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June 25, 2008
In an earlier post I raised the issue of the GP as the gatekeeper of primary health care. It was posed by stating the AMA's position, which is:
General practice is the gateway to allow patients enhanced access to other health professionals - including general practice nurses and allied health service providers such as physiotherapists and dieticians
I then asked why should the GP be the gateway to the health system for those consumers whose preference is to see a dietician, psychologist or a chiropractor? Why cannot we consumers see the latter health professionals direct? Isn't this a reasonable position when there is a shortage of GP's, especially in the outer suburbs of the metropolitan centres and regional Australia? Australia’s health 2008 showed that the overall supply of GPs decreased by 9 per cent between 1997 and 2005.
The GP as gatekeeper has been one of the stumbling blocks upon which health reform has been resisted. The Rudd Government is trying to move this stumbling block to one side in order to make room to tackle the national GP shortage, which makes it difficult for Australians to access primary care. The aim is to give allied health health professionals (nurses and physiotherapists) access to funding under Medicare and the Pharmaceutical Benefits Scheme.
The response by the AMA is direct: patient care would be compromised if anyone without the all round expertise were made the first point of contact in the health system. In her National Press Club address Dr Capolingua, the President of the AMA, ridiculed the ALP's proposal for a "one-stop shop" health centre as a "myth", and said that this would result in the fragmentation of care. She spoke of a scenario where a patient has a brain tumour undiagnosed after going to a super clinic with a weight problem and being referred to a dietician and psychologist. She has also warned that the GP superclinics would put private GP's out of business.
Only 31 GP superclinics are proposed, they offer integrated multidisciplinary care, and are located in areas where it is difficult for families to access their local GP, and so they end up in their local hospital. So it is good health policy to turn to allied health professionals for primary care.
On the AMA's account GPs are the gatekeepers holding the gate open to facilitate access to the most appropriate specialist or allied health provider for each individual patient, and coordinating that care. Since GP's do not have expertise in non-drug care nor in mental health why should they coordinate that care as opposed to the suitably qualified non-medical health professional.
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It is not correct to say that “...GPs do not have expertise in non-drug care or in mental health.” The extensive postgraduate training they are required to take gives them a sound grounding in mental health, which they deal with day after day in practice. Many of their patients have mental disorders; many have mental disturbances associated with physical illness. Moreover, GPs are well familiar with non-drug care. They use it every day. They understand alternative and complementary medicine and many practise it routinely. So your claim that they should not coordinate care cannot be based on your incorrect assertion that GPs do not have expertise in non-drug care or in mental health.
Postgraduate training gives GPs more comprehensive knowledge and skills than any other medical graduate.
The reason GPs are promoted as gatekeepers is for the protection of patients and the sustenance of the health care system, ensuring as it does that patients receive the most timely and appropriate care from the most appropriate health care professional, and that the health care system is used efficiently.
There is a doctor shortage. The gatekeeper role imposes an additional workload on them. But no one has come up with a better system for referral. Can you suggest one? One that ensures that those not comprehensively trained in health care possess sufficient knowledge and skill to recognize serious illness and refer it appropriately. It’s a tall order.