Give GPs problems to solve, not campaign promises

It’s not about money, profit or territory. This is to ensure we don’t conduct experiments – like the North Queensland Pharmacy Trial – that could have lifelong consequences.

In the 1990s I worked for the Medical Board of Queensland. There was one occasion when a case I was handling ended up before a single High Court judge on an application for leave to appeal. It was an instructive experience. I don’t remember much of the hearing, but one memory stuck with me forever. I don’t remember the exact details, but I remember a time when the learned judge repudiated the doctors’ testimonies, with a statement like “well, that’s not how my doctor operates” or words in this sense. I remember this moment so clearly because I realized that in this case a person (a very intelligent and educated person) placed their experience of seeing a GP as a patient on equal footing with expert advice on the conduct of medical practice. It was one of those light bulb moments that lit up my career.

Everyone in the country has an opinion about GP because everyone has seen a GP for something at some point in their life. GPs are accessible – we are experts widely available (albeit with increasing wait times to book). There were days when I felt the weight of it, of being perhaps the most educated person someone in a difficult situation has access to. Our position at the forefront, this ability to support patients in the deepest realities of their lives, is what makes the specialty unique.

However, this very accessibility and the fact that everyone has gone to see a GP is perhaps our greatest vulnerability. Everyone thinks they know what GPs do because they’ve been there. They saw us, experienced the care. This is not to dismiss the importance of the consumer experience, but rather to recognize that watching a football game, even attending it in person, does not make you an elite player. Good reforms happen when technical expertise and consumer experience merge.

When something looks simple, it can give the false impression that the work is simple. Simone Biles makes the ridiculous complexity of the vault simple. Does that mean it is? This means that she has been trained, trained and trained and is an expert in every sense of the word. Experts make the impossible easy. The ease with which healthcare professionals exercise heuristic skills (here and here) to quickly synthesize patients’ demographic and social circumstances, comorbid conditions, pathology and epidemiology and arrive at a diagnosis and treatment choice make this expertise largely invisible.

This has likely contributed to a general perception that most GP tasks are straightforward and can be done safely and appropriately by alternative healthcare professionals with far less training and experience. Some of the work that GPs do can absolutely be done by others. But the health system needs those decisions to be informed by real expert practitioners.

Take the example of some recent problems in Queensland.

The North Queensland Pharmacy trial was a campaign promise by the Palaszczuk government. It was a follow-up to the Urinary Tract Infection (UTI) Treatment Trial/Pilot which allowed patients to come to a pharmacy and be given antibiotics for a UTI. Most notably, empiric prescribing without any testing meets the standards set in current clinical guidelines – in this case, the trial (and now the program) at least followed an established protocol. Significant concerns have been expressed about the diagnostic acumen of pharmacists in this space, but this program is consistent with clinical guidelines – prescribing based only on symptoms. GPs do the same if we treat a UTI via telehealth, but for the most part this is the exception, not the norm.

The UTI scheme appears to have emboldened the Queensland Government and the North Queensland Pharmacy Trial was born. The proposal could exclude physicians (not just GPs, but all physicians) from decisions to diagnose and launch prescription drugs for some pretty big diseases. Hypertension and diabetes were on the initial list where pharmacists could diagnose and prescribe. The details of the proposals are not in the public domain, but within current funding frameworks, it seems almost impossible that pharmacists will be able to implement current guidelines for appropriate care at the same level as physicians.

Take, for example, a diagnosis of diabetes and the prescription of drugs to treat it.

The diagnosis of diabetes is more than a simple finger prick test. This requires an evaluation of symptoms, laboratory measurements, and in some cases a second round of laboratory tests to confirm a diagnosis. This certainly requires laboratory monitoring to determine the need and type of medications, and to assess their effectiveness. Pharmacists cannot provide this standard of care.

In the early stages, many patients can be managed by modifying their diet and lifestyle. At this point, mobilizing a GP chronic disease management plan and team-based care arrangement can have significant benefits, giving patients access to dietetics, diabetes educators, exercise physiology and podiatry, to name a few. Pharmacists cannot provide this standard of care.

Current guidelines also require all of these to be part of an annual cycle of evidence-based care for patients with diabetes. It seems contradictory that GPs aim for an annual cycle of care for patients with diabetes and that the Queensland government has sought to establish policy that directly devalues ​​this, focusing only on access to medicines.

It is of particular concern that the trial has been proposed for an area of ​​Queensland where Aboriginal and Torres Strait Islander people make up a significant proportion of the population. We therefore target an already underprivileged population and substitute care that cuts them off from the recommended diagnostic and treatment capacities. It is no wonder that NACCHO has expressed opposition to the lawsuit.

The trial itself may now be dead (at least postponed) and ultimately conditions such as diabetes and hypertension may be ruled out. An additional argument is redundant, but it is useful to try to understand it as a case study from the government policymaker’s point of view, as a symptom of a problem, rather than delving into the root of the problem itself.

That the Queensland government was even willing to consider this suggests that it has fallen into a three-pronged trap. They have grossly underestimated the clinical complexity and value of general medicine – they are not alone there. They’ve succumbed to political lobbying and donations, and they seem to have been advised by people who don’t know how the funding and regulatory arrangements around GP work, as evidenced by the recent repudiation of the trial by the professional services review director.

These three prongs are recurring themes that continue to bite the interface of policy reform between public health care and general practice. This is what led to this lawsuit being heralded as a campaign promise, making what should be a technical clinical issue rather than a political one.

State health systems have very little practical knowledge of general medicine and very, very few specialized general practitioners among their advisers. In contrast, all other health professions and specialty groups have career paths within the health services that may result in the appointment of nurses, health aides, medical administrators, and other clinical specialists doctors in advisory roles. GP advisors, when employed, are deeply embedded in service structures and their work may be more focused on advising GPs from a service perspective, rather than the other way around. When former GPs move into leadership positions in health services, this is usually not compatible with continuing to work as a GP. External (practising) GPs are seen as stakeholders, not advisers. This is a vitally important difference.

It is patently clear that governments, on the whole, do not understand the work GP does, but they think they do, perhaps because, as the High Court judge of the 1990s, they and their advisers have been clients of general medicine. When GPs try to explain this, we are greeted with turf protection claims (here and here). We advocate for good patient care, just as nurses do when advocating for proper nurse-patient ratios.

It’s not about money, profit or territory. This is to ensure we don’t conduct experiments – like the North Queensland Pharmacy Trial – that could have lifelong consequences.

There is an old adage: “Familiarity breeds contempt”. Sometimes he feels that our political leaders know general medicine so well that they despise our specialty.

The first step in breaking the cycle is for state health departments and ministers to recognize their lack of knowledge about general medicine. General practice has long been a blind spot of state governments, simply because of the state/federal divide, and it appears the Queensland government is an exception, even among its peers at the national level. If state governments want reform, engage the experts, engage GPs and consumers in co-designing models that safely and appropriately harness the expertise of all health professions.

Give us problems to solve, not election promises to implement at any human cost. GPs can be responsive to change, yet be responsible gatekeepers for patient safety when needed.

Dr Jillann Farmer is a Brisbane-based GP and former UN Medical Director.

Statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of WADA, the MJA Where Preview+ unless otherwise stated.

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