General Practice in England and
Australia – a comparison
Dr Mark McCartney
Introduction
General Practice in England is coming under increasing
strain and comparisons have been made with how the service is run in Australia.
This paper makes an informed analysis of the service in each country with
suggestions for politicians, leaders, negotiators and health commissioners to
learn from, with the aim of enhancing the respective service for patients and
doctors
Method
The author is a General Practitioner who currently works
South East Cornwall and in 2013-2014 spent 12 months working as a GP in South
East Queensland. He has over 20 years of experience as a partner in NHS
practice, including time as a medical manager of an Out of Hours Service,
experience of GP commissioning in England and as a political representative on
the GP Committee of the British Medical Association.
Comparative Data has been obtained from various sources in
the English NHS and from the Australian Department of Health. This has been
used in the context of personal experience of working in both systems to share
strengths and weaknesses of equivalent organisations.
Background
The English NHS is founded on some basic principles – that
it meets the needs of everyone, that it be free at the point of delivery and
that it be based on clinical need, not the ability to pay. These principles
were expanded within the NHS constitution in 2009. There is a cultural
difference in Australia, where patients are generally accustomed to paying for
some part of their health costs, either directly or through insurance schemes.
Australia promotes similar principles to the English NHS (http://www.health.gov.au/internet/nhhrc/publishing.nsf/Content/principles-lp)
but recognises the consumer element of payment. Australian culture also
promotes personal and business independence – General Practices are recognised
as small businesses that need to be well organised and profitable to survive
and flourish.
The clinical role of the General Practitioner in the two
countries is broadly similar, with responsibility for delivering primary care
to individual patients and their families. However the roles have evolved in
different ways due to cultural and political differences. The English GP
practice will have a defined population “list” of patients (for which there is
a considerable “capitation” payment), but in Australia patients are free to
seek the opinion of any GP – payment for the service is broadly for
consultations and workload. The systems of payment for GPs will be further
explored, as it forms the key difference between the two countries.
Funding for General Practice
ENGLAND
English General Practice funding is directly from NHS
England. There are two main types of contract, General Medical Services (GMS) and
Personal Medical Services (PMS). The latter is a locally negotiated type of
block services contract to deliver defined services to the registered practice
population and forms about 40% of national contracts. More detailed analysis of
PMS contracts is available at http://www.gpinfo.co.uk
NHSE is currently reviewing PMS contracts which may be
phased out in favour of GMS.
GMS is funded through seven main streams -
1. Global sum & MPIG (Minimum Practice Income Guarantee)
2. Quality (QOF, Quality Outcomes Framework)
3. Enhanced Services
4. Seniority payments
5. Premises
6. Information Technology
7. Dispensing payments (applicable to dispensing GP
practices)
GMS core funding is through the Global Sum, based on the
number of registered patients (capitation) and adjusted for other workload
factors (eg age profile, deprivation, temporary resident numbers). MPIG
(Minimum Practice Income Guarantee) was introduced in 2004 to enhance payments
for practices that would have lost out significantly due to contract changes at
that time: it is being phased out between 2014 and 2020.
Quality payments form a significant part of practice income
(13% of total practice income in one study in Bristol www.gpinfo.co.uk) and
cover various target areas including administrative and clinical achievement.
Enhanced services relate to specific additional clinical services that central
policy may wish practices to offer eg flu immunisation. Seniority payments are
made direct to the individual doctor, based on years of service, but these too
are being phased out. Premises payments are rent reimbursements towards
premises costs or borrowings. There are currently no significant capital grant
payments for practices to enhance their premises, although this was a
significant route for investment in General Practice in the past.
NHS England provides practices with IT hardware and software
through the GP Systems of Choice agreement, although practices are responsible
for some of their costs, including consumables, business systems and specified
enhancements to their systems.
Rural practices with dispensing rights receive additional
funding to cover the costs of supplying and dispensing patient medication.
AUSTRALIA
90% of government funding for General Practice in Australia
is through the Medicare Benefit Schedule (http://www.mbsonline.gov.au/). This
is a payment system for providing specific clinical services in both primary
and secondary care, ranging from brief GP consultations to neurosurgical
services. GPs are at liberty to charge the patient more for their service, but
the patient can recover the gap from Medicare (“out of pocket” expense for the
patient). Sometimes the practice will choose not charge the patient, but claim
the Medicare payment directly – this is known as “bulk billing”. However the
Australian government has recently introduced changes to Medicare that may
require a patient co-payment for GP consultations, radiology and pathology
referrals and some hospital Emergency Department attendances.
