Repainting the General Practice Landscape

• Abstract
• Introduction
• The New Zealand health care system
• Subspecialisation within general practice
• The proposed model
• Benefits of the proposed model
• Conclusion

Abstract

The problem of the ever-growing waiting lists for secondary services has been haunting the public hospital system in New Zealand and probably worldwide for years. Attempts to ameliorate the situation included educating general practitioners on the use of referral guidelines and building more hospital facilities. This article looks at making an impact from another direction by encouraging subspecialisation within general practice in New Zealand. It is envisaged that this will lead to a significant shift of secondary services to the primary sector. The Royal New Zealand College of General Practitioners has already started the process setting up Faculties of special clinical interests. Lack of referrals from their colleagues in a competitive environment is the only impediment to this shift of services from secondary to primary care and for general practitioners to subspecialise. This will be intensified by the competition for patient enrolment when the proposed capitation of individual general practitioners in New Zealand is introduced. The authors suggest that salaried general practitioners employed by their own non-profit making organisation with an open-book policy will set the best scenario to nurture general practitioner subspecialisation. The employment of GPs by their own organisation has the advantage of ensuring that GP input is heard and actioned at management level.

Introduction

An article in a recent issue of the New Zealand GP magazine was titled "GPs grab chance to cut waiting lists" ¹. It described an Independent Practitioners’ Associations’ Council (IPAC)-led scheme to cut waiting lists for specialist assessment in 10 District Health Boards (DHBs). The scheme, as reported, would involve the following steps - referral guidelines would be drawn up for a total of 15 conditions; 10 facilitators would be employed by IPAC and the DHBs to educate general practitioners (GPs); and it was hoped that GPs would follow the guidelines "using specialists only when they are really necessary." It was reported that "Dr Allan Moffitt, one of the GPs involved with IPAC in developing the project, believed that the guidelines would help GPs work better and boost job satisfaction".

Increasingly, long waiting lists at the public hospitals have been a problem nationwide in New Zealand, and probably worldwide. Governments are embarrassed by the problem. The public is dissatisfied but cannot do anything about it. The health professionals are also frustrated and complain that they are always under-funded and under pressure. Each year, despite an increase in the Vote Health budget, the gap between the money available and the demand for services continues to grow. Blame has been variously placed on the higher costs of recent technological advances, growing demands of the patients, an aging population and the health budget not keeping up with inflation. The hope that educating GPs in the use of referral guidelines would cut waiting lists obviously puts the blame on GPs who have not been "using specialists only when they are really necessary".

The New Zealand health care system

When one looks at the New Zealand health care system more carefully, one can always see a number of anomalies and weaknesses depending on which angle one is looking from. This article takes the GPs’ point of view only. Traditionally, GPs are the first point of entry to, and are the foundation of, the health care system. GPs and their practice teams deal with all the conditions that they can cope with and refer those that are beyond their capabilities to specialists. In effect, they co-ordinate the whole spectrum of allied health professionals in the interests of the health of their patient. As described by Dr John Musgrove, the first chairman of the Council of the New Zealand College of General Practitioners, GPs are doctors who can "deal with the health of a family as a whole and be responsible for the continuing care of the family". .² However, even the Rt Hon Helen Clark, New Zealand’s Prime Minister, when speaking at the recent Wellington School of Medicine and Health Sciences 12th annual Sir Arnold Nordmeyer lecture, admitted that New Zealand is one of the few OECD countries where people pay significant fees for primary medical care. The New Zealand government now pays less then 40% of the cost of GPs’ consultations and most adult patients pay their own full costs. Even those patients entitled to subsidies are paying over one-half to two-thirds of the cost of the average consultation fee ³. On the other hand, secondary health care in New Zealand is 100% free to the public. This disparity has not been helped by the Government’s persistent focus in budgets on secondary care. In a way, GPs cannot blame the government for this because they fought for and won the freedom to raise funding by charging the public a reasonable fee.

