Universal healthcare isn’t working when those who need the most care receive the least. Here’s an alternative.
As a regular reader of The Medical Republic, I can sympathise with my many general practitioner colleagues who contribute articles describing their angst with the current state of general practice.
My 47 years as a doctor have been split between public sector emergency medicine (I was a foundation fellow of ACEM) and addiction medicine (again as a foundation fellow).
As a salaried doctor, I have never had to worry about being responsible for the employment of front-of-house staff, back-of-house staff, rent or overheads. From my lens, the funding models for primary care are no longer fit for purpose and the number of stakeholders makes the pathway towards a new funding model a minefield.
I have previously written a perspective piece on this (“The wicked problem in general practice”, TMR 1 July 2022). I think it is timely to think of the oft-forgotten stakeholder, those patients at the Deep End. By that I mean most of my patient cohort, who are the progeny of intergenerational trauma, social marginalisation and educational disadvantage.
I am the clinical director of a public sector addiction medicine service. Many patients are so chaotic that they cannot keep appointments; they have subconscious bias that has made them distrustful of those that they perceive as having power and privilege.
Through a mix of their own aberrant behaviours and societal stigma, they end up beyond the reach of the “free market healthcare economy” that to some extent governs general practice. In essence, they end up burning all their bridges in that area. This places them in an interesting public health predicament for several reasons that I will address.
Real-time prescription drug monitoring (RTPM) is my first cab off the rank. RTPM programs are public health initiatives, developed to combat the rate of avoidable overdoses attributed to certain medications, such as opioids and benzodiazepines. The RTPM also aims to reduce drug diversion and doctor shopping.
There are still large numbers of “legacy” patients who are handballed from doctor to doctor as GPs move in and out of practices. Ideally GPs would spend the time to find out if the patient is still well served by the prescribed drugs and discuss and implement deprescribing options. Unfortunately, I note that many of my colleagues either do not know how to deprescribe or flip when they see the industrial doses requested and terminate care, with a cursory dual “please take over care” referral to the multidisciplinary persistent pain clinic (MDPPC) and the addiction medicine service.
There seems to be a lack of appreciation by GPs for the standard operating procedures of public MDPPCs, in that they are not mandated to “take over care” or else they would rapidly become overwhelmed and operationally constipated. What MDPPCs do offer are recommended management plans for the principal GP.
But in many cases the GP does not want them back! Moreover, the MDPPC patient management plan often includes a shopping list of required multidisciplinary care provider services that are either not accessible or not wanted by the individual patient.
These patients often have purely therapeutic (or iatrogenic) substance use disorder (SUD) with negligible or no history of recreational substance use. Importantly, public sector drug and alcohol units are funded to treat people who inject drugs (PWID), not therapeutic SUD. They are not “our” core business. Despite the nuances between therapeutic and PWID, they both have neuroadaptation to psychoactive substances. Over time, we are now caring for greater numbers of patients who are not and have never been PWID. However, our preference is to replicate the MDPPC model of care.
Anecdotally, there seem to be two ways that doctors can operate.
Those with a solid sense of their own worth and a belief that patient engagement varies with the size of the co-payment do not bulk bill on principle. The other doctors are torn between bulk billing and patient care.
Due to the correlation between poor social indicators and poverty, the patient who most needs more time with a GP is re-routed to eight-minute bulk-billing practices. Complicating this is a business model that is based on customer satisfaction and conflict avoidance. International medical graduates are especially anxious because of the fear of getting a “nudge letter” from some government agency which may affect their visa status.
In any event, a door closes for the patient. With it goes treatment for that patient’s other comorbidities such as chronic cardiovascular, hepatic, renal, or respiratory disease. After all, the patient cohort with therapeutic SUD are more likely to share the social indicators of disease which include intergenerational trauma, social marginalisation and educational disadvantage.
Should the patient be female there are now sexual health, family planning and contraceptive needs which will not be met.
So, the current Medicare model is not fit for purpose. There is scarce evidence that the Commonwealth seriously wants to fix it.
Here’s my crazy idea.
We introduce a two-tier general practice system. One for the privileged and health literate based on a fee-for-service model set by the provider and augmented by Medicare. The other tier serves those who can’t access the “free market” and need a service without any out-of-pocket expense. The latter may be better served via block-funded care, utilising salaried providers. The system would work better if the general practitioner was the “conductor” of a medical workforce “orchestra” that included a collocated multidisciplinary team.
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The devil in the detail is where you would peg the doctor’s salary.
Many have suggested that GP salaries ought to be commensurate with hospital specialist salaries. I would have no problem with that, with the following proviso. The general practitioner would have to complete a training program comparable to the other specialties: two to three years of prevocational training, followed by three years basic GP training and three years advanced training.
The curriculum would need to be expanded and perhaps include elements of a Master of Health Administration. As a true conductor, merely being a medical expert would not suffice. There must be a genuine focus on the six CanMEDS domains of communicator, collaborator, leader, health advocate, scholar and professional. Supervision, faculty development, and assessment methods would be adjusted accordingly. After hours and weekend on call are a given.
Admittedly in the initial phase this would lengthen the pipeline towards an appropriate medical workforce. But competencies in all CanMEDS domains will be essential to an effective rollout. At present they are given no more than lip service by colleges with the sole exception of the Royal Australasian College of Medical Administrators. These new conductors would be administrators of these new-age units serving the Deep End.
Forget about a universal system. It’s clearly broken. Have one for the rich and privileged; one for those at the Deep End. I would love to have your thoughts.
Associate Professor Kees Nydam was at various times an emergency physician and ED director in Wollongong, Campbeltown and Bundaberg. He continues to work as a senior specialist in addiction medicine and to teach medical students attending the University of Queensland, Rural Clinical School. He is also a poet and songwriter.
