Introduction by Croakey: It is clear that political courage will be needed to advance reforms recommended by the national Scope of Practice review, which this week released its second Issues Paper, as covered below by Charles Maskell-Knight.
It will be a great pity if scope of practice reforms are permanently placed in the too-hard basket, he writes, “as they have the potential to streamline the provision of primary care for patients”.
Charles Maskell-Knight writes:
The Scope of Practice Review led by Professor Mark Cormack released its second Issues Paper on the Department of Health and Aged Care website on Wednesday 17 April (though the report is dated 16 April).
The review was commissioned by National Cabinet in April last year as part of a response to the report of the Strengthening Medicare Taskforce. That report had a vision of “coordinated multidisciplinary teams of providers working to their full scope of practice provide person-centred continuity of care”, and recommended that governments should cooperate “to review barriers and incentives for all professionals to work to their full scope of practice”.
Decoding all this, the problem is that under the current system GPs act as monopoly providers, gatekeepers or supervisors for many services that could be provided within the scope of their training by other health professionals.
Allowing other professions to provide these services directly would reduce the load on GPs, and thus increase access to primary care services.
The first Issues Paper, released on 23 January, summarised the evidence the review had gathered about the barriers and enablers to allowing health professionals to work to their full scope of practice, and the associated risks and benefits.
It grouped these issues into five main themes: legislation and regulation; employer practices and settings; education and training; funding policy; and technology.
The second Issues Paper sets out the specific policy and system reforms available to address identified barriers associated with health professionals working to their full scope of practice.
It includes eight broad options, which can be broadly summarised as:
1. Workforce
- Develop a framework and matrix that identifies the specific skills and capabilities of health professionals at entry to practice that informs local authorisation processes, the composition of the care team, and workforce planning consistent with community need
- Ensure health professionals develop the specific skills required to work in primary healthcare
- Ensure that early career and ongoing professional development includes multi-professional learning and practice.
2. Regulation
- Adopt a risk-based approach to regulating scope of practice to complement the protection of title approach
- Establish an independent, evidence-based process for assessment of innovation and change in health workforce models
- Harmonise Drugs and Poisons regulation.
3. Funding and payment
- Develop and implement funding and payment models to create incentives for multidisciplinary care teams working to full scope of practice
- Direct referral pathways supported by technology.
Sector responses
After issuing a pre-emptive media release last week (“Don’t repeat UK health system failures here”), the Royal Australian College of General Practitioners (RACGP) was quick to respond to the Issues Paper once it was released with a further media release: “Everybody needs a GP and general practice must be supported to thrive”.
A stirring call to action – although as far as I can see, the review did not suggest that GPs should be replaced by any other class of health professional.
The College’s main objection to the options in the Issues Paper was to the suggestion of blended payment models.
President Dr Nicole Higgins said: “Funding must be flexible, and fee-for-service retained, so GPs can best respond to our patient’s needs. [We are] calling on the Government to make a firm, public commitment to no capitation. We will never support a funding model that includes UK-style capitation, because we know it doesn’t work. The Government needs to publicly assure GPs that capitation is off the table.”
Again the College is jumping at shadows that aren’t there. The word “capitation” appears in the Issues Paper once, in a description of the New Zealand system.
The blended payment model the review describes would involve amalgamating some squares in the patchwork quilt of current primary care funding programs, and combining these with fee for service payments.
Higgins then called for the scope of practice for GPs to be widened, and “red tape to be cut so GPs can prescribe and dispense more medicines and provide more services, such as for acne treatment, iron infusions, and dementia. This will reduce the need for referrals to other specialists and make it faster and less costly for patients and taxpayers”.
It was reported elsewhere that Higgins said she had already warned Health Minister Mark Butler that GPs were “unlikely to be thrilled with the reform options”, and that “there are 40,000 GP members who are really going to push back”.
The first Issues Paper observed that the groups consulted during its preparation “were broadly divided along professional lines about whether non-medical professionals working to full scope of practice would offer benefits compared with the existing GP-centred primary healthcare model”.
I am sure that as other groups react to the paper, the same division will be apparent.
The first Issues Paper was welcomed by a range of groups including the Australian Primary Health Care Nurses Association, who said that the issues paper “embraces a contemporary understanding of collaborative practice and what nurses are capable of providing to keep people well in the community”.
The Pharmaceutical Society of Australia also welcomed the release of the first Issues Paper, and looked forward to “a future where community pharmacies are supported and funded to fulfil their primary care role as urgent care clinics where pharmacists can triage, manage and consult on a range of acute common ailments”.
I am sure these groups and many others will be supporting the proposals in the current Issues Paper.
What next?
The review has foreshadowed asking for submissions in response to the Issues Paper, but at the time of finalising this article (early on 18 April) no details on timing were available.
Responses to the Issues Paper will be considered in the preparation of a draft report to be released for comment in July. The review will then proceed to finalise the report for presentation to the Minister in October.
Given the inevitability of an election sometime between then and autumn 2024, I suspect that the Government is unlikely to leap into action to implement any recommendations any time soon.
It will be a great pity if they are permanently placed in the too-hard basket, as they have the potential to streamline the provision of primary care for patients. The RACGP’s answer to the pressure on primary care is to train more GPs and pay them more – allowing other trained professionals to bear some of the load will improve access a lot sooner.
• Charles Maskell-Knight PSM was a senior public servant in the Commonwealth Department of Health for over 25 years before retiring in 2021. He worked as a senior adviser to the Aged Care Royal Commission in 2019-20. He is a member of Croakey Health Media. Follow on X/Twitter at @CharlesAndrewMK.
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