Of course, realistically, families’ ability to afford medical insurance or to pay for their own health care, has been eroded by the slowing down of the New Zealand economy relative to the rest of the world in the last 30 years. This is borne out by a drop in the value of the New Zealand dollar exchange rate by 50% relative to most major currencies since the 1970s. In any case, when patients cannot afford to see their GPs as often as they need to, they either wait until they have several health problems or leave it as late as they can bear before consulting their GPs. This means that medical conditions can remain undiagnosed and become more severe before they are uncovered by GPs. By this time, there is sometimes no alternative but to refer the patients to specialists. Sometimes patients with aggravated or multiple health problems just present themselves directly to the accident and emergency services at the hospitals without going through their GPs at all. Last year, New Zealand GP magazine reported, "Auckland’s chronically overloaded hospitals are urging non-acute patients to visit GPs rather than clog up their accident and emergency departments" ⁴. Auckland Healthcare’s director of emergency medicine Peter Freeman was quoted as saying, " We are going to have to look seriously at the ways we manage patients better. Obviously we would hope that patients that can be treated by GPs will go to them and that GPs will hang on to and treat as many patients as they feel they are able to". An important issue is raised here but it does not concern the "ways we manage patients better" as suggested by Peter Freeman. It is the issue of affordability of services provided privately by GPs versus completely free services from publicly funded hospital emergency departments with their wide-ranging support. This is particularly relevant if the patients have to be seen a number of times over a few days or when prolonged consultations and observations are required. The same article also reported, "Auckland will gain no respite from the problem of overloading until a new hospital is built, but that is 3 years away". This implied that to solve the problem, the authority had decided to spend more money building and staffing a new hospital rather than using the same resources to financially support the public accessing their GPs. This might also indicate that the authority has reservations as to the cost-effectiveness of the services provided by GPs compared to those provided by the hospitals. Of course, the authority could have other reasons for its action.

Patients’ financial status can also influence GPs’ referral rates to specialists in another way. There are procedures, and minor surgery is only one of them, that could be performed in GPs’ surgeries but would require expensive equipment, materials and extra time. The GPs are perfectly capable of doing these but their patients cannot afford the expenses. Because these procedures can be provided "without costs to the patients" within the hospital system, patients ask to be referred, thus adding to the already long hospital waiting lists. For years in New Zealand, the maximum amount that could be claimed back from private insurance companies for GP consultation fees has been fixed at a single level, irrespective of the services provided. Though there appears to be some relaxation in this area, it is still very restrictive. This phenomenon applies not just to surgical procedures but also to special medical consultations, which require extra training and investigative support, for example, management of chronic obstructive airways diseases, angina, palpitations, skin diseases and so on. Losing these patients to secondary care has not only resulted in de-skilling and de-motivation of GPs, but has also increased the burden on the hospital waiting lists and the expenses of the private health insurance companies.

In addition, most GPs are also independent small business people and compete with each other for market share. While this might have helped to push down the fee structure and increase the choices for patients, it has also meant "in-fighting" at the foundation level of the health care system. Whether one calls it "healthy competition" or "in-fighting", one negative feature comes out strongly. Imagine what would happen if there were "healthy competition" at the management level of a big company with an aim to dominate the rest of management; and imagine what would happen if there were "healthy competition" within a family for the parents’ attention. One outcome that would be unavoidable is the waste of energy in the "competition", not to mention the "hurt" to each other in the process. Energy wasted in competition within general practice equates to money spent unnecessarily and thus increased cost to the patients or reduced income to the GPs. It also stops general practice from evolving or developing into more advanced models.

Subspecialisation within general practice

Formal subspecialisation is a feature of all medical specialties except general practice. The competition in general practice means that unless GPs with special skills give up general practice altogether, other GPs will not refer patients to them for fear of losing their patients to that other practice. Imagine a GP going to great length and expense to acquire a new skill that could only be practised a few times a year on his or her own patients. The skill will be lost within a short time. In other words, a critical level of exposure to conditions requiring the use of this special skill is necessary for the skill to be maintained and improved upon. Because GPs are still the entry point to the health service, inter-GP referrals are absolutely essential for subspecialties to develop in general practice.

There was a call for general practice subspecialisation with an article published in the New Zealand Family Physician in 1997 ⁵. However, it was a lonely voice at the time. The majority of GPs still insisted that general practice had to remain undifferentiated in order to be "holistic". Last year, Hugh Kininmonth, CEO of the Comprehensive Health Services IPA (CHS), wrote in the May IPA newsletter, "Subspecialisation within general practice has always attracted many GPs. Many CHS members have long been providing skin lesion removal, vasectomy, and other types of surgery, musculoskeletal, sports medicine, acupuncture, counselling and a wide range of other subspecialties outside the realm of pure general practice. The advent of DHBs will present major opportunities to promote the full range of GP skill base". It is also interesting to note that Karen Flegg, the last CEO of the Royal New Zealand College of General Practitioners, prior to her departure from office, predicted that subspecialisation and upskilling of some GPs would reverse the erosion of the scope of general practice and might result in more referrals between GPs. However, she said, GPs would have to get involved in more lobbying if they wanted to help shape the health system ⁶. The targets of lobbying were not specified, but they would have to include the Ministry of Health, the general practice departments of the medical schools, private health insurance companies and all the GPs themselves.

