Are
doctors the cornerstones of primary health care? If they are currently, they
shouldn’t be. Patients should be. The fact that we have in this country a
health system which uses a funding system for primary care centred around
funding providers – not patients, not need – is a sad reflection that
patients are no longer the cornerstone of primary care.

However
I think I’m correct in saying that the debate today is about how GPs and other
health professionals fit into the primary health care system. Technically we’re
really talking about what many call "primary care" as the term "primary health
care" is often used to mean the broader picture – including population health
over which primary care professionals have little impact.

The
current situation is such that the GP is central to care in the majority of
situations – but there are an increasing number of situations in which the
role of the GP is not central. For example, patients with clearly traumatic
musculoskeletal problems will visit a physiotherapist, chiropractor, osteopath,
or podiatrist; those with weight problems visit a dietician or exercise
physiologist; and those with psychological problems visit psychologist and
counsellors. If a patient can afford to access private allied health or dental
care, then this occurs with taxpayer support and without any contact with a GP.

For
those who cannot afford such access, the access to such practitioners is
limited. This is so firstly because GP referral is generally required, secondly
because funding is an issue, and thirdly because access to a GP can also be a
problem. Thus, government currently funds one system which requires GPs to be
the cornerstone and another system which bypasses GPs entirely, the difference
being largely the socio-economic status of the patient. Optometry, it should be
noted, is a little unusual in that government funds the bypassing of GPs for
all and clearly relies on the expertise of the optometrist to recognise those conditions
for which specific GP or specialist care is required.

So
is there a problem with patients bypassing GPs? When AMA President Dr Rosana
Capolingua addressed the National Press Club a few months ago, she raised the
example of a patient with Cushings disease, a tumour of the pituitary gland
which may present with obesity. Her concern was that this patient may be seen
by a dietician and the diagnosis missed. Her example was raised in relation to
a dietician in a Superclinic: the patient was seeing the dietician because a
receptionist had suggested she didn’t need to see a GP first.

Dr
Capolingua continued, "Patients directly access allied health providers now and
should be able to continue to do so." I agree. But rather than patients seeing
such professionals in a fee-for-service small business environment, – if they
can afford it – I think these professionals should be seen in an integrated
primary health centre where finance is not a barrier to access and where it is
much more likely that whoever they see will easily and comfortably ask formally
or informally for input from other members of the team as necessary.

There
is no doubt in my mind that GPs are the best trained health professionals to
perform a detailed assessment and diagnosis of a patient with a complex medical
problem. There is also no doubt in my mind that a physiotherapist may be better
than many GPs in assessing and treating a sprained ankle. GPs have possibly the
most difficult task in medicine – certainly much more difficult than a
specialist. They are expected to know enough about everything to enable them to
know when they are out of their depth and need further advice and to provide
treatment for almost any problem.

What
is desperately needed is a collaborative approach to the assessment and
treatment of patients: "teamwork" is the buzz word. There are several requirements
for teams to function optimally. Firstly, co-location, – as in the Victorian
community health centre model or the Superclinic model – must make teamwork
more likely. It’s often more convenient for patients. But geography and numbers
may make it impractical. Secondly, the funding model needs to be one which
promotes co-operation and avoids perverse incentives. Having all staff funded
in a similar way would be a start: fee-for-service for GPs and salaried service
for other providers works against fostering teamwork. Thirdly, funding for professional
development is required. It would entail all the relevant members of the team
learning together – rather than have doctors learning at a drug company funded
dinner whilst allied health professionals go to their own less salubrious
meeting. Fourthly, simplifying the funding is necessary to streamline the multiple
sources of funds and multiple accountability measures so that money is directed
towards patients rather than programs. Finally, consumer and citizen input on
how the team works and how it determines its priorities is also essential given
my central proposition that patients are the cornerstone of primary health
care.

When
such a team is the norm, the likelihood of referral to the most appropriate
person will increase because all parties are used to working together. Those
patients who self-refer to a dietician with their obesity will see a
professional who will be much more likely to pick something not quite right
about the patient and refer to the GP down the corridor.

Back
to the front desk. Who should decide what to do with the patient when they
arrive at a primary health care centre? A receptionist? A nurse practitioner? Or should
they all go to the doctor? That’s something which needs ongoing assessment as
different models of triaging are implemented. Appropriate training is the key
to the most efficient method of triaging. Where patients aren’t all seen by the
doctor, it’s imperative that the outcome of such practice is assessed, given
the many different possible models. But given that we already have a system
which allows and indeed finances patients to see professionals other than GPs
as first contact and patients are often happy with that, it seems conservative to
suggest we can’t improve on that rather than waste the time of the most highly
trained professional seeing patients that don’t require their expertise.

Nurse
practitioner lead clinics in the UK have had mixed results, with reports of
better patient satisfaction but increased costs because more patients end up
seeing both a nurse practitioner and a doctor. But nurse practitioners working
with increased responsibility in a team with a doctor, permitting the doctor to
concentrate on the most highly skilled aspects of care would seem to be a
sensible option. The scope for such an option is limited however, by the
workforce shortage which affects all health professionals. In places of doctor
shortage in Australia other health professionals are the first contact, and
sometimes the only contact for the patient. There is nothing optimal about
that. Better training for such people is appropriate but it is second best to
having adequate distribution of doctors who remain the most highly trained
health professional on the frontline of primary care.

This is an edited version of an
address delivered by Tim Woodruff to the Victorian Healthcare Association
Annual Conference on 16^th October 2008.