Introduction by Croakey: In her ode to primary care in the article below, GP Dr Karen Price warns against the “cherry picking of diseases”, such as the Coalition’s 10-year Mission for Cardiovascular Health and Labor’s cancer care promises, saying politicians and funding should not privilege one disease over another.
Price says neither of the major parties has shown leadership on health system reform or a vision for reform on primary care in Australia – on that, she says, there is much we could learn from Denmark, which has been able to dramatically reduce the number of hospitals they need because of investment in primary care.
While she welcomes pledges from both major parties to lift the Medicare freeze, she says it “does nothing to repair the damage caused by the de-valuing of GP services by successive governments and years of frozen patient rebates.”
Last week the Royal Australian College of General Practitioners (RACGP) called on the major parties to announce their election commitments to general practice, warning that universal access to primary care in Australia is at risk.
“Nearly 90% of Australians see their GP every year, this is comparison to 68% of Australians filling a prescription, 55% having a pathology test, or 14% being admitted to hospital. When it comes to funding this election, general practice must come first,” said RACGP president Dr Harry Nespolon in a statement.
Despite this, Nespolan said the most recent primary care announcement was a $200 million investment from Labor for the pathology sector if elected – “an area dominated by large corporate organisations”. The RACGP said on Monday they were still waiting for general practice to “take centre stage” in this health-dominated election campaign.
“While any funding in the health space is welcomed, we need to see a real investment made into grassroots patient care this election,” Nespolan said.
As part of its federal election campaigning, the RACGP has released a video warning that US style health care costs are stopping Australians from going to the doctor when they need to.
It says that over the full period of the Medicare rebate freeze, initiated by Labor and continued by the Coalition, $1 billion was “ripped out” of general practice. Nespolan said:
We need to see that funding reinstated if we want to see universal access to primary care remain.”
In its election platform, the Australian Medical Association has highlighted the Government’s 2019-20 Budget investment to general practice, including $448.5 million to improve continuity of care for patients over 70 with chronic conditions, increased funding for the Quality Improvement Incentive for general practices and retention of the Aged Care Access Incentive ($201.5 million), $62.2 million for rural generalist training, and $187.2 million for lifting of the freeze on over 100 Medicare items for general practice.
It notes the Opposition has a similar commitment in relation to the Medicare freeze but says it must “at least match” the other commitments.
Karen Price writes:
A recent article published on long term data in the United States showed that primary care saves more lives than specialty care, with the biggest impact in cardiovascular disease, cancer and respiratory tract disease.
Notably, these are disease-specific cases where prevention, screening and early detection – which all occur in primary care – play a significant role in reducing deaths.
So ‘health’ is not about the MRI scan or the ‘heart health’ check-up.
Yet neither major political party has shown leadership on health system reform or a vision for reform on primary care in Australia.
Both parties supported the Medicare rebate freeze and the unfreezing has done little to recapitalise the funding removed from general practice.
Disease prestige is not visionary reform
Healthcare cannot be about the privileging of one disease over another where one disease is funded to a greater extent than another. Yet we have the cherry picking of diseases such as the Coalition’s heart health care or Labor’s cancer care promises, especially regarding breast cancer. These initiatives do not constitute visionary reform.
Already, there are anecdotes of entrepreneurial business interests forming heart-health-specific screening clinics. A drop-in heart clinic that potentially encourages a gadget-like approach to disease-specific health care sits in contrast to Choosing Wisely’s campaign to reduce the harms of over-screening. Fragmenting care into disease categories attached to random Medicare item numbers is exactly how general practice does NOT work.
Another example of cherry picking is Labor’s breast cancer MRI funding proposal.
If I were a patient needing an MRI for Parkinson’s disease, my stroke, dementia or multiple sclerosis I would be wondering why I had to pay for my care when those with breast cancer do not. The Liberals have chosen heart health care and I wonder why not skin cancer care? Why would politicians inexplicably choose to privilege one disease over another?
Professor Louise Stone articulated such problems in an article in the Medical Journal of Australia last year looking at ‘disease prestige and the hierarchy of suffering’ and how “not all diagnoses are equal in the eyes of the world in which we live”.
Disease-prestige means that diseases lower on the ‘hierarchy’, such as mental illness or bowel disease, carry a burden of stigmas and become less well funded than those regarded as higher level, say breast cancer or heart health.
Are these patients second class patients? I think we can all acknowledge these are universally all difficult and tragic conditions. There is no competition in suffering.
The invisibility of general practice
So far in the election campaign of 2019, I have seen no images in the media of Scott Morrison, Bill Shorten, Greg Hunt or Catherine King associating with GPs.
So far it seems only hospital photos are on offer in this campaign, despite concern that funding decisions behind these election time gifts seem opaque and unclear.