Subspecialisation within general practice, if carried out in an organised way with the GPs retaining 50% to 70% of general practice work and the rest in the chosen subspecialty, would have the following benefits:

• Reduced waiting lists at hospitals
  
  Upskilling of groups of GPs in various clinical areas and encouraging other GPs and practice nurses to refer appropriate patients to these subspecialised GPs instead of to the hospitals would genuinely shorten hospital waiting lists rather than just defer the referrals. The patients’ medical conditions would be dealt with by these subspecialised GPs with the expectation that ongoing secondary referrals would only be for the "really necessary" ones.
  
  Earlier this year, the British Medical Journal reported a new training scheme at Middlesex University that aimed to create "intermediate" GP specialists in ear, nose and throat surgery ⁷. Once qualified, they would be able to perform about 15 ear, nose and throat procedures and to directly refer some other patients for secondary care treatment, eliminating the need for patients to see a consultant before being admitted to secondary care. It was estimated that 30% of problems seen in Ear, Nose and Throat Departments could be managed by GPs with appropriate training. The course was designed to allow GPs to perform certain procedures, such as nasal cautery and flexible rhinolaryngoscopy, in the community. It is perfectly possible that similar schemes could be arranged for other clinical specialties, including some in the surgical, orthopaedic, gynaecological, medical, geriatric and paediatric areas. Consultations with GPs with special skills could be more than financed from the money that would otherwise be used in the hospitals.
  
  
• Improved patient care and health care delivery
  
  Reduction of the waiting time for a second opinion would allay patients’ anxiety and, generally, would allow conditions to be managed at a much earlier stage, thus further reducing the costs of the ongoing management of chronic conditions.
  
  
• Enhanced professional status for and morale of GPs
  
  In a survey of GPs by Professor A Dowell of the Wellington Medical School, published last year, it was ⁸ found that one third indicated they sometimes or always felt unable to remain competent in their role as a GP. Given the constant discovery of new ideas and the development of new methods of diagnosis, investigation and treatment in different specialties, GPs obviously cannot hope to keep up-to-date in all fields of medicine all the time. They would most likely be aware of developments only in the areas in which they are particularly interested. The ability to deal with special conditions would make general practice more interesting to GPs. Receiving referrals from other colleagues would boost their confidence and morale. All these would act as incentives for continuing medical education, as would the sheer job satisfaction and the financial rewards of providing more services after extra training and upskilling.
  
  
• Increased interest from medical graduates in the specialty of general practice
  
  For the first time, the available places in the New Zealand GPs’ training scheme were not all filled in 2001. The reasons for this are currently unclear. The UK had nearly 1,000 vacancies for GPs in 1998. Similar recruitment problems also occurred in the US. Intellectual challenge was a major factor determining the choice of the medical students ⁹ and junior doctors ¹⁰. It was also noted that the younger GPs were aware that their secondary care colleagues had more varied roles and wanted to acquire additional skills ¹¹. Development of subspecialties within general practice would thus help in the recruitment of the future GPs.
  
  
• Broadening of horizons for general practice teams
  
  It is inevitable that the enthusiasm and extra skills of subspecialised GPs would broaden the knowledge base of and increase the range of services provided by general practice teams. This would extend to the whole field of primary health care, including both preventative and treatment services.

Why, then, is there no formal subspecialisation in general practice? What are the obstacles to subspecialisation in general practice? How could these be removed?

First, Colleges of General Practitioners are concerned, mostly from an ideological point of view, about the effects of subspecialisation within the discipline. This is exemplified by the comments of Dr Mayur Lakhani, vice-chairman of the Royal College of General Practitioners in the UK, who warned against what he called "diplomatosis," which he feared had the potential to undermine generalist medical practice. He commented on the Middlesex GP Ear, Nose and Throat training scheme as follows: "We welcome anything that raises standards for patients, but there’s a danger that GPs will feel that if they don’t have a diploma in something they won’t be able to handle it. . . . The MRCGP examination (for membership of the Royal College of General Practitioners) equips GPs for everyday ENT problems. If GPs want to develop their specialist skills further then that’s fine, but anyone who does that must also maintain their general practice skills, otherwise what they’ll actually be doing is deskilling. What patients want is access to GPs who provide holistic not specialist care" ⁷.

