Gatekeeping and General Practice in the Australian Health System

Susan Elizabeth Clarke

A thesis submitted in fulfilment of the requirements for the degree of

Doctor of Philosophy

Faculty of Medicine and Health

School of Public Health

University of Sydney

2021

Statement of Originality

This is to certify that, to the best of my knowledge, the content of this thesis is my own work. This thesis has not been submitted for any degree or other purposes.

I certify that the intellectual content of this thesis is the product of my own work and that all the assistance received in preparing this thesis and sources have been acknowledged.

i Acknowledgements

Special thanks to Professor Andrew Wilson and Dr Justin McNab for their supervision and care throughout this process. Thanks, too, to Professor Lyndal Trevena for her advice in the early years. Love and thanks to my family, mum and dad, Jen and John, Pete and Erin, Tim and Amy who support me in all my odd endeavours. Shout out to Levi, Elias and Siara who give me something to think about other than cats.

Special thanks to all of those who took time to participate in this study. I hope it makes things better.

Thanks to Dr Amy Langford-Ely, Dr Janice Kiem and Dr Chris Podagiel for their excellent GP care.

Capstone Editing provided copyediting and proofreading services, according to the guidelines laid out in the university-endorsed national ‘Guidelines for Editing Research Theses’ and the ‘Australian Standards for Editing Practice’.

ii Abstract

General practice is central to primary care in the Australian health system, yet difficulties proving the value of general practice are ongoing. Advocates of general practice often refer to a key role general practitioners (GPs) play in health system gatekeeping to emphasise the importance of general practice within the system. However, the concept of gatekeeping lacks clarity, and this may lead to unintended consequences for general practice.

This thesis explores the concept of gatekeeping within the Australian health system by considering the expectations of general practice held by policymakers, advocacy groups and general practitioners concerning general practice as the controller of economic value in health care. The study analysed media releases from policymakers and advocacy groups and conducted interviews with 19 GPs. Using a methodology which attempts to reflect a general practice approach to problem solving, the study considered the discourse of policymakers, GPs and advocacy groups concerning waste within the system, to determine attitudes towards gatekeeping.

The study found that policymakers, influenced by neoliberal ideas, equate good health with good economics and have an expectation that GPs will consider cost when making clinical decisions. GPs, while thoughtful of cost, prioritise patient well-being in treatment. Policymaker and GP expectations of care are opposed. While gatekeeping has appeal in a neoliberal environment, failure to meet economic expectations exposes GPs to accusations of poor practice. Advocacy for general practice should recognise the value of general practice in the Australian health system extends beyond reductionist financial expectations and re-centring policy discourse on health outcomes rather than economic outcomes is likely to have most success in improving the status of general practice within the system.

iii Contents

Statement of Originality ...... i Acknowledgements ...... ii Abstract ...... iii Contents ...... iv List of Abbreviations ...... vii Chapter 1: Gatekeeping and the Australian Health System ...... 1 1.1 Why Study Gatekeeping? ...... 1 1.2 Defining Gatekeeping ...... 2 1.3 The Australian Context ...... 5 1.4 The Evidence for Gatekeeping ...... 6 Chapter 2: Methodology...... 10 2.1 Introduction ...... 10 2.2 Aim ...... 11 2.3 Objectives ...... 12 2.4 Data ...... 12 2.5 Steps in Data Analysis...... 13 2.5.1 Step One ...... 13 2.5.2 Step Two ...... 14 2.5.3 Step Three ...... 15 2.5.4 Step Four ...... 15 2.6 What is a General Practice Approach? ...... 16 2.7 In Defence of the General Practice Approach ...... 17 2.8 Positioning the Researcher in the Research ...... 21 2.9 Conclusion ...... 25 Chapter 3: General Practice and the Australian Health System in Context...... 26 3.1 Introduction ...... 26 3.2 Background ...... 26 3.3 The Australian Healthcare System and the Rise of Medicare ...... 27 3.4 Stakeholders in the Australian Health System ...... 29 3.4.1 Royal College of General Practitioners (RACGP) ...... 29 3.4.2 Australian Medical Association (AMA)...... 30 3.4.3 Consumers Health Forum of Australia (CHF) ...... 30 3.4.4 Other Stakeholders ...... 31 3.5 Politics and Ideology ...... 31 3.6 The Role of General Practice ...... 34 3.6.1 Reforms ...... 35 3.6.2 Reinvention ...... 38 3.7 Conclusion ...... 41 Chapter 4: Referrals and Research Assumptions ...... 43 4.1 Methodology ...... 43 4.2 Background ...... 43 4.3 Findings ...... 45 4.3.1 Referrals ...... 45 4.3.2 Quality of Referrals ...... 48

iv 4.3.3 The Problem of Inappropriateness ...... 50 4.4 Conclusion ...... 58 Chapter 5: Policymaker Claims ...... 60 5.1 Mr Dutton ...... 60 5.1.1 Situational Claims ...... 60 5.1.2 Attributional Claims ...... 62 5.1.3 Action Claims ...... 63 5.2 Ms Ley...... 66 5.2.1 Situational Claims ...... 66 5.2.2 Attributional Claims ...... 67 5.2.3 Action Claims ...... 68 5.3 Mr Hunt ...... 70 5.3.1 Situational Claims ...... 70 5.3.2 Attributional Claims ...... 71 5.3.3 Action Claims ...... 72 5.4 Discussion ...... 73 5.5 Conclusion ...... 74 Chapter 6: Advocacy Stakeholder Claims ...... 76 6.1 Australian Medical Association (AMA) ...... 76 6.1.1 Situational Claims ...... 76 6.1.2 Attributional Claims ...... 77 6.1.3 Action Claims ...... 79 6.2 Royal Australian College of General Practitioners (RACGP) ...... 80 6.2.1 Situational Claims ...... 80 6.2.2 Attributional Claims ...... 81 6.2.3 Action Claims ...... 81 6.3 Consumers Health Forum of Australia (CHF) ...... 83 6.3.1 Situational Claims ...... 83 6.3.2 Attributional Claims ...... 85 6.3.3 Action Claims ...... 86 6.4 Discussion ...... 88 6.5 What Does this Mean for General Practice? ...... 90 6.6 Conclusion ...... 91 Chapter 7: General Practice Claims ...... 92 7.1 Situational Claims ...... 92 7.2 Attributional Claims ...... 104 7.3 Action Claims ...... 105 7.4 Other Initiatives ...... 114 7.5 Discussion ...... 116 7.6 Conclusion ...... 117 Chapter 8: What is the answer? ...... 119 8.1 Situational Claims ...... 120 8.1.1 Are Costs Spiralling Out of Control? ...... 120 8.1.2 Does an Ageing Population Increase Health Expenditure? ...... 122 8.1.3 Are Chronic Diseases Poorly Managed? ...... 123 8.1.4 Are Medicare Item Numbers for Chronic Disease Management Being Abused? . 123 8.1.5 Is Six-minute Medicine a Problem? ...... 124 8.1.6 Is Out-of-pocket Expenditure a Problem in Australia? ...... 124 8.1.7 Are Poor Discharge Summaries a Problem? ...... 125

v 8.2 Attributional Claims ...... 126 8.2.1 Is Poor Health Literacy a Problem? ...... 126 8.2.2 Does Patient Pressure Affect Investigation Ordering? ...... 126 8.2.3 Is Duplication of Investigations a Problem?...... 127 8.2.4 Is Low-value Care a Problem? ...... 127 8.2.5 Do GPs Order Inappropriate Tests?...... 128 8.3 Action Claims ...... 129 8.3.1 Will Co-payments Reduce Costs to the Health System? ...... 129 8.3.2 Will Changing Payment Methods Change GP Behaviour? ...... 130 8.3.3 Will a National Electronic Health Record Reduce Costs and Improve Efficiency? ...... 131 8.3.4 Will Private Health Insurance Reduce Government Spending on Health? ...... 132 8.4 Conclusion ...... 133 Chapter 9: Framing the Issue ...... 135 9.1 A Review of Framing Analysis ...... 135 9.2 How will Framing Analysis be Performed? ...... 140 9.2.1 Policymakers ...... 141 9.2.2 Stakeholders ...... 146 9.3 Discussion ...... 151 Chapter 10: General Practice Framing ...... 157 10.1 The Heterogeneity of General Practice ...... 157 10.2 The System Does Not Support General Practice ...... 158 10.3 General Practice Complexity and the Discourse of Difficulty ...... 160 10.4 Good Doctors and Bad Doctors ...... 161 10.5 General Practice is Responsible for Patients’ Well-being ...... 163 10.6 Health as Well-being ...... 167 10.7 Responsibilities and Gatekeeping ...... 168 Chapter 11: Considering the Diagnosis and Treatment ...... 171 11.1 Introduction ...... 171 11.2 Summarising the Consultation ...... 171 11.3 Diagnosis ...... 172 11.4 Treatment ...... 176 Chapter 12: The Follow-up ...... 181 12.1 The Situation Review ...... 181 12.2 Reflection ...... 184 12.3 Limitations ...... 186 Appendices ...... 187 References ...... 198

vi List of Abbreviations

ACRRM Australian College of Rural and Remote Medicine

AIHW Australian Institute of Health and Welfare

AMA Australian Medical Association

BEACH Bettering Evaluation of Care and Health

CHF Consumers Health Forum of Australia

GDP gross domestic product

GP general practitioner

MBS Medicare Benefits Schedule

OECD Organisation for Economic Cooperation and Development

PBS Pharmaceutical Benefits Scheme

RACGP Royal Australian College of General Practitioners

RCT randomised controlled trial

UK United Kingdom

US United States

vii Chapter 1: Gatekeeping and the Australian Health System

Advocates of general practice in Australia often refer to general practitioners (GPs) as gatekeepers of the Australian health system. Attributing a gatekeeping role to general practice is used to promote the value of general practice to healthcare, an ongoing concern for the discipline in Australia. As the cost of health services continues to increase and populations become more demanding about their health, governments around the world are faced with the difficult task of balancing provision of appropriate healthcare with increasing financial constraints. The constraining of health care costs anticipated from effective gatekeeping has had widespread appeal as policymakers seek to reduce spending by reducing the uptake of inappropriate and expensive medical care. A specialty willing to embrace the role of gatekeeping should, therefore, be regarded as valuable to policymakers. Yet general practice in Australia, probably more than any other specialty, is faced with frequent attempts by policymakers to limit the scope, number, and level of reimbursement for government subsidized services which suggest it is regarded as problematic rather than valuable. Ironically, claims to a poorly defined gatekeeping status may be detrimental for general practice as these claims may encourage unrealistic expectations of general practice as a panacea for exorbitant health spending. Superficial understandings of the gatekeeper role may fail to appreciate both the complexities of healthcare and of general practice, resulting in unmet expectations. Should GPs persist with claims of gatekeeping or should advocacy for general practice attempt to prove value in other ways? Answering this question requires an exploration of the role of gatekeeping within the Australian health system and the expectations of gatekeeping held by policymakers, advocates within the health system and GPs themselves. It also requires an understanding of the contextual factors that mould these perceptions. Understanding how gatekeeping is conceptualised and the factors that impact on gatekeeping and gatekeepers can help unpack a challenging policy issue currently facing policymakers and GPs in Australia: how to reduce waste, in the form of inappropriate and overused services, in the health system.

1.1 Why Study Gatekeeping?

The interest of governments and policymakers in gatekeeping stems from a widespread assumption that gatekeeping is an effective tool for reducing healthcare costs. Phillips et al. (2004) note that gatekeepers are normally considered essential for health systems wishing to remain cost effective. The ability of the National Health Service in the United Kingdom (UK)

1 to constrain costs has long been thought to be due to the UK’s well-established gatekeeping system (Bowling & Redfern, 2000, p. 216). Others assume that gatekeeping systems will reduce the amount of unnecessary secondary and tertiary care and thus result in lower expenditure for both patients and governments (Brekke, Nuscheler & Straume, 2006, p. 150). Gatekeeping has long been associated with primary care provision, which likely has its origins in the Declaration of Alma-Ata and the perception of primary healthcare as a way of constraining health system costs (World Health Organization, 1978). Studies detailing the benefits of primary (medical) care, including a reduction in deaths, improved health outcomes and lower costs to health systems, have further cemented the association of primary care providers with cost control within health systems (Starfield, Shi & Macinko, 2005, p. 459). Indeed, primary care providers are the medical professionals most commonly identified as gatekeepers within the literature (Allard, Jelovac & Leger, 2011; Biro, 2013; Brekke et al., 2006; Godager, Iversen & Ma, 2015; González, 2009; Kulu-Glasgow, Delnoij & de Bakker, 1998; Steele, Glazier, Agha & Moineddin, 2009). Various groups representing the interests of primary care providers often reference this gatekeeping function, and subsequent cost effectiveness, to justify a policy focus on primary care within health systems (Britt & Miller, 2015; Kidd, 2014). Yet the role of the gatekeeper has often been controversial, with policymakers, patients and even doctors expressing mistrust or ambivalence about the role (Gross, Tabenkin & Brammli-Greenburg, 2000; Tabenkin & Gross, 2000; Tabenkin, Gross, Brammli-Greenburg, Steinmetz & Elhayany, 2001). Mixed evidence for the effectiveness of gatekeeping has further confused the issue and the role of gatekeeping in health systems lacks clarity.

