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Are GP gatekeepers a historical relic? « Previous | |Next »
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.

| Posted by Gary Sauer-Thompson at 7:11 AM | | Comments (20)
Comments

Comments

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.

GAry,

I remember flicking over to a doco on SBS about this subject. Where a health professional was travelling around the world looking at different systems to take back to the US. I sticking point for him to was the referral to a specialist. There is an asian country, my mind signals South Korea but i'm not sure, that has the direct access model.

One point on having to go through your GP to see a specialist that I've personally had experience with is the time taken out of one's life. If you are lucky enough to have a local GP who you have been seeing for years, it would still take you close to 2 weeks to book in (atleast it does here).

Ad astra,
are you arguing that I should see a GP instead of a psychologist for my mental health problems? Or that GP's are more qualified than psychologists re non drug mental health care?

If not, then why should I see a GP instead of a psychologist? What health benefit does having to see the GP gatekeeper confer over and above the care the psychologist provides?

Ad astra,
You say:

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.

What happens in those part of regional Australia where it is difficult to see a GP or there is no GP? That implies no primary health care.If not, what do you suggest?

Dean,
your experience indicates that it is good policy sense for GP's to relax their hold on routine services that other health professionals can handle in order for them to concentrate on the patients who are in most need of their kind of care.

In the discussion about gateways I have seen no mention of the US Wal-Mart initiative: it is opening medical clinics co-located in its stores. They are independently operated and typically staffed by a nurse practitioner, who provides a menu of preventive and routine basic health services. They are open 7 days with clearly posted price lists and far less expensive for the services they can provide than going to a GP or hospital emergency room.

http://www.walmart.com/catalog/catalog.gsp?cat=554492

More about them at http://www.rncentral.com/nursing-library/careplans/20-surprising-ways-wal-mart-clinics-affect-us-healthcare

It is possible that someone going to Wal-Mart because of a weight problem turns out to have an undiagnosed brain tumour, but how likely is it that someone with a weight problem would go to a GP about it in the first place? Even if they did, how likely is it that a busy GP would raise it as a serious possibility? How many brain cancer cases are established in Australia each year by GPs whose patient presents with a weight problem?

It is about a decade since the nurse practitional level of the nursing profession was established in Australia, but it has been firmly resisted by the AMA.

Ad astra
you say that there is a GP shortage and then say there is no alternative to the GP as gatekeeper. I quote:

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.

That assumes that allied health professionals are not able to diagnose conditions to ensure preventative health care?

Fort example, a dietician cannot do this for diet? Is that what you mean? A chiropractor is unable to do this for musculoskeletal conditions? A psychologist is unable to do this with mental health? Midwives do not have the knowledge and skills to help women give birth?

Do not these examples indicate that we turn to specific health professionals for specific types of conditions or illnesses. That we do not need a Dr. Finlay type generalist any more.

MikeM,
it is becginning to happen in a limited way at your local community pharmacy. Though this is being done by the local pharmicist not the nurse practitioner.

"But no one has come up with a better system for referral. Can you suggest one?"
Two off the top of my head:

There is the Japanese system of everyone presenting to the local hospital waiting room and seeing a doctor when its your turn. Like a less intense version of an ER (but of course you have one of those too). In an aging society, much like we are becoming, its packed with elderly people waiting their turn for prescriptions, but if you can wait an hour or two, you are guaranteed to see someone on the day. Very handy when you are really quite sick with flu or sinus but need a sick certificate for work.

Alternatively there is the method of individuals self-diagnosing, where possible. This is where people who have obvious conditions present to the obvious person to deal with it - like pregnancy, as suggested above. In cases where an individual knows there is a problem but doesnt know what it is, or perhaps how to deal with it, or needs a checkup, or advice, or someone to help them manage their multiple illnesses, or just a sick certificate, then GPs are the obvious way to go. And they will be able to handle the workflow. There will be some incorrect self-referrals. Shock. Horror. These will most likely lead to referral to a GP.

I wonder how much of this issue is doctors refusing to let the power over the body go to the owner of the body?

The GP's act as a filter.
Filtering those that don't perhaps need specialist care.

In my opinion Dietitians and Chiropractors should be able to take people without a referral from a GP.

Mental health is a different story. The GP is an integral part of the day to day management of mental health. Psychologist need this filter especially in the lower socio economic areas.

The referral issue is not an easy one to resolve, made more difficult by the shortage of GPs, which often means delay in getting an appointment.

You ask Gary whether you should see a GP instead of a psychologist for your mental health problems, and query whether GPs are more qualified than psychologists in non-drug mental health care? GPs treat mental health problems every day and are trained to diagnose them and manage most of them themselves, often using non-drug therapy. Sometimes they refer to psychologists when they can better provide the services the patient needs, such as, for example, prolonged counselling. The referral system does not denigrate any other health professional; it simply prescribes the route through which patients move around the health care system, which as I said in my first post is to ensure that there has been an informed holistic assessment of the patient before referring for specific management.

Can a psychologist, no matter how well trained in this special discipline, confidently exclude non-psychiatric causes of psychological problems, such as a brain tumour? Picking up on other posts, can a dietician, no matter how experienced, detect an undiagnosed cause for the patient’s condition, such as celiac disease? Can a chiropractor detect systemic causes of muscle pain for which a patient might consult, such as statin-induced muscle pain? It is the unusual and the unexpected that GPs deal with daily. They are trained to separate those who have serious or unusual illnesses from the vast array with prevalent conditions that respond to routine treatment. But it is not easy, and even the most experienced and best trained GPs do sometimes miss important conditions. But, because of their training they are better placed to carry out comprehensive patient assessments and detect unusual disease than more narrowly trained health professionals, and it is this capacity to screen patients in this way before referral that underpins the current referral system.

