Do hospitals and hospital based specialists appreciate General Practice?

Karen Price

First of all let me precede my comments with a caveat drawn from social media, hashtag #notallspecialists.

I have on occasion heard hospital based specialists be incredulous that GPs do not have routine access to the eTG (therapeutic guidelines) and the inevitable “GPs should…..” statement followed.  It seems that those who made the observation were blissfully unaware of the thousands of dollars an eTG subscription would cost the average General Practice in an economic environment of underfunding of primary care. Most hospital based specialists appear to have no appreciation of the cost of doing GP medical business.    Another wondered whether the education provided to GPs should be at a final year medical student level?  I subsequently wondered if our fellowship was invisible.   I hear from those in my family who are in the hospital environment how often the hidden curriculum of “Just a GP” comes up in informal hospital settings and I wonder why?

Let me put in a plug for the GPsDownUnder forum which I helped found and provides an opportunity for peer to peer based  GP led education on all sorts of patient and practice related issues. And I can tell you that a common lament is that the Hospital based context for GP education is inappropriate and misses the mark.  It has some relevance but largely misses the many contexts and education needs of General Practice. So often hospital centered education focuses on management and single disease interventions which utilise an enormous allied health team and expensive equipment. Undoubtedly such (important) work is easily seen, easily measured and therefore rewarded.  As I observed in the 2019 federal election “health care” became synonymous with a glossy photo opportunity in the hospital. The community hospital of General Practice where most of health care is performed was ignored. 

However trying to understand General Practice proves very difficult.  For instance, new data collections have become mandated in GP.  The recent clamouring for GP data as a ‘QIPIP’ is concerning as we risk being made into data collectors for a public health exercise utilising tick box government-derived, ‘performance’ measures.   This is also not our context.  How do we explain that we are the primary diagnosticians, over time, in a sea of low prevalence, with complex care and competing probabilities manifesting in a patient centered care model occurring in an under-resourced environment, every ten to fifteen minutes?    Such collected data may have little bearing on GP quality or outcomes and it could be argued the patients’ health-needs, will no longer drive the consultation.

The WHO describes primary care as

1. Meeting people’s health needs throughout their lives;

2. Addressing the broader determinants of health through multi-sectorial policy and action;

3. Empowering individuals, families and communities to take charge of their own health.

However primary care is NOT general practice.  Regarding the WHO definition I wonder who of us in any part of primary care has responsibility for policy outcomes- given we are not able to influence at a legislative level on the socio-economic determinants of health?  General Practice does include, of course, and overlap with our community based allied health colleagues and our public health colleagues. However I have seen an excellent presentation on how even town planning contributes to health outcomes with properly designed open spaces and public transport.  I am comfortable as a GP viewing the complexity of health in the individual in a larger socio-cultural context. I treat the individual however.   

The RACGP  describes General practice more specifically with a long list of descriptors  such as;  person centeredness, continuity of care, comprehensiveness, whole person care, diagnostic and therapeutic skill, co-ordination and clinical team work, continuing quality improvement,  professional clinical and ethical standards maintenance, leadership equity and advocacy skills; and the first point of contact for all patients at all stages and all ages with all diseases over a lifetime.  That’s quite a list and in my life of work in General Practice it is all applicable. 

Perhaps this is why in some parts of the hospital and in politics the cognitive blindness to the vast complexity of health care work that occurs outside hospital walls persists?  Is hospital work privileged due to the invisible volumes of triage, diagnostics and ongoing management that occur in General Practice? It is easier to understand a single disease intervention that is for sure.  Does this introduce a simplicity linear bias to hospital work and reward?   We shall have to ask our policy leaders.

It is notable that the 2018 Astana declaration admits that the direction of health care policy needs an adjustment;

“Health resources have been overwhelmingly focused on single disease interventions rather than strong, comprehensive health systems”

The Astana declaration from the world’s heads of Government and health care leaders in 2018 declared a vision that seems at odds with current policy behaviour.  Australia is an active WHO member state so it seems timely to remind our legislators and our hospital colleagues of the impetus for change in behaviour attitudes and funding that are needed to fulfill the idealistic vision of Astana.

The Astana declaration says the world needs to;

(1) make bold political choices for health across all sectors;

(2) build sustainable primary health care;

(3) empower individuals and communities; and

(4) align stakeholder support to national policies, strategies and plans.

A radical and brave healthcare reform seems possible. But re-framing healthcare needs those courageous enough to lead.  Such action might just contribute to greater appreciation and less unsubstantiated comments from some within the hospital sector. Maybe then with political bravery we can cease the privileged single disease cherry picking that is a favourite past time of current Australian health care policy.

The capacity, scope and evidence for the outcomes in a well-resourced General Practice and Primary Care is overwhelming and it is time that attitudes and funding aligns with that evidence. Its time I stopped hearing that “GPs should…..”  statement, from those who never have.

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