1.2 Defining Gatekeeping

Although gatekeeping is often analysed, in-depth explicit definitions of gatekeeping are surprisingly sparse. A search of the databases Medline (via Ovid), Embase and Global Health (via Ovid) using the MESH the terms ‘Health services accessibility’, ‘gatekeeping’, ‘referral and consultation’, ‘costs and cost analysis’, ‘health policy’ and key words ‘gatekeep*’, ‘ration*’, ‘finance*’, ‘cost*’ and ‘policy’ retrieved 41 articles discussing gatekeeping. Almost all define gatekeeping simply as the requirement of patients to have a referral from a primary care provider before accessing specialist care (Allard et al., 2011; Biro, 2013; Brekke et al., 2006; Dusheiko, Gravelle, Yu & Campbell, 2007; Engstrom, Foldevi & Borgquist, 2001; Ferris, Chang, Blumenthal & Pearson, 2001; Ferris, Chang, Perrin, Blumenthal & Pearson,

2 2002; Godager et al., 2015; González, 2009; Haas, Phillips, Baker, Sonnebom & McCulloch, 2003; Himmel, Dieterich & Kochen, 2000; Kulu-Glasgow et al., 1998; Pati, Shea, Rabinowitz & Carrasquillo, 2003; Shi, Forrest, von Schrader & Ng, 2003; Steele et al., 2009; Velasco Garrido, Zentner & Busse, 2011). For example, Ferris et al. (2001, p. 1312) note that ‘authorisation of referrals to specialists by a designated primary care provider is commonly referred to as gatekeeping’. Similarly, Pati et al. (2003), in their discussion of gatekeeping within health maintenance organisations in the United States (US), note that ‘This system requires a designated primary care provider to authorize subspecialist referrals’. Allard et al. (2011, p. 881) note that gatekeeping was a recent trend to ‘force patients to seek a referral by a GP before accessing specialty care’. Dusheiko et al. (2007, p. 743) describe gatekeeping as restricting access to elective hospital care, while Brekke et al. (2006, p. 150) claim that patients in gatekeeping systems simply do not have direct access to secondary care. Under this definition, every health system in which patients are required to obtain a referral before accessing specialist care can be regarded as a gatekeeping system. Few attempt to define gatekeeping beyond this definition. Tabenkin and Gross (2000) provide perhaps the most detailed description of gatekeeping:

the authority to decide upon referrals to specialists, to implement the diagnostic work- up and patient management in the primary care clinics, to consider finances when deciding about medical care, and to co-ordinate the actions of other caregivers, thus guaranteeing continuity of care. (p. 75)

While exact definitions may be lacking, further analysis of the literature reveal two implied models of gatekeeping. These models are important as each speaks to different expectations of gatekeeping within health systems. The first model focusses on restricting access to expensive care and has strong financial connotations (Malcomson, 2003, p. 1). Restricting access to care reflects the traditional understanding of gatekeeping outside the health arena. As Hegney et al. (2004, p. 845) note, gatekeeping in many forms has been around for centuries and has generally involved designated persons acting to restrict access to certain goods and services. In health systems, expensive treatments are assumed to be specialist care and secondary hospital services, hence the need for referral (Brekke et al., 2006, p. 149; Delnoij, Van Merode, Paulus & Groenewegen, 2000, p. 22; González, 2009, p. 731; Pedersen, Andersen & Søndergaard, 2012, p. S35). In some countries, gatekeeping also involves restricting access to subsidised medication (Carlsen & Norheim, 2005). The designated gatekeeper, by this definition, is in control of rationing scarce or expensive resources. This model is considered desirable within

3 systems where patient care is highly subsidised by either the government or health insurance schemes (Scott, 2000, p. 1177). Within this system, patient choice tends to be restricted and there is a strong focus on reducing or sustaining costs. Perhaps the most notable examples of this type of gatekeeping system are the health maintenance organisations in the US. Within these organisations, primary care providers are often offered incentives to restrict patient access to non-GP specialist care (Forrest, 2003, p. 694). This understanding of gatekeeping has strong negative connotations with concentrated efforts to keep the ‘gate’ closed. This model can be considered a ‘financial’ model of gatekeeping.

The second model regards the requirement of a referral to access non-GP specialist care as part of a patient-centred strategy to assist patients in navigating complex health systems. This includes a role for the health professional in care coordination (Byrnes, Crawford & Sieh, 2013; Chevreul & Durand-Zaleski, 2012; Forrest, 2003; Gross et al., 2000; Gross, Tabenkin & Brammli-Greenburg, 2001; Grumbach et al., 1999; Halm, Causino & Blumenthal, 1997; Hoffman, Stein, Maier, Rieder & Dorner, 2013; Russell & Mitchell, 2002; Schwenkglenks, Preiswerk, Lehner, Weber & Szucs, 2006; Tabenkin & Gross, 2000; Tabenkin et al., 2001; Wammes et al., 2014; Wyke et al., 2002). For example, Grumbach et al. (1999, p. 261) have described the gatekeeper function as having an emphasis on ‘providing first- contact care and coordinating referrals’. Forrest (2003, p. 692) notes the collaborative nature of this type of gatekeeping with doctors working with patients to determine the best course of action and whether the patient requires non-GP specialist care.

This reflects a different perception of gatekeeping that, in contrast to the ‘closed gate’ or ‘financial’ model of gatekeeping, could be referred to as the ‘open gate’ model. Restricting access to non-GP specialty care is required to prevent duplication of services and unnecessary treatments and investigations, however patient choice is not restricted but regarded as a factor influencing the type of care which should be made available to the patient. The gatekeeper opens the gate rather than keeping it closed. Referral from a primary care provider in this scenario is important in the process of providing best care for patients. Such coordination of care is expected to be cost effective as patients avoid spending time and money on irrelevant or potentially harmful treatments. However, here cost-effectiveness for the government may be a co-lateral benefit rather than the primary aim of gatekeeping. The concept of patient- centred care, prominent in general practice discourse, has perhaps been most influential in the development of this understanding of gatekeeping.

4 Different models of gatekeeping can be expected to produce different outcomes regarding cost effectiveness and patient care. A financial or closed-gate model of gatekeeping can be expected to be cost effective as expensive treatment is rationed or refused. This is the rationale in the managed care scenarios (Ferris et al., 2001; Grumbach et al., 1999; Haas et al., 2003; Pati et al., 2003; Shi et al., 2003). A patient-centred model of gatekeeping could potentially increase costs to systems as good patient outcomes are not necessarily compatible with a reduction in health spending. However, many advocates of the patient-centred understanding of gatekeeping point to a strong financial rationale where coordination of care results in positive financial outcomes for the health system (and the patient) through the aforementioned reduction in the duplication of services and restriction of unnecessary investigations and treatments (Gross et al., 2000, p. 222).

1.3 The Australian Context

On the surface, the Australian health system fits the widely held definition of a gatekeeping system provided in Section 1.2. To access subsidised non-GP specialist care within the Australian health system, patients require a referral from a primary care provider. This is most often a GP, although patients can also be referred to public outpatient departments from public hospital emergency departments. Referrals from a GP are valid for 12 months and patients are usually required to see their GP for another referral if they need ongoing non-GP specialist care after the 12-month limit. Non-GP specialist-to-specialist referrals can occur but are only valid for three months and patients must see their GP for a further referral if ongoing treatment is required. Patients can access non-GP specialist care without a referral, but they will not receive a Medicare rebate for such a visit. Medicare rebates are available for both private care and some bulk-billed public non-GP specialist outpatient care through the Medicare Benefits Schedule (MBS). Doctors within the system are mostly paid a fee for each service (paid by patients, who are wholly or partially rebated the amount by Medicare), although some Medicare item numbers do provide reimbursement for GP management of patients with chronic diseases. These item numbers pay for a coordinated care plan rather than individual treatment episodes. Patients also require referral from either their GP or non-GP specialist for pathology and radiology investigations and to receive subsidised medications on the Pharmaceutical Benefits Scheme (PBS). The requirement for a referral to access these services suggests that there is an expectation of gatekeeping within the system. Whether this functions as a true barrier to accessing more expensive care or investigations is unknown.

5 Perhaps the most significant discussion of general practice and gatekeeping within the political sphere came during the tenure of Nicola Roxon as Federal Minister for Health. In response to the claim by then president of the AMA, Dr Rosanna Capolingua, that GPs were the most effective gatekeepers in the health system, Ms Roxon mused on the appropriateness of using the term gatekeeping (Metherell, 2008). Interestingly, Ms Roxon’s view of gatekeeping reflected the “closed gate” understanding of gatekeeping and indicated an assumption that GPs were a road block for people attempting to access the system. She stated “Surely we need GPs to help facilitate access to health care, not stand at the door keeping people out? The phrase 'gatekeeper' is a loaded one and belongs to an old debate."(Metherell, 2008). For Ms Roxon, the closed gate scenario was not desirable for health.

Such a perspective was comparatively nuanced compared with most understandings of gatekeeping within the Australian health system and her call to retire the term has been largely unheeded. GPs are still referred to as gatekeepers within the Australian health system and the term is usually used regarding referrals to non-GP specialists without reference to any further expectations of GPs in this role. The literature rarely clarifies if the type of gatekeeping referred to reflects an open or closed type of gatekeeping. For example, Del Mar (2014, p. 367) regards the GP gatekeeping role simply as being a ‘bottleneck to accessing specialist services’. Hall (2015, p. 495) claims that ‘Primary care physicians (general practitioners, or GPs) play a central role as gatekeepers to the rest of the system; all specialist care requires a GP referral’. She further notes that this role centres on the coordination of care for patients, more illustrative of the “open gate” system of gatekeeping (p. 495). Knight (2010, p. 889) shares this understanding of Australian gatekeeping GPs as central to the coordination of patient care. Such coordination of care is thought to constrain healthcare costs through efficient use of resources without restricting access to health care, as per the “closed gate” version of gatekeeping. The idea of Australian GPs taking a proactive role in reducing costs within the healthcare system in the style of a “closed gate” system is not discussed. Which, if any, version of gatekeeping occurs in the Australian health system is explored in further chapters.

1.4 The Evidence for Gatekeeping

Evidence for the effectiveness of gatekeeping is difficult to find and the subject of much debate. Until recently, it has been widely assumed that gatekeeping is an effective tool for reducing healthcare costs. This assumption has only recently been challenged. A systematic review of the effects of gatekeeping found only weak evidence that gatekeeping reduces health system

6 costs (Velasco Garrido et al., 2011). Delnoij et al. (2000, p. 25) found that gatekeeping systems were able to constrain ambulatory care costs, but gatekeeping did not appear to reduce the number of hospital admissions. Biro (2013, p. 31) found that wealthier patients were more likely to access non-GP specialist care under a gatekeeping system, although this care was usually private and resulted in an increased cost only for the patient. Evidence for the effects of gatekeeping on patient outcomes is even less clear. As Velasco Garrido et al. (2011) note, the improvement of patient outcomes through gatekeeping has rarely been studied.

The evidence for gatekeeping, therefore, is mixed and often weak. This mixed evidence has caused some institutions to review their reliance on the gatekeeping function. For example, some health maintenance organisations in the US have recently removed gatekeeping requirements (González, 2009). The difficulty with determining success or otherwise of gatekeeping is likely due to the failure to differentiate between the models of gatekeeping. Velasco Garrido et al.’s (2011, p. 31) systematic review included studies from Switzerland, Germany, Denmark, the Netherlands, the UK and the US. It could be argued that a system in which profit is the aim of gatekeeping, as is the case of many HMOs, may be quite different from a system which aims to lessen the strain of government spending on patient care. However, no distinction has been made between models and, once again, the requirement of a referral to visit a non-GP specialist appears sufficient to define both as gatekeeping. These studies may be comparing quite different systems which may explain the mixed evidence for gatekeeping outcomes.

