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.