Of course, this concern could be dealt with in various ways. For example, with an agreement between the Colleges of General Practitioners and their subspecialised Fellows on the necessity to retain general practice as a significant part of their practice in order to fulfil the re-accreditation requirements of their College Fellowships. In actual fact, most GPs with special skills now have mixed proportions of general practice and their subspecialties, rather than practising fully in the subspecialty. On the other hand, in addition to setting standards, the Colleges of General Practitioners have to be more politically active and more involved in the "well-being of the general practitioners", with particular attention to the stresses and rewards of general practice, to make the discipline an attractive and desirable long-term career. If they do not engage with these issues, they cannot blame disenchanted GPs for using the subspecialty scenario as vehicles to leave general practice altogether.

Second, inter-GP referrals are essential if subspecialised GPs are to have adequate regular exposure to conditions in their area of interest to maintain their specialised skills. Insufficient inter-GP referrals can arise from fear of competition for the patients’ base. This would be enhanced particularly with the introduction of capitation of individual GPs. Here, a subsidy from the government is tied to the number of patients registered with a particular GP. A referral to another GP will lead to a reduction of income for the original GP, because the subsidy will follow the patient to the second GP. This would become a disincentive for inter-GP referrals.

The proposed model

For a few years, it has been clear that New Zealand is moving towards capitation for primary care services.

The IPAs are in favour as it would produce a fairer distribution of health dollars - population-based funding. Some expect that population-based funding would make primary care health services, both preventive and therapeutic, more accessible for the general public. However, this would only be the case if extra funding were available. So far, it seems that the scheme proposes only a re-distribution of the existing cake and that the majority of IPAs are ready to pass the risks onto their members by capitation of individual GPs. This would intensify competition among the GPs, who would then try to recruit as many patients into their practices as possible. Introducing their patients to another GP with a special skill would invite the risk of losing these patients altogether and thus part of their practice’s income base.

In response to the capitation scenario, an alternative model in which GPs would become salaried under the IPA structure was introduced in a doctors’ magazine Viewpoint earlier this year ¹² and was recently summarised in the New Zealand Family Physician ¹³. The proposer of this model does not object in principle to capitation as a means of population-based funding for primary care at the IPA level. The main objection is the capitation of individual GPs because this does not seem to carry any extra incentive for individual capitated GP to carry out more preventative work for the practice population than before. Capitation of individual GPs would only increase competition among GPs with a view to protecting or increasing his/her practice population. As a result of this, there would be unnecessary duplication of services. In addition, if more clinical work were passed onto practice nurses in the capitation environment as suggested by those who promote this system, there would be the danger of creating a two-tiered health care system. Patients with community services cards would be seen by the nurses and those without the card would be seen by the GPs. Non-card holders would not attract any funding for their consultations and, to make the practice viable, the GPs would have to see these patients themselves.

In the proposed alternative model of general practice, capitation would be applied at the IPA level, which would become the employers of all the workers in their practices. The IPAs, with governance from the GPs, practice nurses and the community, would take up the role of organising the primary care services in the locality . The funding would come from government subsidy through the District Health Boards (DHBs) and fee-for-service payments from the public. The IPAs would remain not-for-profit organisations.

Initially, the GPs would sell their practices to the IPAs for a sum reached through an agreed formula. They would be paid an amount for the practice equipment and hardware as assessed by an independent consultant firm. The agreed price for the goodwill of each practice could be paid by the IPAs, along with interest, either over an agreed period or when the vendor-GP retires from the service. An alternative would be for the participating GPs to lease their practices to their IPA at mutually agreed figures. The salaries or wages of all workers, including the GPs themselves, would be determined fairly by obtaining recommendations from two consulting firms. The IPAs would have an "open-book" policy so that the public could scrutinise where the money has gone.

This model would bring a number of advantages to the public, the government and all the primary health care workers within the IPAs, mainly because there would be realistic overall planning and provision of health care for the population. The boundaries between GPs and those between GPs and nurses would also disappear. Competition for the dollar would disappear to be replaced by real co-operation and co-ordinated services.

Benefits of the proposed model

The main advantages to the public would be better access to the primary health care team because:

The IPAs could develop a team approach to primary health care in a more effective way as financial burdens would have been taken away from the individual practices and GPs. The most appropriate service for each patient would be provided by the doctor, the nurse or other health workers. As a result, there will be less waiting time for patients.

Economies of scale from integrating all the practices as well as amalgamating the smaller practices would result in savings and might be reflected in a reduction of fees to patients or the provision of extra services. Inter-GP referrals could happen freely as there would be no need for competition for enrolled patients to individual practices. This would facilitate subspecialisation within general practice and lead to a wider and more advanced range of services to the public. Similar scenarios would appear for practice nurses.