Gatekeeping, therefore, is a term fraught with difficulties. Without a clear understanding of what gatekeeping entails, those involved in policy formation may struggle to formulate policy that adequately addresses the perceived needs of individual health systems. Those tasked with policy implementation are likely to have trouble clarifying roles and expectations for those given the task of gatekeeping. Similarly, if those charged with the task of gatekeeping hold different understandings of gatekeeping to those of policymakers, the resulting dissonance could lead to significant implementation issues. For example, a physician with an understanding of the patient-centred model of gatekeeping may not, to a policymaker, appear to be adequately restricting patient access to more expensive secondary and tertiary care. The acceptability of gatekeeping to patients is a further important consideration. If patients find gatekeeping unacceptable this is likely to influence political perspectives of gatekeeping.

7 Is gatekeeping, therefore, really of any value to healthcare systems? Given the difficulties in clarifying gatekeeping and the potential pitfalls of implementing a gatekeeping system, should we, as Ferris et al. (2001) suggest, ‘leave gatekeeping behind’? Should governments be utilising medical professionals in efforts to constrain health spending? Governments have numerous policy options regarding constraining health spending that would not require health professional input, such as restricting the ability of doctors to order investigations (Buse, Mays & Walt, 2005, p. 131). This would seem a sensible solution given the decided ambivalence of medical professionals to performing tasks that involve a requirement to consider resource constraints when making clinical decisions (Gross et al., 2001). The problem for policymakers is that health consumers prefer health professionals to make decisions about health resources (Omar, Tinghög, Tinghög & Carlsson, 2009). This makes medical professionals acting as gatekeepers a politically expedient idea, giving policymakers a sense of distance from potentially controversial decision-making.

In Australia, the concept of gatekeeper is poorly defined, as are the expectations of this role despite the system superficially fulfilling the criteria for a gatekeeping system. Several questions arise. Do current policymakers hold an expectation that closed or open gatekeeping will occur in the Australian health system? If so, at what level do they expect this would occur and what form would it take? Do GPs regard gatekeeping as part of their role, and do they feel any responsibility towards managing waste and improving efficiency within the system? Do patients accept a GP role in cost-containment? What barriers and enablers of gatekeeping exist within the system? Is it possible to align policymaker and GP expectations to produce primary care policy that effectively reduces waste in the health system, or should policymakers look elsewhere for savings within the health system? Does being perceived as gatekeepers add value to general practice? Is gatekeeping rewarded within the Medicare system? This research aims to explore these questions through exploring perceptions of waste in the health system.

This subject reflects, somewhat, the wider contextual issue facing general practice: defining who we are and what we do (see Section 2.8 for the researcher’s position within the research). Gatekeeping has been used to promote the value of general practice and, therefore, expectations of general practice in this area are important. As a GP, policies that impact on general practice are undoubtedly an area of concern. However, a reading of policies through a GP lens suggests policymakers often have little understanding of the everyday challenges faced by GPs and the voices of GPs are muffled by the louder voices of non-GP specialists, health economists and

8 even those purporting to advocate for general practice. Understanding the GP perspective remains a challenge for research in general practice. Adding to this confusion is a hierarchical concept of medical care in which GPs are considered the country cousins of ‘real’ doctors. Research hierarchies also add to this confusion by promoting research more aptly applied to non-GP specialist care over research appropriate for general practice. These factors add to the problem of defining value for and of general practice.

This research aims to not only analyse the subject of gatekeeping within the Australian health system, but also to present a GP perspective of policy, practice and purpose. There are currently multiple issues facing general practice and the Australian health system. Gatekeeping represents two important issues: how GPs define themselves and how health systems can constrain costs. Exploring the subject of gatekeeping will add to the knowledge of general practice in Australia. Deconstructing gatekeeping using a general practice approach to problem solving may challenge accepted assumptions about general practice, leading to greater understanding of what GPs do. This can assist in better policy production for primary care.

9 Chapter 2: Methodology

2.1 Introduction

The movement towards evidence-based medicine in the late 20th century produced an understanding within medical circles of what was, and what was not, acceptable evidence in medicine. Objectivity, power and minimisation of variables were key features of acceptable evidence while anecdote and experience were not. Subsequently, the randomised controlled trial (RCT) and other quantitative inquiry gained favour in medicine while qualitative inquiry was ignored. The context of the medical consultation was regarded as a complication requiring control. This has proven problematic as contextual factors have a significant impact on the progress of a consultation in general practice and this has resulted in many research findings being difficult to apply in the general practice context. Quantitative research often fails to adequately represent the reality of general practice. This circumstance is only occasionally alluded to in the plethora of research concerned with the application of evidence-base medicine in general practice. Qualitative research, because of the consideration of contextual factors, may benefit general practice, however, it is not highly valued as evidence. The association of qualitative research with general practice may therefore add to the image issues experienced by general practice: an undervalued research paradigm for an undervalued specialty. Qualitative research, too, may not entirely satisfy GPs who require objective information to enable decision making. Research in general practice is therefore problematic.

Of concern to myself, too, is the lack of a general practice voice in medical research which truthfully reflects general practice in a way which is recognisable to GPs and which helps develop an understanding of general practice for those outside the discipline. This is important when developing policy for primary care as misunderstandings of how GPs practise can lead to erroneous policy formulation. Developing a clear GP voice in research is imperative for the development of the specialty. This methodology is informed by the researcher themselves being a general practitioner and thus data analysis is interpreted from a GP perspective. This thesis hopes to present more than a perspective, however, and attempts a methodology that illustrates general practice approaches to problem solving and analysis. By using a four-step process which reflects a general practice consultation approach, this study hopes to present a true depiction of the daily life of GPs by considering a policy problem. These steps involve consideration of the contextual factors affecting general practice along with deconstructing the

10 discourse of policymakers, advocacy groups and GPs. This reflects the need of GPs to understand the context of each patient encounter accompanied by an active listening approach which engages in sense making with the patient within the consultation.

The data analysed here consists of media releases from health ministers and advocacy groups and interviews with individual GPs. Media releases are a medium for argumentation, used by policymakers and advocacy groups to promote their policy positions. Policymakers from herein will refer to health ministers as they have the ultimate responsibility for the type of policy which is produced and for promoting certain policies over others. Analysis of the arguments about policy assists with understanding the contextual factors which influence policy decision making. For this research, they also provide important information concerning the expectations policymakers have of general practice with regards to gatekeeping. Interviews with individual GPs provide a counter to crafted political arguments. Where these arguments present an attempt at presenting issues in a certain way, GP discussions represent a more pragmatic perspective on problems within the health system. GP perspectives provide a coalface interpretation of issues within the system. By comparing these perspectives, areas of agreement may be discovered which can then be used to improve policy formulation and implementation in primary care and provide ways of reducing costs to the health system.

2.2 Aim

The aim of this research is to address two issues affecting general practice. The first is that of gatekeeping. Do policymakers expect GPs to act as gatekeepers, do GPs expect to act as gatekeepers, and what does this imply for the current role of GPs with the Australian health system? Should advocacy for general practice promote gatekeeping as a general practice priority? Stakeholder perceptions of what gatekeepers are, and what they should be doing, can impact policy formulation and implementation. This is important as gatekeeping potentially influences cost control within the health system. Dissonance of stakeholder perceptions may have a negative impact on healthcare costs and spending. Identifying similarities of perception may assist with more effective policy formation and improve cost containment within the system. The second issue affecting GPs which is discussed here, is a perceived lack of understanding of general practice demonstrated by policymakers. This will be addressed by demonstrating a general practice approach to problem solving through a focus on the policy problem of economic waste. GPs are regularly faced with complex diagnostic and management dilemmas. Solving these dilemmas requires good clinical acumen which consists not only of a

11 knowledge of disease processes and the evidence for treatment but also an understanding of the patient’s circumstances and their beliefs about health. Like GPs, policymakers find themselves faced with complex policy dilemmas. The general practice approach of context, evidence and understanding can offer policymakers a unique insight into a policy problem and provide insight into the nature of general practice. The importance of understanding the nature of general practice is often overlooked in discussions of policy. Assumptions about who GPs are and what they do can lead to poor policy if these assumptions are incorrect. It is hoped that a better understanding of the implications of gatekeeping for general practice will develop along with a better understanding of the place of GPs in the Australian health system. By addressing these issues, this study hopes to add to the knowledge of general practice within the Australian health system.

2.3 Objectives

This research has the following objectives:

• explore the concept of gatekeeping within the Australian health system • consider policymaker and advocacy group understandings of the problems within the system and the expectations they have of general practice • explore GP understandings of waste to determine if they act, or are willing to act, as gatekeepers within the Australian health system • consider the barriers and enablers of general practice gatekeeping • consider the differences and similarities in stakeholder expectations of gatekeeping to enable capitalisation of areas of agreement • determine if gatekeeping promotes the value of general practice within the system.

2.4 Data

The data for this research consists of media releases from the Department of Health, Australian Medical Association (AMA), Royal Australian College of General Practitioners (RACGP) and Consumers Health Forum of Australia (CHF). It also includes semi-structured interviews with GPs. Media release data was collected between January 2016 and December 2017. The time period under discussion was September 2013 until July 2017. This time period was chosen because the Liberal/National coalition, in power when this study was being considered, gained office in September 2013 and remained in power in 2017. Media releases provide valuable

12 information for research as they present insight into how stakeholders understand a situation and how they wish the situation to be. The claims organisations and individuals make about situations also project a worldview that preferences certain facts and scenarios over others. While media releases represent organisational views, interviews represent individual perspectives. The relevance of both perspectives will be discussed later in this chapter. Media releases were selected for analysis if they discussed a primary care problem or cost issue. GP participants were recruited through advertising within Primary Health Networks and through social media networks. Participants were volunteers and represent a variety of practice types and locations throughout Australia. Demographic details are provided in Appendix A. Semi- structured interviews with GPs were conducted between July 2016 and March 2017. The interviews with GPs were conducted face to face and by phone. Interviews were recorded and were transcribed by a professional transcription service. GPs were asked a series of questions to elicit their opinions regarding issues of waste within the Australian health system. Questions were informed by analysis of media releases and further questions arose from opinions expressed in the interviews. By focussing on the subject of waste within the system it was possible to elicit stakeholder awareness of costs and their understandings of responsibility for cost control. This provides insight into perspectives of gatekeeping. Identifying who or what is responsible for managing costs assists with identification of potential gatekeeping roles within the system. Ethics approval for this research was received from the University of Sydney Human Research Ethics Committee (Project Number 2016/154).

2.5 Steps in Data Analysis

To achieve the aims of this research, data was analysed by using what I consider to be a general practice approach to problem solving. This approach has been developed from over 15 years of experience in general practice in urban, rural and remote locations. The four steps in this approach are detailed below.

2.5.1 Step One

The first step in this approach involves describing the contextual factors influencing the problem. This process is an explicit reflection of an implicit process in general practice. Experienced GPs generally have acquired a deep understanding of the communities in which they work and the various contextual factors that may impact on patient presentations. In this step, the contextual factors are explored by considering the history of general practice in

13 Australia in Chapter 3. To provide a further understanding of how general practice is perceived, exploration and critique of academic portrayals of general practice is performed in Chapter 4. This step provides a description of the context in which general practice is embedded and which impacts on the acceptability or otherwise of gatekeeping.

2.5.2 Step Two

This study involves both deductive and inductive thematic discourse analysis. Both forms of analysis provide important information. For step two, a deductive thematic analysis has been used. Deductive thematic analysis searches data for answers to specific questions while inductive analysis searches for themes within the data (Crabtree & Miller, 1999, p. 167). In deductive analysis, predetermined codes are used to identify themes within the text (Hsieh & Shannon, 2005, p. 1282). The codes used for this analysis are based on the categorisations used by Fairclough and Fairclough (2012) for political discourse analysis and represent the following three themes:

• Situational claims (i.e., what are the causes of waste in the Australian health system?) • Attributional claims (i.e., who is responsible for managing waste in the Australian health system?) • Action claims (i.e., what must be done to control waste in the Australian health system?)