Public health expenditure sits at about 2 per cent of the total health expenditure, and General Practice at around 7.4 per cent.
This is despite what we know about the significant downstream savings that would come with further primary and prevention investment, where the benefits of prevention are obvious in the metaphor calls for parking the ambulance at the bottom of the cliff rather than building a fence at the upper cliff edge.
Yet the genuine health savings of prevention within public health and primary care remain largely un-articulated by our politicians who perhaps find tackling the long hard haul of, for example, quitting smoking not sexy enough for their media ‘bites’. (Croakey note: Labor did last week release its preventive health policy).
We are much more susceptible to the idea of a solitary hero with a solitary intervention, inserting a coronary artery stent, than about managing cardiovascular risk factors in primary care and preventing heart disease or stroke in the first place.
It is much more difficult for a government to measure integrated whole person care and certainly there is an invisibility of the value of therapeutic relationships – we lack not only funding for integrated primary care but also discrete single intervention time-limited measures on quality in the primary care sector.
Disadvantage and the failure of the free market
A lack of funding in primary care is likely to harm particular groups, including people living in rural and remote areas, women, Aboriginal and Torres Strait Islander people and communities, refugees and those with chronic complex health care, to name a few.
The highly lauded free market approach to general practice is now breaking, not just at the bulk billing level but in lack of supply to rural and remote regions where we know health outcomes are worse because of a lack of access to health care services.
In South Australia, for example, an estimated 60 GP positions need to be filled and training places are also not being taken up, telling us that a workforce issue is looming when our youngest doctors shun primary care.
There is a lot of ribbon cutting at the billion dollar Royal Adelaide Hospital, but the latest closure of yet another rural facility in regional and remote areas attracts no such bevy of press photographers.
Lifting the freeze does not repair all the damage
Both sides of politics have pledged to lift the Medicare freeze but that does nothing to repair the damage caused by the de-valuing of GP services by successive governments and years of frozen patient rebates.
GPs who have absorbed this bipartisan neglect over the years are increasingly unable to subsidise the loss of 50 per cent of the recommended fee. A recent ABC Fact Check found there has been a steady increase in out of pocket costs for GPs since the early 1990s.
We must pay our practice nurses and hardworking reception staff amongst all the other small business costs of leases and equipment.
The RACGP has released national advertisements to demonstrate the increasing health care gaps which will disproportionately affect those least able to pay.
One of my major concerns is that women, through increasing poverty in older age and the persisting gender pay gap, may find health care increasingly difficult to afford.
Affordability will only get worse, and the metaphor is apt of loading up the most efficient and effective workhorse of the health care system until it breaks.
This makes no sense if the outcome desired is the health of the nation and health that is equitably distributed.
Building sustainable care
Earlier this year RACGP released its White Paper – Vision for general practice and a sustainable healthcare system for member and stakeholder consultation, that involves continuous comprehensive, coordinated, high-quality medical care that is accessible to all.
It outlines the urgent need to recognise and reward General Practitioners as specialists, and how that will assist with lower emergency department presentations and hospital readmission rates, and deliver health benefits for Aboriginal and Torres Strait Islander communities.
The White Paper estimates $3 billion annual savings to the health care system overall with well supported primary care that allows GPs to develop hubs of multi-disciplinary teams that have been shown over and over to deliver the health care outcomes that the Australian electorate is seeking.
In Denmark, as the Australian Financial Review reported (paywall), the number of hospitals have been cut from 98 in 1999 to 32 hospitals by recapitalising primary care.
It says nine out of ten Danish health care problems are managed in primary care with significantly fewer costs, including less disruptive and costly hospital admissions and more home-based care with a well-known family practice at the centre of that health care relationship. This radical change included policy that non-emergency patients in Denmark must present a letter of referral to any Emergency Department.
You can read further complex discussion of the radical reform here and here.
What’s not to love about a therapeutic relationship with General Practice doctors, nurses, pharmacists and the myriad coordinated allied health who know you in your own community?
It’s what we trained as specialist GPs for 10-12 years to do.
We have the skills and training and we love to work together with our allied health colleagues for our patient’s family’s health. Ninety per cent of Australian patients already choose a single usual general practice clinic.
A federal election challenge
I therefore issue the challenge to our politicians to show courage and leadership and to get in line with international health care system reform.
We don’t need any more false promises such as privileging cancer care over other health care needs. Rather we need a world-class health care system that functions for all people, for all diseases with the care of your family doctor team. In most cases, this care occurs within your community.
Without a radical reinvestment and courageous leadership, there will be an irreversible loss of the family doctor in Australia, and with that a generational loss of health outcomes and training opportunities.
Dr Karen Price is a clinician with 25 years’ experience in General Practice, who is currently a PhD candidate at Monash University in Melbourne.