The IPAs could link up all the computers of the practices and allow patients access to any practice in case of emergencies, with full clinical notes available. For rural areas, the IPAs could arrange a volunteer roster of short duration to give city or urban doctors and nurses a taste of the rural experience. This would also be a way of providing relievers for rural health workers, without disruption to health care delivery to the public.

For the Government, this model would provide:

Real population-based health care. IPAs could run health maintenance and disease prevention programmes more cost-effectively than individual GPs. Education in health matters could be provided to the public by professional health care trainers en masse rather than via the piecemeal approach of individual consultations. This is not to say that the latter is less valuable. It would just be more cost-effective in the long run if health education and health promotion could be provided en masse, especially for disease prevention.

The government could clearly see where the health care money has gone because the primary health sector would then have an "open-book" policy. It would have more confidence in allocating money to the right places, where it would get the money’s worth.

Waiting lists at public hospitals would be dramatically reduced if IPAs were to encourage subspecialisation, which skills could then be facilitated and maintained by more inter-GP referrals. This would apply not only to surgical or other procedures but also to areas such as medical, geriatrics, paediatrics and psychiatry. Exposure of urban or city health workers to rural practices might help to recruit workers to those areas. If IPAs had a policy of re-locating those who were tired of rural practice after a period of time, it will also help to attract more health workers to these areas because they would not feel trapped for life. This could, therefore, also be one of the ways to solve the ongoing rural crisis.

For the doctors, and nurses, this proposed model would deliver the following benefits:

The stress of competing with other practices would be taken away. Co-operation and co-ordination would be the order of the day.

No more time would be wasted in handling General Medical Services (GMS) claims, as it would be taken care of by the IPAs.

Nurses would be able to do more clinical work appropriate to their training and could become more specialised as well.

General practitioners would be able to subspecialise and provide some special services in the community given the right training and back-up facilities. Inter-GP referrals would help to maintain the appropriate skills. A team-like approach within the IPAs would create an atmosphere that would create more job satisfaction.

Existing GPs would feel more secure as they would receive the goodwill part of the sale of their practices to the IPAs over a number of years or on retirement, as they choose. New doctors would not have to "buy" into a practice. Superannuation schemes could also be arranged to provide for further security.

A career pathway could be structured for general practice as in other specialties. Research and academic involvement could be facilitated. In the long run, that would mean further improvement of services in the community.

Representation of doctors and nurses on the Board of Directors of these new IPAs would give medical health workers some say in the management and direction of the services provided. This would be a distinct advantage over private corporatisation or National Health Service scenarios. All the workers would receive a fair and reasonable salary with incentives added to encourage further professional development.

Career pathways could be provided for all staff so that they would commit to the health care industry.

Government funding and contribution from the public through fee-for-service would be forthcoming because the IPAs would have an "open-book" policy and everyone would know where the money had gone. As long as the money had been spent reasonably, the non-profit-making IPAs should have no problem convincing the government or the public to contribute to help them break even.

Conclusion

This model could be an all-win model, and the general practice landscape would never be the same again. The only requirement is the courage and determination on the part of GPs themselves to recognise that general practice is an evolving discipline, and the philosophical underpinning may have to change over time to accommodate changes in the social system and the requirements of the consumers. Also, GPs have to realise that what is practised by specialists today can become an integral part of general practice tomorrow. This is nothing new as more than 95% of the resource people for continuing medical education sessions (CMEs) in general practice are provided from among specialists. In other words, the dividing line between generalists and specialists is not constant and can shift. The concept of generalists being confined to primary care should also be reviewed. Perhaps, health service provision should now be labelled as Community Health Service and Hospital Health Service. General practitioners should explore and widen the range of services that they are providing in the community, even though it may mean further training and subspecialisation. The breed of GPs with special interests should be encouraged to develop but remain within the Colleges of General Practitioners. New Zealand is leading the world in this regard. On 24 March 2001, the Council of the Royal New Zealand College of General Practitioners decided to give Faculty status to Breast Medicine, Medical Acupuncture and Appearance Medicine. As Ian St George pointed out, " In accepting these new colleagues we have shown a preparedness to celebrate diversity, to accept differences, to make room for innovation, to consider evidence and accommodate change rather than react with doctrinal rigidity" ¹⁴.

Perhaps, in the future, general practice would change its name to community practice, where continuity of care would still be provided, but additionally, more advanced non-hospital based medical and health services would also be available from what are now known as the general practice teams.

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