Unlike the political discourse approach of Fairclough and Fairclough (2012), the approach here is largely descriptive. The purpose is to highlight the ideas stakeholders have about the causes of, responsibility for, and solutions for reducing economic waste in the Australian health system. A focus on waste reveals both attitudes and practical approaches to gatekeeping. Policymakers, advocacy groups and GPs may have different understandings of what problems exist, who is responsible and what should be done. This impacts on the effectiveness of gatekeeping. If similarities of opinions exist, this can provide a basis for improved communication between stakeholders to reduce economic waste within the health system. Identifying similarities and differences of perspectives is the first step to finding solutions for complex policy problems (Head, 2008, p. 106). As members of all groups participate in the health system at different levels, understanding differences in problem and solution identification can supply context to a multifaceted conversation about gatekeeping. The descriptive approach applied here will help to highlight areas that may not have been considered by other stakeholders and help to consolidate agreement about future policy

14 approaches. A diversity of opinions can also illustrate the difficulties associated with a one- size-fits-all policy approach. This step reflects the process of history taking in general practice where the GP explores the patient’s definition and experience of the problem and their expectations for a solution.

2.5.3 Step Three

This step involves considering the evidence for the problems and solutions uncovered in Step Two. The use of evidence in health policy is known to be problematic, with policy often based on little evidence or a broad definition of evidence that may not be recognisable to researchers (Buse et al., 2005, p. 160). Therefore, it cannot be assumed that policymakers or interest groups are basing decisions and opinions on reliable evidence. It is also possible that the opinions of GPs are the result of numerous biases that prevent them from seeing the larger picture (Scott, Soon, Elshaug & Lindner, 2017). This step reflects two aspects of the general practice consultation: examination of the patient to search for signs which confirm suspicions of illness and consideration of the current evidence for the patient’s presentation and management. The purpose here is to determine what, if any, evidence exists for the claims being made, to consider the extent and accuracy of GP understandings of the health system which can determine their suitability as gatekeepers, and to consider possible directions of further research.

2.5.4 Step Four

The final step consists of an inductive analysis of the data using the process of framing analysis. A literature review of framing analysis begins Chapter 9. Framing analysis assists stakeholders in the policy process by revealing hidden complexity in policy discussions (Koon et al., 2016). The process of policy development is often conceptualised as an argument over facts (Shiffman, 2009, p. 609). If this were the case, it could be assumed that policy would be based on the most compelling arguments. Yet, as Rein and Schön (1996, p. 87) note, the number of facts is often quite small, while the number of interpretations of these facts is quite large. Framing analysis helps to make sense of these scenarios by making explicit what is implicit, that is, highlighting the hidden factors with which actors make sense of scenarios (Jones & Exworthy, 2014, p. 198). This step reflects the process in which GPs negotiate meaning with patients and is perhaps the most crucial part of the process. Without an understanding of the values and worldview of stakeholders, any policy process may flounder, despite a seeming agreement of ideas (Van Hulst & Yanow, 2016, p. 96). In much the same way, developing a

15 management plan for a patient without understanding the patient’s perceptions of their problems is unlikely to result in effective medicine or the desired outcome.

2.6 What is a General Practice Approach?

The process by which GPs constantly manage patient expectations and perspectives with available evidence is relevant to the policy arena. The tension between evidence for policy and stakeholder expectations is an ongoing issue for policymakers. Where medical treatment success or failure can depend on the ability of the GP to effectively negotiate between patient perspectives and evidence, the failure or otherwise of policy can depend on the ability of policy to effectively address both the concerns of stakeholders and evidence for what works best. In short, GPs understand at a micro level what policymakers face at a macro level. Therefore, general practice perspectives on problem solving may be beneficial for policymakers.

In a daily session, GPs are required to manage a wide variety of medical issues while navigating a complex social environment (Sturmberg, O’Halloran & Martin, 2010, p. 475). Diagnosing a problem is only the beginning for the GP. Each patient consulted comes with their own cultural beliefs about illness and expectations of what a doctor can and should do. Patient presentations are a product of both their current personal circumstances and the wider socio-political circumstances in which they are situated. Patient beliefs about health may not match the accepted biomedical model and their current circumstances may create the need for tactical manoeuvring on the part of the doctor to ensure the patient receives appropriate care. This involves developing an understanding of not only the medical issue at hand, but also an understanding of how the patient perceives the issue and any required treatment. It involves taking account of the person’s ability to access further treatment or follow the advice given. This can depend on numerous conditions such as education level, financial situations and level of social support. The problem for doctors is that clinical decision-making that accounts for patient perspectives sits uneasily with the positivist outlook of evidence-based medicine. Where the evidence may suggest one treatment pathway, patient factors may suggest another for which the evidence is limited. Therefore, the task of the GP is to bridge the epistemological divide between patient beliefs and perceptions and the demands of evidence-based medicine (Bensing, 2000). Evidence suggests that GPs manage this task well (Bensing, 2000).

How GPs do this is a consideration of much research (González-González et al., 2007; Ogden et al., 2004; Sans-Corrales et al., 2006). In 2001, the Kalamazoo Consensus Statement on

16 communication in medical consultations detailed seven aspects of consultations regarded as essential for good clinical communication (Makoul, 2001): establishing a relationship with the patient, allowing the patient to articulate their concerns, information gathering through both open and closed questioning, exploring the patient’s perspective, sharing information, developing a mutually agreed upon plan and allowing closure for the patient (p. 391). Clinical examination and testing are included in the sharing of information. Clinicians obviously need to weigh the evidence before considering a mutually agreed plan. These elements were regarded as the basis for clinical consultations that would lead to positive health outcomes (Mauksch, Dugdale, Dodson & Epstein, 2008, p. 1387).

A general practice approach to problem solving, therefore, considers the medical problem, treatment options and solutions within a multifaceted and contested understanding of what is real. I believe that this approach could be useful when considering a policy problem. Firstly, a GP requires an understanding of the context in which the patient is presenting with a problem. In policy, this requires an understanding of the context in which a problem is defined. Secondly, a GP would consider how the problem is perceived by the patient. In policy research, this begins with considering how the problem is defined by the relevant stakeholders. Thirdly, the GP would consider the evidence for the problem by considering clinical examination and investigation findings. If a diagnosis were readily available, GPs would also consider the evidence for potential treatments and procedures. In policy, this would involve a study of the available evidence for the problems under discussion. A GP would then consider how the patient is likely to perceive both a diagnosis and the treatment options available. How a patient understands a disease or illness is likely to impact on how they understand the need or otherwise for treatment. In policy, this would involve the policymaker attempting to understand the factors influencing the way in which stakeholders perceive the issues under discussion. Finally, the GP would present options to the patient and a mutually agreed plan would be decided on. Likewise, a policymaker could present their policy issues to stakeholders to develop a mutually acceptable policy solution. The approach taken for this research reflects this general practice process and will hopefully achieve the aims of analysing complexity, providing practical solutions and illustrating how GPs make decisions.

2.7 In Defence of the General Practice Approach

The steps in this approach demonstrate the complex reasoning involved in each general practice consultation. I consider this to be missing from much research about general practice. The

17 failure to recognise complex clinical reasoning in general practice can lead to superficial analyses of general practice performance and incorrect assumptions about what general practitioners do. General practice research has long been considered problematic. Critiques of general practice research in Australia usually highlight the low rate of research compared with other specialities (Askew, Clavarino, Glasziou & Del Mar, 2002; McAvoy, 2005). This is despite a rapid increase in research outputs since the beginning of the twenty-first century (Askew et al., 2002). Much has been written on the reluctance of GPs to enter academia and the general reluctance of non-academic practitioners to participate in clinical research. Time is often considered an important barrier, while ethical concerns and interruption of workflow were other contributing factors to GP non-participation (Messner et al., 2016).

Also of concern is the type of research considered suitable for general practice. There are ongoing concerns that traditional quantitative research has little relevance for everyday general practice, and there are increasing calls for research that provides contextualised evidence to explain ongoing issues within the health system (Martin & Sturmberg, 2005). The lack of relevance of randomised controlled trials (RCTs) for clinical situations in general practice has been frequently discussed (Askew et al., 2002). It is increasingly acknowledged that the type of evidence available through clinical trials has limited usefulness for GPs faced with undifferentiated presentations and multiple comorbidities (Jackson, Janamian, Van Weel & Dunbar, 2014; Martin & Sturmberg, 2005). Evidence often comes from other specialisations and sits awkwardly in general practice (Tilyard & Dovey, 2000). As well as recognising the difficulties associated with a general application of evidence-based medicine to general practice there is also recognition that the desire to quantify medical interactions has not led to an improvement in health outcomes (Wilensky, 2004). Further, it is becoming increasingly obvious that medical practice does not lend itself well to the rigorous scrutiny associated with pure sciences (Sturmberg et al., 2014, p. 1039). Despite this, the RCT and quantitative research still experience greater status than qualitative research in medical circles (Askew et al., 2002).

This is a problem as studies suggest that potentially more than 50% of general practice research is qualitative (Jaye, 2002; McAvoy, 2005). Qualitative research has been embraced by general practice researchers to provide contextual evidence for clinical scenarios (Jaye, 2002). Chew- Graham, May and Perry (2002) claim that qualitative research resonates with general practice because it reflects general practice processes of meaning making. Qualitative research is thought to appeal to GPs due to its perceived usefulness in untangling complex situations (Jaye,

18 2002). The predominance of qualitative research in general practice has led to criticism that general practice research does not include enough quantitative research of interventions in general practice (Heal, Veitch & Preston, 2008). This criticism strikes at the heart of general practice which is still striving to prove itself as a specialty. Having the ‘right’ type of evidence is crucial for improving the reputation of general practice (Rosemann & Szecsenyi, 2004). Unfortunately, despite the apparent potential for answering general practice questions, qualitative research is not seen as the right evidence. The privileging of quantitative research over qualitative research is demonstrated in various ways. Most tellingly is the National Health and Medical Research Council (2009) evidence hierarchy for the development of guidelines which does not include qualitative evidence. The low value placed on research that best reflects general practice adds to the undervaluing of general practice (Shapiro, 1992).

The issue here is one of ontology. Ontology refers to our worldview, the underlying assumptions that we make about the nature of reality (Lincoln, Lyndham & Guba, 2011, p. 102). Science is underpinned by a positivist ontology, the ‘belief in a single, identifiable reality’ (Lincoln et al., 2011, p. 102). Our underlying belief about the nature of reality determines our approach to research. For scientists, a positivist ontology precedes a belief in objectivity, an epistemology which demands scientific rigor with little or no interaction with the subject/s under study (Lincoln et al., 2011). Quantitative research reflects a positivist ontology. Much (but not all) qualitative research is underpinned by a constructivist ontology, where reality is considered constructed by our beliefs and experiences. Reality is therefore personal and multiple realities exist. A constructivist ontology precedes a subjective epistemology and research underpinned by this understanding is transactional in nature. Reality is co-created between the researcher and the researched. To the positivist, constructivist research appears biased and lacking in clear outcomes. To the constructivist, positivist research appears overly confident in its assertions of truth. The problem (or advantage) for medicine is that it can potentially encompass both worldviews.

Traditional biomedicine reflects a positivist epistemology; a single truth able to be dissected and analysed (Lincoln et al., 2011, p. 102). Thus, doctors are often encouraged to take an ‘objective observer’ role in research, which requires limited or no interaction with those under observation (Lincoln et al., 2011, p. 102; Wilson, 2000). Such a worldview strongly values gold standards and the RCT figures as the methodology of choice (Lincoln et al., 2011). Wilson (2000) argues that medical students are socialised into this positivist worldview. He believes

19 that this creates issues for students when faced with patients who persistently challenge this epistemology (p. 206). My experience as a GP supports this perspective.

Wilson (2000) believes that a positivist approach to medicine is inappropriate and that a constructivist worldview (in which truth is a matter of individual interpretation) would serve to help doctors navigate clinical scenarios in ways beneficial for both the patient and doctor and this belief underlies the ontological approach of this methodology. Wilson’s view is perhaps mirrored by those doctors who claim to practice the ‘art’ of medicine rather than the ‘science’ (Salmon et al., 2007, p. 272). Many GPs, myself included, would have little difficulty understanding this perspective given the daily negotiation of meaning experienced in a doctor– patient consultation. Britten, Jones, Murphy and Stacy (1995) claim that this negotiation involves making the patient’s model fit the doctor’s medical model. However, I feel that this oversimplifies a complex sense-making process between doctor and patient. Should (or could) GPs embrace constructivist epistemologies in the hope that the resulting plethora of ‘truths’ will reduce the complexity of general practice? This study hopes to challenge the traditional medical ontology by exploring this issue.