The remainder of government funding in Australia is through
the Practice Incentives Program
(http://www.medicareaustralia.gov.au/provider/incentives/pip/) which is aimed
at supporting general practice activities that encourage continuing
improvements, quality care, enhance capacity, and improve access and health
outcomes for patients. Administered by the Australian Government Department of
Human Services (Human Services) on behalf of the Department of Health, PIP is
part of a blended payment approach for general practice. The following areas
are targeted under the PIP – Quality Prescribing, Diabetes, Cervical screening,
Asthma, Indigenous health, eHealth, After Hours, Teaching, Rural loading,
Procedural GP (eg intrapartum
obstetrics) and Aged Care access.
Comparing funding
arrangements
GP practices in England thus have a relatively fixed income
– there is some scope for taking on new NHS work by increasing the number of
registered patients or providing additional services under a DES, but the
additional income is relatively small compared to the core and quality funding
streams. There is a little opportunity for private medical work; this is
usually limited to private medical examinations and other peripheral services.
GPs are limited in their ability to charge patients. GP practices are also
responsible for meeting (or dealing with) the demands of their registered
patients, who are unwell or think they are unwell. There is also a risk to the
quality of patient care when demand is high. Since no funding is attached to
individual consultations, there is no stimulus to increase the number of
appointments. With increasing demand, pressure on appointments increases. At
the same time practices will be attempting to maintain profits by controlling
access.
Australian GP practices can increase their income by seeing
more patients and providing more services which attract a fee or Medicare
rebate. Working harder and longer will generate more income, although there may
additional expenses. If there are no appointments available GPs are at liberty
to turn patients away, although this may not necessarily be good business sense,
or for good patient care. However patients are at liberty to visit other
practices that have available appointments and are not restricted to using a
practice that they may usually attend. The system ensures that GPs remain
motivated and are paid for the services that they provide. It improves access
for patients who feel that urgent attention is required, at the risk of reduced
continuity of care and duplication of effort and investigation. Payments for
individual services may encourage practices to provide more services, which may
lead to supplier induced demand, or gaming, to improve practice profits.
General practice from
the patient’s perspective
In England, at present, a patient may only register with one
practice. For those with chronic conditions needing regular appointments they will
be able to develop a relationship with one GP to maintain continuity, but there
is a sense that requests for appointments on the day are more likely to be with
a duty doctor or other clinician in the practice who has spare capacity. Similar
issues occur in Australia, particularly with many doctors now choosing to
reduce their working hours from entirely full time. The key differences in
Australia are the payment for the consultation and the fact that the patient
can choose to attend another practice on any particular day, subject to
availability. The patient is not “registered” with the practice.
These differences perhaps improve the experience of booking
an appointment better for the patient in Australia. Payment for services,
including consultations, motivates the GP to improve access and availability
for regular patients. The continuity improves the experience for both patient
and GP; there is increased efficiency with less duplication of effort, probably
fewer investigations, prescriptions and possibly fewer clinical errors. The
practice may be able to offer the patient chronic disease services which are
beneficial to all.
Individual GPs in Australia that are popular with patients
may become overbooked with appointments, thus reducing access and availability.
Neighbouring GPs may be able to manage the extra workload, but there is loss of
continuity and medical records become fragmented. From the GP perspective the
ability to limit the amount of work in a day is attractive, but there is
balance to be struck.
Back in England GPs are faced with increasing demands for appointments,
but they and patients have nowhere else to go. GPs are contracted to deal with
all their registered patients. As demand and workload increases then practices
are faced with managing GP access by restricting appointment availability,
limiting consultations to one issue, triaging calls or undertaking more
telephone consultations. Overspill can be taken up only by the patient
attending minor injury units, emergency departments or walk in centres. In
these situations patients may be faced with long delays in a waiting room or
seeing a clinician with training or experience different to that of a GP. There
is limited availability to private General Practice in England, which struggles
to compete against the NHS GP service which is free to the patient.
The General
Practitioner’s perspective
There are lots of things about General Practice in Australia
that make it a much better experience than working as a GP in England.
1.
Patient expectations – these are high, but this
is not a problem working in a well organised and funded system. GPs are expected to “fix” things first time,
which is not always possible, but makes the job challenging and interesting. There
has been no media campaign criticising doctors, which has allowed a positive
working environment to thrive.
2.
Doctor patient relationship – payment for
consulting does alter the relationship, particularly when the patient agenda is
not met. This does require some skill – for example antibiotic prescribing.