It is not that referral process is designed to protect GPs’ own patch; they are already so busy they’re not looking for more work. It is to ensure that patients are comprehensively assessed before referral to another health professional less well placed to carry out that assessment.

Dialogue is needed between all health professionals and health planners to see how the referral system can be improved, while still retaining the patient safeguards inherent in the present system. It is a complex issue not amenable to simplistic solutions.

It seems to me that the pro-gatekeeper argument rests on the assumptions that the patient is an incapable stranger to their own body, and that given the opportunity people will abandon GPs in droves.

Les points out the variabilities of three different circumstances and midwives are another pretty obvious one. I don't see any suggestion that it should be compulsory to see a dietician rather than a GP, rather the proposal gives patients the option of either going direct to a dietician or getting a referral. What's the problem with that?

Ad astra,
you describe an ideal situation where all is well with a few hiccups. You do acknowledge a problem re referrals, where you say:

The referral issue is not an easy one to resolve, made more difficult by the shortage of GPs, which often means delay in getting an appointment.

That is not the full story is it? In many parts of regional Australia there is no GP. So what do people do?

Why not use other health professional who are there and who do broad based primary care by default. The safeguards are there with respect to registration and accreditation for the patient.

It seems to me that this referrable problem is easy to resolve when the GP's are absent on the ground in regional Australia. Those doing the primary care should be able to refer if they have the professional competencies.

Ad astra,
just how manay cases of mental illness are caused by a brain tumour as opposed to stress, marriage breakdown or unemployment? Are you implying that the biological causes of mental illness far outweigh the social causes?

Your argument implies that GP's are trained to deal with biological causes of illness (biomedicine) and that the psychologist deals with the social causes (the the social model of health) Is that right?

Surely the psychologist is more competent to deal with the social causes of mental illness. And we can achieve much better health outcomes by going to the psychologist.

My second point is that I Can see no reason whatsover for the top physiotherapist to have to refer a patient to a specialist via the local GP. It makes good health sense for this phsyio to refer direct to the specialist.

Ad astra,
if there is a workforce shortage of GPs and there are areas of no Gps then it makes sense to train other health professionals so they have the competencies to:

separate those who have serious or unusual illnesses from the vast array with prevalent conditions that respond to routine treatment.

They can then refer the serious or unusual illnesses onto the specialist.

Doesn't the issue boil down to what the professional competencies are to make these kind of assessments or diagnoses? Professional competencies rather than the particular professional?

There are two separate parts to the problem. There is the part that says that somebody does not need 10 years training in order to administer a flu shot or perform a number of other basic health maintenance and treatment functions. This is the area that Wal-Mart is tackling in the US. Some US health funds actually cover treatment cost from Wal-Mart-associated clinics.

As Nan pointed out in an earlier post, pharmacists already do some of this, advising and recommending non-prescription compounds. It is also the role that the occupation of nurse practitioner was devised to address.

One of the reasons that nurses leave the profession (I know, my wife used to be one) is lack of recognised professional status and career path - again both things that could and should be addressed.

The other part of the problem is gatekeeper for specialist services whose appropriateness to circumstance a GP is able to judge.

Does this include psychological services? What happens in an outback area where there is no GP?

But while the overall problem is unmet demand for GP services, the two parts of it may yield to rather different solutions.

I am responsible for my own health. I do not want to hand over care to someone else- often a male, aged, busy and takes weeks to get an appointment anyway!
I thank the lucky stars that a podiatrist had the fortitude to refer me for an scan and x-ray of my foot following a foot injury 4 months earlier. My GP ignored my complaints of the continous pain especially following the long shifts on my feet. Perhaps if I had been managed correctly I wouldn't be suffering the effects of indifference.

As I read these blogs it became clear that the concept of the GP as controller of the body's health is entrenched. Aside from the AMA's protection of their patch, I'm not sure that I understand what the fuss is all about.
To answer Mike, in rural areas where there never has been a GP, qualified Remote Area Nurses have been doin' it for themselves for years. Obviously they refer serious illness to appropriate centres in the same way GPs are meant to do.
The newish role of qualified Nurse Practitioner is based on this model and provides first class health care. These nurses have proved their ability to triage and treat.

And in my experience, the well qualified midwife is the clear first contact for pregnant women. Medicos, that is obstetricians, are comparative latecomers to this area of health. Qualified midwives are specialists in diagnosing variations in the normal pathway and refer the client to the appropriate specialist as required.

I do understand the possible anxiety of the conscientious
GP to this new model of care but I suggest they give it a try. They may find that Minister Roxon has given them a support not a competitor.
Bernice

Bernice,
good point:

in rural areas where there never has been a GP, qualified Remote Area Nurses have been doin' it for themselves for years. Obviously they refer serious illness to appropriate centres in the same way GPs are meant to do.

Obviously the qualified Remote Area Nurses have the professional competencies to provide primary care. As Peter says it is the professional competencies that are the issue re public safety, not the particular health professional.

It is odd that the AMA does not recognize this.Its solution is for GP's to visit areas where there is no GP.

Such a predictable protection of patch.