For GPs, however, both positivist and constructivist worldviews are necessary in day-to-day consultative practice, in a way that may not be so apparent in non-GP specialist practice. Shapiro (1992, p. 95) claims that qualitative research shares similar values to general practice, most notably the ‘ways of knowing’ that involve understanding the interconnectedness of patient presentations with underlying beliefs about the world. This is true as not everything in general practice fits the medical model. However, while I agree that the underlying constructivist ontology of qualitative research reflects general practice in a way that quantitative research is unlikely to achieve, I feel that GPs still value research that provides clear suggestions for appropriate diagnosis and treatment. GPs also value objective facts. For example, vaccinations work, as do antibiotics for bacterial infections. From a GP perspective, those who deny the effectiveness of these interventions are not embracing a separate (and equally valid) reality, they are simply wrong.

Some would argue that belief in both an objective reality and created realities is pure constructivism. However, this is difficult to rationalise when faced with the daily evidence of things that work. Perhaps it is possible to embrace both perspectives. This, of course, has traditionally not been regarded as possible by social scientists as a constructivist worldview is regarded as incompatible with a positivist worldview (Lincoln et al., 2011, p. 117). However,

20 as Tilyard and Dovey (2000, p. 150) note, ‘general practice cannot afford to sacrifice its practical orientation by becoming hung up on pondering the philosophic base of other disciplines’. GPs deal with presentations that can be easily categorised and presentations that will likely never fit into any medical category. My perspective is that in dealing with the former, we can, and do, try to look for evidence of best practice. In dealing with the latter type of presentation, we engage in sense-making with the patient, the result of which is unlikely to satisfy a believer in objective truth but will hopefully satisfy the patient. GPs therefore move with relative ease between epistemologies, and I reason that this is what general practice research can offer social sciences.

Although research underpinned by constructivist philosophies may not fully satisfy the GP searching for a way through a complex clinical scenario, research underpinned by positivist philosophies may be regarded with equal suspicion by oversimplifying the same scenario. Research for general practice needs to both acknowledge complexity and provide practical solutions. I would further add that research for general practice should reflect general practice perspectives on problem solving as demonstrating GP problem solving serves as a reminder of the diagnostic abilities of GPs and the undifferentiated nature of their work. Seeing their practice reflected in research may make research more palatable for GPs while helping to improve the understanding of general practice for non-clinicians. This research attempts to embrace these considerations and present a genuine general practice approach to problem solving. In this way, I hope to avoid the critique of Salmon et al. (2007, p. 272) that GP research is ‘intrinsically uninteresting’.

2.8 Positioning the Researcher in the Research

In considering these aims, it is not possible to make a claim of objectivity. For this research, I have chosen to position myself firmly within general practice—an insider looking around and out rather than in. This is a common feature of action research (Williamson, 2012). The aim of the action researcher is to be considered as a part of the group (Melrose, 2001, p. 161). Members of the group are encouraged to engage in research as a group with the researcher acting as a facilitator (Johansson & Lindhult, 2008; Marincowitz, 2003). In this way, action research is ‘participative and democratic’ (Bridges & Meyer, 2007, p. 390). Action research has been divided into the Northern and Southern schools of thought. Practitioners of the Northern school have been influenced by Kurt Lewin and promote a pragmatic approach to problem solving (Walsh, Grant & Coleman, 2008). The Southern school has been influenced

21 by Fals-Borda and Paolo Freire and focusses on critical emancipatory research (Baum, MacDougall & Smith, 2006). Action research is a form of research common in health (Bradbury & Lifvergren, 2016; Cordeiro, Rittenmeyer & Soares, 2015; Meyer & Batehup, 1997; Nichols, 1997).

This research cannot be regarded as action research as the research participants did not participate in the design and implementation of the research. However, there are certain aspects of action research that may have had some influence. An activist research praxis, per Fals- Borda (1996), involves resisting the prevailing positivist approach in research by aligning research with the needs of the community or group under discussion (Fals-Borda, 1996, p. 79). Traditionally, positivist research has tended to adopt an outsider approach which both creates an unequal relationship between the researcher and the researched and risks becoming a tool for the dominant power (Cushman, 1999, p. 332). An activist praxis seeks to diminish these effects by actively participating in the community being researched (Cushman, 1999). This concept resonates in general practice because of the perception that GPs are often ignored in the research process.

Participation in a community comes with certain responsibilities and an activist praxis implies some degree of politicisation of research. Much research is inherently political, with the capacity to be used to support or undermine political positions (Aldrich & Mooney, 2001, p. 162). However, the traditional research position of objectivity often relegates responsibility for the way this research is interpreted and used to forces outside of academia. Within an activist praxis, research is conducted for the purpose of politicisation. This form of politicisation implies a loss of objectivity, the holy grail of positivist research. Choudry (2013, p. 129) notes the tension between the responsibilities of the researcher to both research paradigms and the implied ethical commitment to the group in which the researcher is a participant. Hale (2006, p. 100) claims that these dual responsibilities are inherently compromising for activist research yet also likely to provide a deeper understanding than would be available to the objective researcher. The notion that the researcher in such situations cannot avoid partiality is a common criticism of action/activist research (Walsh et al., 2008, p. 129). Such apparently inherent bias has been regarded as the reason this research is often considered invalid (Walsh et al., 2008).

The concept of validity has proven problematic for qualitative research (Lincoln et al., 2011; McTaggart, 1998; Melrose, 2001). Internal validity, which considers the cogency of causal relationships between variables, and external validity, which considers claims of

22 generalisability for research, can be difficult to accommodate in qualitative research (Creswell, 2012, p. 303; Lincoln et al., 2011, p. 120). Again, the understanding of validity in qualitative research is affected by the ontological stance of the researcher (Creswell & Miller, 2000, p. 125). Thus, while a positivist stance would understand validity in the traditional scientific sense noted above, a constructivist stance could understand validity in terms of trustworthiness or authenticity (Creswell & Miller, 2000, p. 126). Critical theorists, however, may regard validity in terms of the outcomes of research (does the research disrupt the status quo) or in the ethical nature of the relationship between the researcher and the researched (Lincoln et al., 2011, p. 122).

For this research, I will consider the concepts of trustworthiness and authenticity. Perhaps the most quoted work on the concept of trustworthiness is that of Guba (1981). Guba (1981) developed four criteria for assessing trustworthiness—credibility, transferability, dependability, and confirmability (p. 80). Credibility is proof that the researcher has accurately represented the data and could be achieved by adopting several approaches (Shenton, 2004). These include, among others, adopting a recognised form of qualitative research, proving a good acquaintance with the community under observation and using triangulation to verify results (Shenton, 2004, p. 65). Other ways in which credibility could be achieved is through researcher reflexivity and verification of research findings by participants (Shenton, 2004).

Transferability, like the concept of external validity, where the possibility of applying results to another situation is considered, has also proven difficult for qualitative researchers. Qualitative research is by its nature situational, the production of a specific confluence of events. Most qualitative researchers will not make generalisability claims for their research (Guba, 1981). Here, the use of ‘thick’ description is considered a way in which a researcher enables the reader to determine whether the research applies to their situation (Creswell & Miller, 2000, p. 128). Dependability, the process whereby the interpretation of the data is trusted, is also problematic for qualitative research. However, Shenton (2004) considers a thick description of the research process as sufficient here. Such a process would enable an independent researcher to perform the same research again; however, unlike the concept of external validity, there is no expectation that similar results would be achieved. Confirmability is the process or processes by which the researcher ensures that the results of research are the perspectives of the researched and not those of the researcher (Shenton, 2004). If a researcher could confidently address all these issues, trustworthiness is thought to have been achieved.

23 I propose several strategies to demonstrate the trustworthiness of this research. To demonstrate credibility, I have used both deductive and inductive thematic analyses. Both are recognised qualitative research methods. For the rest of the analysis, I adopted what I hope will be recognised by GPs as a general practice approach. I also hope to demonstrate reflexivity through my own reflections on the impact of my beliefs and values on the study at hand (Altheide & Johnson, 2011, p. 591). Transferability and dependability here rely on thick description of the data.

To demonstrate trustworthiness is to demonstrate the qualitative equivalent of quantitative rigour (Schwandt, Lincoln & Guba, 2007, p. 12). Such criteria are considered able to satisfy observer questions of validity. However, Lincoln and Guba (1986) have suggested that something more is required to satisfy questions of validity among researchers with constructivist/interpretivist ontologies. They refer to this concept as ‘authenticity’. An ethical relationship with participants in the research process is central to this concept. Lincoln and Guba (1986, pp. 80–81) have described several different forms of authentication, including fairness, ontological authentication, educative authentication, catalytic authentication, and tactical authentication. Fairness describes the adequacy of representation of views with attempts to ensure that the multiple views and interpretations expressed in research are considered equally (Lincoln & Guba, 1986). Such a construct attempts to ensure that the values of some stakeholders will not be advanced to the detriment of others (p. 79). Processes to ensure fairness include informed consent, complaint mechanisms and member-checking (p. 79). Informed consent for this study was obtained in writing and verbally with both written and verbal explanations given to participants.

While fairness insists on all voices being represented equally, ontological authentication considers the ability of the research to improve awareness of the multiplicity of perspectives that exist regarding the subject being researched (Lincoln & Guba, 1986). Educative authentication builds on ontological authentication by not only acknowledging multiple viewpoints, but also encouraging participants to explore these different value systems (Lincoln & Guba, 1986). Catalytic authentication is aspirational in nature, considering how the research is likely to inspire change, while tactical authentication considers the effectiveness of such change (Lincoln & Guba, 1986). Underlying these descriptions of authentication is the assumption that the purpose of qualitative enquiry is social change. This research aims to demonstrate authenticity by improving understandings of general practice to improve primary

24 care policy. Fairness, for this research, is demonstrated using multiple sources of information to discuss the issue at hand.

I chose not to adopt the role of an ‘objective observer’ for this research, a choice that sits uneasily with the traditions of my medical upbringing. Although as a GP the ontological argument is perhaps weighted towards positivism, as a researcher it is firmly weighted towards constructivism. This may be difficult for some of my medical colleagues to comprehend, although I suspect the notion of objectivity is slowly losing its lustre (see, e.g., Lexchin, Bero, Djulbegovic & Clark, 2003). As Lincoln et al. (2011, p. 120) note, there are ‘fairly strong theoretical, philosophical, and pragmatic rationales for examining the concept of objectivity and finding it wanting’.

2.9 Conclusion

This research aims to demonstrate a GP problem-solving approach through a focus on economic waste within the Australian health system, which in turn deconstructs the concept of gatekeeping. The GP gatekeeper as the solution to wasteful practices is a common theme in discussions of gatekeeping. A general practice approach considers both objective and subjective evidence. In the process of exploring these issues I hope to demonstrate a general practice approach to problem solving to address misperceptions of the process of general practice.

25 Chapter 3: General Practice and the Australian Health System in Context

3.1 Introduction

This chapter provides contextual information about general practice and the Australian health system. Context is important when considering the factors influencing a patient’s presentation in general practice, and the same applies when considering the factors influencing a policy problem. General practice responses to policy involve a complex interaction of history and present circumstances. General practice plays a fundamental role in the Australian health system, being the first and often only contact most Australians have with the health system. Yet the story of general practice in Australia could best be described as Sisyphean. Like the Greek hero condemned to an eternity of pushing a rock uphill, general practice appears destined to confront the same challenges time and again. The issues now facing general practice have changed little since the fragmentation of medicine due to sub-specialisation began in the mid- twentieth century. Problems with training, payment and professional recognition continue to plague general practice and these issues have not been addressed despite a constant cycle of reform and reinvention. This chapter describes the current issues confronting Australian general practice and considers the contextual and historical influences on these issues.

3.2 Background

The Australian healthcare system achieves good health outcomes at reasonable expense (Hall, 2015; Organisation for Economic Cooperation and Development [OECD], 2017a; Savage, 2003). Life expectancy is increasing, outcomes from treatment of malignancy are improving and smoking is now at its lowest ever level (OECD, 2017a). Despite this, the system has been criticised for fragmentation of services, increasing inequity of health outcomes, and increasing out-of-pocket expenses (Hall, 2015). There is also concern about the sustainability of the current system and the ability to meet the needs of a growing and ageing population (Segal & Bolton, 2009). Health systems are a complex interaction between multiple stakeholders, local and global contexts, and funding sources. Further complicating the Australian health system is the federal system, which divides responsibility for healthcare between local, state, and federal levels of government and consists of a troublesome mix of public and private provision of healthcare. Finally, an ideological transformation since the introduction of universal health

26 coverage, from a welfare-state focus to neoliberal thinking, has resulted in a health system at odds with the worldview of policymakers. To understand the interplay of these features and their impact on the health system and on general practice, a brief description of each is provided.

