia), Medical Home (USA ) or GP Commissioning(UK).
Unless such names are synonymous with explicit and shared responsibility for co-ordination of care so that outcomes are consistently good populations may not experience much overall, added benefit. Fast access to an audited standard or a regulated parameter that can be achieved with some negative consequences may be an out of date way of delivering quality. It has been clear for many years that socioeconomic factors are critical to better health and longevity. Healthcare needs to sit with local government and the third/ not for profit sector and share expertise . The health impacts of every local decision should be considered in advance rather years later when the negative impacts no affordable fresh food outlets, parks, college access or new employment are clearly evident. Making people healthier requires an holistic approach rather than a new organization name. The three aims of better experience for patients, better health for populations and improved value for society may benefit from joining up the organizations determining health rather than rethinking how they govern each others decisions.

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