Scope creep threatens health: AMA

Some barriers exist for good reason, the association says, raising concerns about patient safety, fragmentation, and national consistency.

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While the AMA backs “appropriate and safe” scope expansion, it cannot condone “costly” and “fragmented” care, the association says in its submission to the scope of practice review.

The “Unleashing the potential of our workforce” scope of practice review, commissioned by DoHAC last year, aims to “examine the barriers and incentives health practitioners face working to their full scope of practice in primary care”.

In its submission to the review, which closed to submissions on 16 October, the AMA highlighted the opportunity for developing “collaborative, patient-centred models of care”.

“The AMA supports all health practitioners to work to their full scope of practice and we do not fundamentally oppose the expansion of scope where it is safe, collaborative, appropriate and benefits patients and the health system,” the group said.

But clarification was necessary to outline “appropriate and safe” expansions of scope “that put patient and community safety first”, it added.

“Inappropriate ‘scope creep’ for the purposes of trying to fill service gaps is a major threat to the health of the community,” the AMA said.

The association drew particular attention to UTI trials and risk of antimicrobial resistance.

“The AMA has been seriously alarmed by the complete lack of concern regarding the outcomes of the UTI prescribing trial in Queensland.

“Hundreds of patients required medical treatment after receiving a prescription from a pharmacy, and the AMA Queensland member survey found at least 240 doctors had treated a patient with a misdiagnosis.”

In concurrence with the RACGP, the group lobbied against substitution, particularly pharmacist prescribing, as it lacked evidence to support improved outcomes, may increase costs and can lead to overprescribing.

“All discussions of the expansion of pharmacist scope of practice in Australia have focused on autonomous prescribing in community pharmacy settings.”

Instead, the focus should be collaboration and well-funded and resourced general practice, they said.

“There is strong evidence that where GPs are well-funded and resourced the health outcomes of individuals and communities under their care are improved, health expenditure savings are generated, health resources are better utilised, and duplication of services and wastage of healthcare funding is minimised.”

Also of concern were the;osts associated with scope expansion. The submission noted that evidence from the US demonstrated a cost of nearly $43 more per patient when comparing non-medically led primary care to physician-led primary care.

“This additional cost was a result of inappropriate prescribing, unnecessary referrals to specialists, and unnecessary orders for diagnostic imaging studies,” they said.

Another central concern; fragmentation of care. Instead, the group called for integration, with all non-medical prescribing occurring in collaboration with medical practitioners.

“What we don’t want to see is more health professions trying to carve out independent roles, which inevitably results in more fragmented care, waste and higher long term health system costs,” said Professor Robson.

“We need to build on the strengths of our health care system, recognising the skills that different health care professions bring to the care of a patient.

“At the same time, we need to ensure any care takes place in a well-coordinated model that is guided by a doctor’s medical diagnosis.”

The group also raised concerns over how scope expansions were varying across states.

“We need to see consistency across states and a commitment to the agreed-upon pathways,” said Professor Robson.

“We don’t want to see more examples of industry lobby groups deciding their own National Board’s position on the scope of a profession is not to their liking and working with the states to undermine that.”

Professor Robson said the AMA hoped for “patient-centred, GP-led teamwork” rather than “rearranging of the deck chairs at the cost of quality patient care” as innovation and collaboration already occurs in general practice.

The submission drew attention to international models, such as the Nuka System of Care in Alaska, which facilitates collaborative care that improves patient outcomes.

In fact, the association said, some barriers may need to be re-established, as it did not support only the removal of barriers to facilitate wider scope without consideration for the reason these barriers or regulations exists.

“While the AMA appreciates the intention of exploring barriers and enablers to working to full scope, it implies that expanding scope of practice is objectively a positive and that we should be working only to expand scope and remove the barriers we have in place. We do not support this.

“There are processes, or barriers, that the AMA had assumed were still in place prior to the announcement of the North Queensland [pharmacy] prescribing pilot that have been all but ignored. The AMA would like to see these processes, detailed below, reestablished and updated.”