3.3 The Australian Healthcare System and the Rise of Medicare

Understanding the Australian health system begins with understanding the impact of federalism on health policy and implementation. Although at the beginning of Federation the states had responsibility for healthcare, a High Court amendment to the Constitution after the Second World War gave the federal government power over pharmaceutical, sickness and hospital benefits. Along with being the sole collector of income tax, this move gave the federal government significant power over state health policies (France, 2008). The lasting result of these decisions has been frequent shifting of blame for health policy between federal and state governments. Following the Second World War, when other Western governments were attempting to provide universally free health coverage, the largely conservative Australian governments supported free enterprise and market-based health policy (De Voe & Short, 2003). The emerging National Health Service in the UK was regarded with mistrust. In an early High Court ruling that widened the scope of the federal government’s powers in health, the government was prohibited from drafting doctors into a national health scheme (De Voe & Short, 2003). Attempts at public health coverage mostly took the shape of subsidised private insurance schemes (De Voe & Short, 2003). These schemes often provided inadequate coverage for those insured and those who could not afford the insurance were left with no cover at all (De Voe & Short, 2003). Many doctors treated the poor for free, relying on wealthier patients to make up the difference (Liebhold, 2000). Honorary positions in public hospitals allowed doctors to treat private patients in the public system in return for treating public patients for free (Linton, 1985). Such arrangements allowed doctors to insist that only the very poorest could receive treatment in public hospitals. The power of the medical profession to block policy initiatives was seen in the demise of several government programs focussed on provision of free healthcare due to physicians’ refusal to participate in these schemes (Gray, 1996). This power was to lessen significantly when the Whitlam Labor Government came to power and introduced Medibank.

The introduction of Medibank in 1976 without the support of the medical profession was to prove pivotal for the Australian healthcare system. However, after only nine months, a change

27 of government brought about significant alterations to the original vision, the result of which was that private health insurance for paying customers was eventually reinstituted. However, Medibank formed the basis for the Medicare initiative introduced by the Labor Party when it regained power in the 1983 election. Established in 1984, Medicare provided funding to the states to ensure that state hospitals would provide free healthcare to any Australian citizen. At the same time, a schedule of medical rebates could be claimed by patients visiting GPs or other private specialists. The MBS provided subsidisation for patient expenses through a fee-for- service arrangement for private doctors. Doctors were eligible for a Medicare provider number on completing their internship and could choose to charge either the Medicare amount (effectively at no cost to the patient) or charge a higher fee after which the patient could then claim a rebate from the government (Gray, 1996). Medicare also subsidises pathology and radiology investigations and the PBS. The PBS ensures that payment for medication is capped at an agreed amount (Bais & Wyndham, 1997).

Various schemes exist to ensure that patients do not suffer hardship from out-of-pocket expenses. Concern that expenses were impacting the health of children and pensioners prompted the conservative Liberal/National Coalition to introduce a scheme in 2004 to encourage GPs to ‘bulk bill’ these groups. Bulk billing occurs when the treating doctor chooses to accept the scheduled government rebate which is signed over to the doctor by the patient. Patients are thus not subject to any out-of-pocket expense. Medicare rebates have traditionally been indexed yearly in line with inflation, though this indexation was controversially frozen in 2013, causing a deterioration of relationships between medical groups and the government (Rollins, 2016). Further controversy stems from the difference in remuneration received by non-GP specialists compared to GPs. Non-GP specialists receive a significantly higher rebate than general practitioners, often for the same procedure or consultation. The random assignment of differing rates of remuneration to GPs and non-GP specialists originated in the 1970 National Health Act and has been an ongoing source of conflict (Harris & Zwar, 2014). A further source of conflict between the government and doctors has been the provision of funding for the public hospital system.

Funding for the state hospital systems has, until recently, been agreed to in the Australian Health Care agreements; five-year agreements detailing the funding states will receive from Medicare. Funding amounts are not guaranteed, and a criticism of these agreements is that long-term healthcare plans are not possible without an assured funding base (Duckett, 2004).

28 States have full responsibility for public hospitals and must meet any shortfall with their own funding. States are required to fulfil federal government requirements to receive some funding, a process thought to stymie local initiatives (Duckett, 2004). Local initiatives are also hampered by the power division between state and federal governments as general practice falls largely under the control of the federal government. Integration between general practice and public hospitals is considered poor. Adding to this complexity is the number of stakeholders vying for recognition.

3.4 Stakeholders in the Australian Health System

Stakeholders are those affected by the implementation of certain policies within the Australian health system. That myriad stakeholders exist within the Australian health system comes as no surprise given the complexity of the multilayered system. Medical and paramedical interest groups vie with consumer groups and business interests for a slice of the A$170 billion health budget. Identification of stakeholders is important in policy as understanding the barriers and enablers of certain policies can assist policymakers with implementation planning. These stakeholders have varying interests in Medicare and varying levels of power within the system to influence policy within this area. This thesis is concerned with the RACGP, AMA and CHF. These stakeholders share an interest in general practice and primary care and have been chosen because they have, during the time under study, been advocates for general practice. The arguments these stakeholders use to advocate for general practice affects how policy makers think about general practice and how general practice is represented in the public imagination. It is, therefore, important to understand stakeholder expectations of gatekeeping to understand how the value of general practice is promoted. The CHF also provides important insights into the acceptability, for patients, of GP gatekeeping. Other stakeholders are important and will be briefly discussed however it is beyond the scope of this study to consider all stakeholders within the system.

3.4.1 Royal College of General Practitioners (RACGP)

According to the latest government data, there are currently 35,942 GPs registered in Australia (Australian Institute of Health and Welfare [AIHW], 2018a). The RACGP represents approximately 26,000 of those GPs and is thus the largest advocacy group for GPs. The college was founded in 1958 as the Australian College of General Practitioners and, in 1968, received a royal charter allowing it to add the ‘Royal’ title to its name. Originally founded to encourage

29 continuing education of GPs and provide community support, the college was forced into an advocacy role when issues of disparate remuneration between non-GP specialists and GPs came to the fore (Woodhouse, 2008). The RACGP has largely been unsuccessful in securing equal pay for GPs, although it has had some success with advocating for smaller pay rises (Woodhouse, 2020). The college has also experienced issues with its flagship training program, which was removed from its control in 2001 (Australian General Practice Training, 2010). Control of the training program has recently been returned to the college. The college was also criticised for its insufficient representation of rural and remote GPs, resulting in a split from the college to form the Australian College of Rural and Remote Medicine (ACRRM). Although the RACGP has a high level of interest in the Australian health system and Medicare, the influence of the college is perhaps best described as moderate, with small gains made but failure to achieve long-term aims.

3.4.2 Australian Medical Association (AMA)

The AMA was formed in 1962 as a result of a merger of state-based faculties of the British Medical Association. With a membership of over 43,000, the AMA advocates on issues as diverse as Medicare, private health insurance, vaccination, and same-sex marriage (AMA, 2017a). Members include doctors from all specialties. The AMA is often depicted as an organisation with political leanings towards conservatism. Indeed, in the early years, the AMA formed a corporate partnership with the Liberal/National Coalition (De Voe & Short, 2003). Although this partnership was not to last, accusations of conservative bias remain despite this being contested by the executive body (AMA, 2012). The power of the AMA received a significant blow with the introduction of Medibank, which gained parliamentary approval despite vigorous opposition from doctors (Liebhold, 2000). The AMA has also been accused of representing the interests of non-GP specialists over those of GPs and this has led to a rift between the AMA and the RACGP. Despite these issues, the AMA remains a powerful stakeholder within the Australian health system with both a high interest and high influence in policy circles.

3.4.3 Consumers Health Forum of Australia (CHF)

Health policy is often regarded as disproportionately representing the interests of medical professionals. Attempts to modify this have resulted in the establishment of consumer health groups. Multiple consumer advocacy groups exist within the Australian political sphere. Many

30 of these, such as Osteoporosis Australia or the National Heart Foundation, are concerned with advocating for improved treatment of specific diseases. The CHF claims to advocate for better health systems and processes through provision of a consumer perspective (CHF, 2018). A priority of the CHF is a universal health system and equity of access based on perceived need (CHF, 2018). Although membership is relatively small, the strength of the CHF lies in its representation across a wide variety of health issues and the presence of CHF members on over 80 health advisory panels. The forum also has a relatively large social media presence. The CHF has a high interest in the outcomes of health policy and a moderate level of power.

3.4.4 Other Stakeholders

Other stakeholders include the various specialist colleges which represent a further 14 recognised specialties in Australia (Storey, 2014). These include the Royal Australian College of Surgeons, the Australian College of Rural and Remote Medicine and the Royal Australian College of Physicians, among others. Specialty colleges are largely concerned with training programs for the specialty as much of the advocacy work for specialties is performed by the AMA. However, colleges will occasionally advocate for their members if required. There are also organisations representing the business interests of specialty college members such as the Australian Diagnostic Imaging Association (which represents the interests of private radiological services) and Australian Pathology (which represents pathology services). The Pharmacy Guild, representing pharmacists, and Medicines Australia, representing the interest of pharmaceutical companies, are both powerful advocacy organisations. Further lobby groups represent allied health practitioners and paramedical staff. Various groups have at times been identified with either of the major political parties, but ideological mixing in politics has often caused breaches between advocacy groups and politicians.

3.5 Politics and Ideology

The Australian political landscape is dominated by the Labor Party and a conservative Coalition of the Liberal and National parties. For most of the time since Federation, Australian voters have maintained strong identification with the major political parties, a factor thought to enable an ongoing de facto two-party system (Gray, 1996). However, this is changing as more, smaller parties are elected to the Senate, occasionally controlling the balance of power, and making the political landscape unpredictable. The underlying philosophies of the major parties are quite different, and these philosophies have a strong impact in the health policy

31 arena. The Liberal Party lays claim to the libertarian values of small government, minimal taxation, and encouragement of individual and private enterprise (Liberal Party of Australia, 2018). The Australian Labor Party claims the values of fairness and equality of access to basic services and a strong association with the union movement (Australian Labor Party, 2018). The Liberal/National Coalition has long supported private enterprise involvement with healthcare, while the Labor Party has fought for a system of socialised medicine to ensure that everyone has equal access to healthcare. However, traditional political economy ideological categorisations do not adequately reflect the rather centrist nature of both parties, and each party has at times introduced legislation that would appear at odds with the party’s ideological preferences. For example, the introduction of the bulk-billing incentive, encouraging essentially free healthcare, was a conservative Coalition initiative despite being largely at odds with most conservative party policies concerning individual responsibility for health care. The clash of ideology with political expedience creates an unstable health policy environment as policies based in ideology may be adjusted according to public approbation. The right to healthcare is not guaranteed by the Australian Constitution, leaving no safeguard for the continued provision of universal healthcare (Gray, 1996). However, Australians appear particularly attached to Medicare and threats to the ongoing sustainability of Medicare have proven damaging for political parties.

Both parties have been influenced by the dominant ideologies of the time and it could be argued that this is the cause of much of the precarious nature of Medicare, which is constantly challenged by government policies. Many post-war industrialised nations had embraced the welfare state with the priority of insuring minimum living standards through progressive taxation and protected market systems (Cook, 2006). However, Medicare was introduced during a time when disillusionment with socialised medicine and welfare states was rising in other countries such as the UK (Spies-Butcher, 2014). The Labor ideal of free, universal healthcare in a system of salaried doctors was essentially prohibited by the constitutional amendment against conscription of doctors into such a system and would have been unlikely given the vehement opposition to such a system from the medical community. Gray (1996) argues that social liberal ideals have strongly influenced society making universal access to healthcare broadly popular. However, Spies-Butcher (2014) credits the design of Medicare, with private doctors accessing a fee-for-service, as making an otherwise unpalatable proposition reasonably acceptable. The continuation of private health insurance and private medical care, albeit on a reduced basis, was also regarded as necessary for the continued

32 success of the Medicare system (Spies-Butcher, 2014). The existence of private health insurance alongside a free public health system is ideologically fraught, as such a system has the potential to undermine the principle of universal, equitable healthcare, creating a two-tiered system with differing levels of access to treatment (Cook, 2006).