However there is a benefit in that an overt financial value is placed on the
consultation and other services rendered
3.
Workload – the GP is in control of his workload
– appointments can be booked at whatever interval is required. Some doctors are
able to consult at a faster rate and may be able to earn more for that, but GPs
can choose to book patients at 10, 15 or even 20 minute intervals to allow them
to work at a rate they are comfortable with
4.
Access to radiology – with Medicare rebates
available to patients for most investigations, the GP can arrange ultrasound,
CT and MRI at often no cost to the patient. The investigation and results can
be made available at almost alarming speed. However this is great for dealing
with symptomatology suggestive of cancer or other conditions which might
require urgent intervention. When referrals are required the GP can arrange a
full work up prior to specialist review. There is no urgent referral system for
investigation of cancer as most of the tests can be undertaken in primary care.
5.
Access to pathology – my experience of pathology
collection and reporting was that the service in Australia was much quicker
6.
Financial arrangements – GP pay in Australia is
similar to England (http://www.hscic.gov.uk/searchcatalogue?productid=13317&q=doctors+earnings&sort=Relevance&size=10&page=1#top)
, although the cost of living is higher. Medical indemnity costs are less,
mainly because they are subsidised by the government. GPs can earn more by
working harder and for longer hours, but the positive motivating factor is that
GPs can bill for specific services and procedures as well as payments for care
plans etc as part of chronic disease management payments. Most GPs working for
practices in Australia are not paid a salary but a percentage of their
billings.
7.
Relationship with secondary care – private
specialists have good access for advice and referrals with a positive
relationship with GPs. Communication between primary and secondary care is on
the whole much better. There are also better relationships between GPs and
junior doctors – hospital admissions are arranged on the traditional doctor to
doctor basis
8.
Professional development – there is a feeling of
greater flexibility and scope for professional development in Australia if the
GP so wishes. There is less bureaucracy associated with licensing.
9.
There is no QOF. In fact monitoring of referrals
and prescribing is of very light touch compared to England. Consultations are
not dominated by the computer screen in the room.
10.
The Australian climate and lifestyle is great if
you love the outdoors.
There are however
some downsides to the ways of working for GPs in Australia
1.
Private General Practice – patients who pay for
consultations are more likely to expect or demand a specific investigation or
treatment. Establishing and agreeing what is appropriate for these patients can
sometimes be a challenge. Patients may be seeing several practitioners for
treatment and there is no certainty about what investigations have been
undertake or medication prescribed.
2.
Easy access to investigations can lead to
patients expecting a test for every condition. There is a possibility of over
investigation, with follow up tests exposing patients to unnecessary risk or
harm.
3.
Medical record keeping (including clinical
coding) and information sharing is of poorer quality in Australia. There is no
unified patient record – this can lead to duplication of effort and
expenditure, including potentially invasive tests. Attempts to create a unified
record, the PCEHR, appear to be faltering.
4.
Potential lack of follow up – patients who do
not respond to treatment may visit another facility, so the GP will not get
feedback on the success or otherwise of any treatment plan. The lack of
continuity can be frustrating for all, particularly when patients come back to
the original GP with an unresolved issue.
5.
Lack of a health safety net for some patients – uninsured patients may be
referred to the public hospital system where waiting lists can be very long or
some treatments just not available
6.
Safeguarding for children and vulnerable adults
is more difficult to deal with when there is no named responsible GP
7.
Progress to greater use of secure electronic
referrals is being made in Australia, but fax machines still seem to be the
most important piece of equipment in a GP surgery. This may be because
specialists and secondary care are less likely to be set up to receive or
transmit information in any other way.
8.
For patients to get some prescriptions on the
Pharmaceutical Benefit Scheme (eg opiates, certain branded products) requires
the GP to telephone a central line to get authority to issue (http://www.pbs.gov.au/pbs/home).
This is a tedious distraction in a consultation, although it does provide some
control on the prescribing of these medications.
9.
There is no system of payment for services
provided by practice nurses (these type of payments were scrapped by a previous
government in an attempt to save money). The GP literally has to oversee all
their work to enable the billing process.
10.
Continuing medical education is still dominated
by pharmaceutical companies and other private health providers.
What can NHS England
learn from the Australian perspective?
General Practice in Australia and the UK are experiencing
similar population health and demographic challenges. There are also reported
shortages of GPs in both countries. Here are some suggestions for NHS England
based on personal experience of working in both countries.
1.