The existence of private health insurance along with the public health system was a deliberate attempt to marry the ideals of the welfare state with those of neoliberal ideals of market superiority for regulating services. This was to become known as the ‘Third Way’ and the Australian Labor Party was considered the pioneer of this approach (Buchanan & Watson, 2001). Concern that protectionist economic policies were causing Australia to fall behind the rest of the world drove the Labor Party to adopt neoliberal free market policies (Johnson & Tonkiss, 2002). Attempts to rationalise neoliberal policies with traditional Labor Party adherence to a welfare state ideology resulted in the Third Way approach which combined these policies with a readjusted focus on social welfare. Introduction of means testing was claimed to ensure that those most in need received services while simultaneously reducing costs to the system (Johnson & Tonkiss, 2002). Welfare recipients who were able were required to train or perform voluntary work and the importance of individual effort was emphasised. Private health insurance, reducing the pressure on the public system by allowing those who could pay to do so, appeared a natural response in such a climate. The party also developed legislation to make private health insurance more competitive to stimulate the private health insurance market and remove pressure from the public system. Unlike the conservative parties, however, the Labor Party provided no financial subsidies to private health insurers (Spies- Butcher, 2014).

The free medical care available through the public hospital system, and the onus on the government to maintain funding and standards, was a constant irritant to the conservative side of politics, with frequent attempts to withdraw Medicare services, or limit availability of Medicare rebates (Spies-Butcher, 2014). The conservative Coalition of the Liberal/National parties has long embraced neoliberal ideology without the welfare considerations of the Labor Party. The hallmarks of neoliberalism—market-based policies, individual responsibility for health and privatisation—have remained central to attempts to modify the Australian health system (Rushton & Williams, 2012). However, perceived threats to Medicare have at times been electorally disastrous for the Coalition. Thus, when attempts to withdraw services have proven unpopular, the Coalition has tended to refocus on increasing private health insurance

33 coverage and have provided rebates on private health insurance levies since 1999. A Medicare surcharge was introduced for those who have not taken out private health insurance by the time they are 30 (Cook, 2006). Ideology, therefore, strongly influences the health policy space in Australia.

3.6 The Role of General Practice

The introduction of Medicare is undoubtedly the most significant federal health policy initiative of the twentieth century and Medicare currently forms the basis of the Australian health system. While the AMA vociferously opposed the creation of Medibank, the RACGP remained silent, a position considered by the government to indicate tacit agreement to the proposals (Woodhouse, 2020). Although GPs mostly work privately, Medicare funding accounts for a large proportion of GP incomes. Government estimates suggest that the cost to Medicare of GP services was approximately A$7.5 billion in the year 2016–2017 (Department of Health, 2018). General practice was responsible for approximately 37% of all Medicare billing claims (Department of Health, 2018). Funding for Medicare continues to be an area of government focus and general practice has found itself at the centre of this focus. Whether justified or not, this has resulted in a need for general practice to respond to frequent challenges from policymakers. The result is an ongoing cycle of reform and reinvention unique to the specialty of general practice.

General practice is one of the younger specialties in Australia, having received official recognition as a specialty only in 2002 (Harris & Zwar, 2014). However, general practice has long identified as a separate entity from hospital-based specialties, and organisations representing general practice existed well before official recognition of the specialty. As previously noted, the Australian College of General Practitioners was established in 1958 (Dammery, 2002a). The college was formed in response to a perception that the scope of general practice was being eroded with subspecialists taking over positions originally filled by GPs (White, 2000). Most historians agree that this began with the rise of sub-specialisation during the wars of the early twentieth century (Harris & Zwar, 2014; Storey, 2014; Woodhouse, 2008). During these wars, many GPs received further training and experience, especially in the surgical field, while medical discoveries such as the electrocardiogram and insulin in the 1920s led to an increase in the number of internal medicine specialists (Storey, 2014). Specialists of this era were GPs who had received further training in specialised disciplines. However, given the relatively low demand for such specialisation, most continued to practice as generalists.

34 Following the Second World War, medical schools began to offer specialist training, providing a direct pathway from medical school. This resulted in non-GP specialists no longer having any generalist experience. A further consequence was the gradual move of GPs away from care of their patients in hospitals towards practice in community consultation rooms. As specialist surgeons united and formed the Royal Australasian College of Surgeons, conflict arose over the ability of GPs to perform surgeries which had traditionally been within their purview (Storey, 2014). The reduction in the scope of practice of GPs can also be seen in the reduced number of GPs providing obstetric care and anaesthesia (ACRRM, 2007).

The newly formed college sought to push back against this trend and turned its attention to the education and training of GPs (Harris & Zwar, 2014). A 1964 survey found many deficiencies in the practice of GPs (Jungfer & Last, 1964). Access to further education had proven difficult for GPs who were often required to attend their nearest hospital to receive further instruction from non-GP specialists. Many GPs found this process frustrating, with non-GP specialists considered to have little idea about the problems facing GPs (Jungfer & Last, 1964). The Family Medicine Training Program, a formal educational program, was established in 1973. However, this was an entirely voluntary process (Harris & Zwar, 2014). Fifteen years later, the college was able to negotiate government recognition of the training program in the form of higher Medicare rebates for graduates of the program through the process of vocational registration (Harris & Zwar, 2014). This was considered highly problematic by those GPs who had not undertaken the program and was the cause of much division within the ranks of general practice (White, 2000). The formation of the ACRRM highlighted a further division (ACRRM, 2007).

3.6.1 Reforms

Reforms to general practice have tended to focus primarily on training and payment methods. Calls for reform have often come from within the ranks of GPs themselves. When the Australian College of General Practitioners was formed in 1958 with an invitation-only membership, the stated aim was to ensure the primacy of the GP within the health system by requiring members to undertake ongoing approved postgraduate education (Woodhouse, 2008). Six years later, Jungfer and Last (1964) published their findings which suggested that access to postgraduate training was poor and badly regarded, significant gaps in knowledge were evident and GPs were failing to fulfil the responsibility of family care which the college was eager to claim as the domain of general practice. Jungfer and Last (1964) hypothesised

35 several reasons for this situation, including work and time pressure and non-GP specialty- dictated training regarded as inappropriate for general practice. However, their primary hypothesis centred on the quality of doctors entering general practice, claiming, ‘it is possible that general practice is attracting recruits mainly among graduates who, in terms of examination performance, are of below average ability’ (p. 76). The attractiveness of the general practice career path was considered to rank much lower than that of non-GP specialty practice. Poor financial remuneration is perceived by many to reflect a lack of respect for general practice, the result of which is a persistent claim of poor morale in the specialty (Coote, 2009; Dammery, 2002b; Gandevia, 1971; Harris & Harris, 2006; Jungfer & Last, 1964; Kidd, Leeder, Shaw, Thistlethwaite & Corcoran, 2008; Marjoribanks & Lewis, 2003; Scott, 2006; Van Der Weyden, 2003).

This lack of regard for general practice, combined with a lack of a formal training program and lack of recognition as a specialty, likely contributed to the significant disparity in government rebates offered to GPs compared to specialists in the National Health Act of 1970. Again, this was associated with a decline in perceived status and morale within the profession (Gandevia, 1971). The push for specialist recognition for general practice received a further blow with the release of the Karmel Report which, although acknowledging the need for general practice to be included in medical school curricula, rejected the suggestion that general practice be regarded as a separate specialty (Kamien, 2003). In attempting to address these issues, the RACGP lobbied for and received a small amount of funding to start the Family Medicine Training Program (Trumble, 2011). The program was often criticised for a lack of articulated endpoints or exit examination (Trumble, 2011). The success of the program in improving perceptions of general practice is debatable given that some 15 years later training remained optional, morale remained low and general practice had failed to achieve specialty status (Coote, 2009). A series of further reforms followed. Training was once again considered central to these reforms but was now linked with financial incentives.

In 1989, vocational training became linked to higher Medicare rebates with the development of the Vocational Register. Vocational registration gave increased legitimacy to the college examination and increased the level of government oversight of general practice (Coote, 2009). Oversight was considered necessary as new issues had arisen and drawn government attention to general practice. Medicare, it was thought, not only did not reward GPs for their work, but also encouraged poor practices through a fee-for-service model (Coote, 2009). Poor practices

36 included over-investigation, increased referrals to non-GP specialists, a lack of preventative healthcare and an unwillingness to manage complex patients with chronic illness (Coote, 2009). A combination of training and increased payments was regarded as the solution to this issue, both by the government and the RACGP. The government further attempted to address this problem by introducing supplementary payments, beginning with the Better Practice Program in 1994 which later became the Practice Incentives Program (Harris & Zwar, 2014). These payments were offered to practices ostensibly to assist with the maintenance of the practice or purchase of new equipment in return for achieving certain goals. In 1999, the government introduced the Enhanced Primary Care Program which remunerated GPs for provision of care coordination (Harris & Zwar, 2014). To be eligible for the Practice Incentives Program payments, practices were required to achieve accreditation, which some GPs felt would increase the standing of general practice by providing evidence of quality (White, 2000). However, the scheme drew a large amount of criticism for the perceived government interference in general practice (Trumble, 2011).

Government interference was perhaps most marked in general practice training. An oversupply of urban GPs and an undersupply of rural and remote GPs led to questions regarding the appropriateness of general practice training for modern workforce requirements. To address this issue, candidates for general practice were now required to compete for training placements and a compulsory rural term was instituted (Australian General Practice Training, 2010). In 1996, the government restricted provision of Medicare provider numbers to those who had completed training. The problem persisted, however, and in 1997, the government announced a Review of General Practice Training, the findings of which resulted in training being removed from the auspices of the RACGP to a private training provider, General Practice Education and Training Ltd (Australian General Practice Training, 2010). This was a further blow to the desire for specialist recognition as all other specialist colleges were responsible for training within their specialty.

A further attempt to improve general practice saw the development of Divisions of General Practice, government-funded collaborations of GPs tasked with ongoing GP education and support as well as integration of general practice and hospital care (Harris & Zwar, 2014). Considered a way for GPs to unite for a common cause, the divisions were a relative success with over 94% of general practitioners belonging to a division by 2004. However, whether they had a positive effect on regional health outcomes is controversial (White, 2000). White (2000)

37 claimed that divisions were another way in which general practice was able to assert an identity separate from other specialties, while Harris and Zwar (2014) claimed that divisions were primarily a vehicle for the implementation of government reforms and initiatives. Most divisions were later replaced by Medicare Locals, an initiative of the Labor Government, and these were subsequently replaced by Primary Health Networks under the Liberal/National Coalition. Medicare Locals were established following the National Health and Hospitals Reform Commission report which was released in 2009 and which criticised Divisions of General Practice for having a limited scope and lacking coordination of services between and within divisions (Department of Health and Ageing, 2010). Interestingly, these were the same criticisms levelled at Medicare Locals in a 2013 review which saw the absorption of Medicare Locals into the larger Primary Health Networks (Robinson et al., 2015). As these external reforms continued, internal reinvention became a priority for general practice.

3.6.2 Reinvention

These issues have created a crisis of identity, a consistent theme in discussions of the ‘problem’ of general practice in the Australian context. Assumptions about who GPs are, what is their scope of practice and what benefits GPs bring to the health system underly debates about healthcare financing and governance. These issues haunted twentieth century attempts to establish general practice and cause ongoing problems for general practice in the twenty-first century. Criticism of general practice as a vague, ill-defined profession appeared in the Lancet in 1950 and was regarded as the stimulus for the foundation of the Royal College of General Practitioners in the UK, which subsequently led to the establishment of the RACGP (Dammery, 2002b; Trumble, 2011). General practice as a specialty stood in stark contrast to other specialties which could be defined either by the organ on which they were focussed (e.g., dermatology and cardiology) or by the age of the patient (e.g., paediatrics and geriatrics) (Lee, 2015). The diversity of practices and settings added to this problem. The skills of GPs often overlapped with those of non-GP specialists, leading to conflict (Storey, 2014). The idea of the GP as the leftover of specialty training is a common perception that has persisted in various forms in Australia over the decades (Harris & Zwar, 2014). As previously noted, this had a significant impact on remuneration for general practice, but it also affected patient understandings of the role of the GP within the health system and has impacted the use of gatekeeping to promote the value of general practice. The longstanding nature of this issue has

38 seen several different responses from general practice, the first of which attempted to define the GP as the family doctor.