Australian General Practice is respected as a
business entity that thrives on the support and encouragement of a sustainable
business model, which includes relatively stable income streams and payments
based on services provided, which are on the whole clinically proven and
evidence based. NHS England should reduce the perpetual change model of the
annual contracting process and resist the urge to move core payments into
politically motivated schemes such as extended hours and admission avoidance. NHS
England also needs to seriously consider an investment programme for GP
premises, which are in generally in poor condition to those in Australia. The
current system of GP payments does not encourage practices to invest in their
own premises, particularly when property costs are so high.
2.
Access to GPs in Australia is improved by
Medicare payments for individual patient consultations and NHS England could
consider introducing this element into GP pay, rather than stoking up demand
and making small flat payments to practices simply for “opening their doors”.
3.
Availability and access to radiology and
ultrasound investigation for GPs could be improved to the level of service in
Australia. It is felt that this would have a dramatic effect on reducing demand
for secondary care appointments in England.
4.
NHS GPs could be allowed to offer private
services to their patients in England. This would allow practices to improve
access to core NHS services and increase the resources available. However, as
in Australia, there should be a defined level of service available to all
patients, irrespective of their ability to pay.
5.
Barriers to communication between primary and
secondary care in England include the Choose and Book service and a poor level
of consultant secretarial support. Improving communication would have benefits
for patient care and possibly reduce hospital admissions.
6.
Appraisal and revalidation in England has become
onerous and is generally disliked by GPs. It is expensive and there is no
evidence that it is more effective than the Australian system of a three yearly
programme of CPD credits.
7.
There is a target led culture of management in
England, exemplified by the QOF GP payment system. The system of practice
incentive payments in Australia is more light touch and less intrusive in
doctor patient consultations. NHS England should consider reducing the value of
target payments, something that may enhance access to GPs and the patient
experience
What can Australia
learn from England’s NHS?
The major advantages seen in England are population based GP
lists and the continuity provided by the unified GP record. However these may
not be culturally acceptable in Australia, where citizens utilise their right
to attend any GP that is available and willing to see them. However the
Australian government could take some action to improve the current situation.
1.
Medicare rebates for patients attending the same
GP practice could be increased to a higher level to encourage continuity of
care. Follow up and continuity for families, particularly those with possible
safeguarding concerns could be enhanced by creating a special Medicare payment
to encourage patients to continue to attend the same practice. Recently
proposed changes to Medicare, including the copayment for consultations and
investigations, may have some unforeseen consequences on patient care. Patient
consulting patterns may change in ways to undermine any perceived financial
benefits of the copayment plan.
2.
The Australian GP clinical records could be
improved by linking payments to clinical coding at the time of clinical
consultations, with additional financial incentives for updating clinical
summaries and sharing information with other GP practices. The Australian
equivalent of the English Summary Care Record is the PCEHR (http://www.nehta.gov.au/our-work/pcehr),
and has been dogged by similar problems. It is not the answer to improving the
clinical records. Australia could look at what has happened with clinical
records in England and learn from all the mistakes that have been made. Privacy
and information sharing legislation in Australia could be reviewed and a higher
status given for information governance in practices.
3.
The current system of monitoring GP prescribing
in Australia appears haphazard and not effective. There is a high level of
branded prescribing and Pharmaceutical companies continue to have a strong
influence on GP prescribing habits. Drug budgets for practices are not feasible
given that there is not a defined patient list. However the Authority system
for prescribing could be further streamlined and the savings invested in a more
rigorous data collection, monitoring and feedback scheme. The National
Prescribing Service (http://www.nps.org.au/)
could have a role in this, but significant investment would be required
4.
While access to radiology services for GPs
appears to be excellent, there is a high cost for this service and easy access
combined with high patient expectation for scans may be leading to unnecessary
and potentially harmful tests. Quality could be possibly improved with
additional training or other methods such as screening of requests for certain
tests as part of the Medicare rebate process.
5.
Australia could improve the system of payment
for services delivered by practice nurses. This would free up time for
practices to focus on patient issues which require GP intervention.
6.
In Australia there is an evolving system of
communication between primary and secondary care, which is diverse and led by
local pioneers. However the use of practice fax machines to circumvent privacy
and confidentiality issues should be discouraged, with support given to secure
electronic messaging.
Summary
The GP contracting and delivery in England and Australia is
explained and compared. The experience of working in two different models of
General Practice has been described and used to illustrate the advantages and
disadvantages of each model. The author has made some suggestions for possible
enhancements that could be made by leaders, commissioners and politicians.
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