The idea that the GP served as the family doctor was reinforced in the first Australian College of General Practitioners annual report by the first president, William Connolly, who understood the role of the family doctor to be that of ‘counsellor, guide and friend to his patients’ (Woodhouse, 2008). Jungfer and Last (1964, p. 78) refer to a ‘widely held belief that the general practitioner is most appropriately suited to undertake the continuing care of individuals and their families’. The understanding that GPs provided more than medical advice was also reinforced by Jungfer and Last’s (1964) disappointment in the lack of social and emotional assessment of patients carried out by the GPs they surveyed. Communication skills and whole person care were regarded as the unique contribution of general practice to health. At the same time, the term ‘Family Physician’ had been chosen by colleagues in the US to describe the specialty of general practice in an attempt to differentiate practitioners who had received training from those who had not (Lee, 2015). The Family Medical Care Education and Research Foundation was established in Australia in 1967. A Department of Family Medicine was also established at a hospital in Victoria and the name of the RACGP journal publication was changed to Australian Family Physician to reflect changes happening overseas at the time. The term was also later used in the title of the college’s training program when it was instituted in 1973. Woodhouse (2020) notes that this title appeared to appeal to the Labor Government of the time which was attempting to introduce a form of universal health insurance. More widely, however, the term ‘Family Medicine’ was criticised as being less understandable than ‘general practitioner’ and was not adopted by GPs in Australia (Lee, 2015). The framing of the GP as the family doctor saw neither an increase in the desirability of the profession or in remuneration. Graduates flowed towards specialty practice in increasing numbers and the government persisted with plans to reimburse specialists at higher rates than GPs.

Finding a place in the healthcare system was further challenged by the usurpation of traditional areas of general practice by hospital specialists. GPs traditionally had admitting rights to local hospitals and these duties were being overtaken by non-GP specialists for whom a hospital appointment was considered prestigious (Storey, 2014). When the fight here appeared to be lost, general practice sought to claim the domain of community medicine. Following the findings of the Karmel Report, general practice had been taught as a branch of community medicine along with public health (Kamien, 2003). When the federal health minister

39 established the Better Health Commission in 1985, the college submission sought to remind policymakers of the role that GPs could play in preventative healthcare within communities (RACGP, 2018). In the annual report for the RACGP Tasmanian faculty, the provost wrote:

If general practice is to survive as a fundamental part of our health system we have to be seen as being legitimately the authority on matters of health in the community. Make no mistake, this is being eroded on all sides by health bureaucracy, the paramedical profession, pharmacists, other specialties, academics, hospitals and practitioners of alternative medicine. (as cited in RACGP, 2018).

The idea of paying doctors differently to encourage more preventative healthcare was floated at the time, with Minister for Health Dr Neal Blewett promoting health maintenance organisations as a possible solution to this issue (Commonwealth of Australia, 1986). When the final report was produced, however, it favoured a greater role for public health practitioners over GPs (Commonwealth of Australia, 1986). Once again, the scope of general practice was diminished.

General practice was to have the greatest success both with recognition and remuneration in a process that began in the late 1980s. The RACGP had been working on descriptions of general practice, the purpose of which was to gain recognition and appropriate remuneration for GP work. Recognition as a medical specialty was now the focus of the college representation. The result of this work was the establishment of vocational registration in 1989. From a policy perspective, this move was calculated to ultimately save costs, with a government expectation that well-paid GPs were more likely to manage complex conditions in the community (Coote, 2009). From a GP perspective, it was hoped this move would result in the recognition that the specialty felt was late in coming. This was partially achieved. The number of new graduates considering general practice as a career did indeed seem to increase, the result of which was a government cap on the number of applicants in response to concerns about oversupply. Yet commentators continued to suggest that general practice was yet to consolidate its place within the health system and issues concerning remuneration remained unsolved (Coote, 2009). Indeed, the government continued to express concerns that current payment methods were encouraging superficial consultations and excessive referrals without the expected gain of chronic disease management (Coote, 2009). Yet again, general practice required renewal and change.

A strategic document distributed to general practices in 1992 claimed that the proposals within would allow general practice to ‘reassert its role as the cornerstone of Australia’s health care

40 system’ (General Practice Consultative Committee, 1992). The idea that general practice was central to the health system was a relatively new concept, although perhaps having its origins in the 1978 Declaration of Alma-Ata which championed primary healthcare (World Health Organization, 1978). The Declaration regarded community-based health programs as being most beneficial for positive health outcomes and general practice as a community-based health specialty was therefore well placed to fulfil this role. This was further encouraged by the work of Barbara Starfield (1994) in which the importance of primary care was emphasised. The role of primary care in creating stable health systems and the stronger performances of health systems with strong primary care sectors is now well known. However, it took some time for the benefits to become apparent (Australian General Practice Training, 2010; Kidd, 2016). Proponents of general practice sought to capitalise on this perception and general practice was now framed as the centre of a well-functioning health system (Van Der Weyden, 2003). The vision of highly skilled generalists capable of managing almost all problems at a community level has appeal for policymakers interested in decreasing costs to the health system through reducing the requirement of secondary care. Preventing the overuse of secondary care is also the purpose of a further iteration of the GP as the gatekeeper to the health system. GPs as gatekeepers provided yet another justification for general practice claiming a central place in the health system.

3.7 Conclusion

Establishing a coherent identity and place within the Australian health system has been a difficult and ongoing process for GPs and the role of the GP gatekeeper is consistent with the ongoing narrative. Reinvention and reform have focussed on remuneration and training. The identity of GPs has progressed through several iterations such as the family doctor, the community doctor, and the gatekeeper. This fluidity of identity has created difficulties for policymakers attempting to integrate general practice into successful policy. This in turn has created difficulties for GPs with regards to accessing training and remuneration. Elements of all identities persist in the modern definitions of general practice. The focus on family and community medicine, preventative healthcare and the claim of centrality to the health system as primary care physicians are all frequently referred to whenever attempts to define general practice are made (ACRRM, 2007; White, 2000). Claims of a different professional outlook and expertise in communication and holistic patient-centred care attempt to further distinguish general practice from non-GP specialties. Faced with the ongoing need to justify their existence

41 within the health system, the gatekeeper role may be the key to the identity crisis of Australian general practice. Having both potentially positive financial and health effects, serving as a gatekeeper could be a pathway to increased professional respect and remuneration for GPs. However, gatekeeping could simply be another reinvention of general practice destined to fail.

42 Chapter 4: Referrals and Research Assumptions

The requirement of referrals to access non-GP specialists is what differentiates gatekeeping from non-gatekeeping systems in most discussions regarding gatekeeping. This chapter considers what is known about referrals to secondary care. In doing so, it serves dual purposes. Firstly, it provides information about referrals, a potential proxy for gatekeeping. Exploring the nature of referrals can help illuminate researcher beliefs about gatekeeping and their expectations of general practice. Secondly, it considers the assumptions about general practice which are evident in research. I argue that research about referrals fails to provide clarity regarding GP processes and gatekeeping. Instead, it highlights researcher bias which has negatively impacted perceptions about general practice among those inclined to read academic works. I further argue that policy based on such research is likely to fail as incorrect assumptions lead to ill-conceived suggestions for action. Understanding the impact of research on general practice helps provide important contextual information for understanding the subject of gatekeeping.

4.1 Methodology

For this chapter, a literature search of the Medline, Google Scholar and ProQuest databases was performed. Articles were selected if they directly discussed the referral process from primary to secondary care. A total of 96 articles were selected for this review. Articles can be divided into articles concerning referral quality (N = 18), referral appropriateness (N = 14), variation in referrals (N = 39) and interventions to improve any of these factors (N = 16). Several studies reviewed both quality and appropriateness (N = 6) or quality and variation (N = 3). This chapter is concerned with the underlying assumptions made by researchers about general practice and the findings about referrals and gatekeeping. Therefore, it considers the claims researchers make, how these claims highlight assumptions about general practice and what evidence exists for the validity of these assumptions.

4.2 Background

Gatekeeping health systems are regarded as ways to improve both patient outcomes and cost efficiency (see Section 1.1). As the requirement of a referral from primary to secondary care is the most common definition of gatekeeping, I hypothesise that referrals can serve as a proxy

43 for gatekeeping. For example, a good referral system in which all patients requiring secondary care were referred and those not requiring secondary care were managed in general practice, would be a reflection of good gatekeeping. If this is true, assessing the appropriateness or otherwise of a referral can serve as an assessment of the standard of general practice gatekeeping. It is possible, however, that the definition of gatekeeping systems lacks complexity and this review considers whether referrals do provide a good proxy for gatekeeping. What makes a referral appropriate is unclear. Foot, Naylor and Imison (2010, p. 47) suggest that an ideal referral would be appropriately timed, appropriately directed, contain sufficient information for triage decision-making and support patient-centred decision-making about health. The referrer, therefore, has multiple responsibilities both to the patient and the health system. Those who manage these tasks well are effective gatekeepers. In most gatekeeping systems, the GP is usually the practitioner patients must see before being referred to secondary care. The GP is therefore the doctor responsible for ensuring the adequacy and appropriateness of referrals to secondary care.

Why GPs refer has been the subject of much speculation and some research. Thorsen, Hartveit and Baerheim (2012) found that GPs referred patients for second opinions, for further treatment they were unable to provide and as a way of initiating shared management of patients. Hirsch et al. (2012) described three referral patterns in their study of the German healthcare system. Here, GPs referred for therapeutic purposes (which the treating physician was unable to provide), for diagnostic uncertainty and to alleviate patient concerns (Hirsch et al., 2012, p. 577). These reasons are echoed in many studies. However, it is interesting to note that the type of study determines which reason is given priority. Studies based on review of written referrals suggest that the majority of referrals are for diagnostic and therapeutic uncertainty (Bekkelund & Salvesen, 2006; Brennan & Houssami, 2006; Gran & Nordvåg, 2000), while studies of GP perceptions of referral writing have found that GPs may also refer at patients’ request (Little et al., 2004; Olav Thorsen et al., 2012), to share the care of difficult patients (Clemence & Seamark, 2003) or if there is a lack of resources to deal with the issue at the primary care level (Jamous, Jalbert, Kalloniatis & Boon, 2014). Such findings suggest that a written referral alone may not adequately represent the context in which it is written and that behind each written referral is a story of negotiated complexity.

Rates of referral from primary care to secondary care differ from country to country. In the UK, referral rates are estimated to be around one referral in every 20 patient encounters in

44 primary care (Foot et al., 2010). Referral rates had increased by around 14% within the five years prior to release of these statistics (Foot et al., 2010). Recent Australian studies estimated that the rate of referral to a medical specialist was around 6.2 per 100 problems encountered (Britt et al., 2016, p. 109). This had increased from 5.4 per 100 problem encounters 10 years previously (p. 109). Norwegian referral rates have been estimated at 8.2 per 100 patient encounters, a rise of 0.2% over 10 years (Ringberg, Fleten, Deraas, Hasvold & Førde, 2013). These referral rates are an average across all patient encounters and specialties. Referrals to some specialties may be higher or lower than the average and change over time. For example, Britt et al. (2016, p. 109) found that referrals to psychiatrists, cardiologists and dermatologists in Australia had increased over 10 years while referrals to ophthalmologists had significantly decreased. However, from the statistics currently available, it does appear that referral rates from primary care to secondary care are increasing.

4.3 Findings

4.3.1 Referrals

Researchers make several claims about referrals. The first claim is that inappropriate referrals are an emerging problem within health systems and stems from studies considering variation in referral patterns among GPs. That variation in referrals from general practice exists is a well- recognised phenomenon (Carlsen, Aakvik & Norheim, 2008; O’Donnell, 2000; Starfield, Forrest, Nutting & von Schrader, 2002). Some GPs appear to refer to specialty care at a significantly higher or lower rate than their peers. For example, Baughan, Keatings and O’Neill’s (2011) study of urgent cancer referrals found that the highest-referring GP referred at a rate of six times that of the lowest-referring GP. Attempts to explain variation because of differences in GP and patient characteristics has had mixed results. Research focussing on patient, GP and practice characteristics have estimated that these explain about 45% of variation, leaving much variation in referral rates unexplained (O’Donnell, 2000). Montgomery et al. (2006) found that neither GP nor patient characteristics could be identified as influencing GP referral rates to a renal outpatients’ department. Forrest et al. (2006) and Ferguson et al. (2002, p. 175) also found no physician characteristics that influenced referral patterns. However, Ringberg et al. (2013) found that male GPs and trained family physicians were likely to refer less. Rossdale et al. (2007) and Ingram et al. (2009) found that female GPs were more likely to refer patients to emergency from an after-hours service. Conversely, Carlsen et al. (2008, p. 4) noted a higher referral rate for male GPs, but they did not consider this statistically

45 significant. Toleration of risk has also been noted to affect referral rates (Ingram et al., 2009), although others have found no statistically significant difference in this area (Forrest et al., 2006). Samant et al. (2007) found that rural GPs were more likely to refer cancer patients for radiation therapy, as were GPs who had hospital admitting privileges, while Ramanathan et al. (2011) found that urban GPs were more likely to refer patients with suspected cancer to a non- GP specialist. Other factors appeared to make no difference to referral rates. Xu et al. (2013) found that the threat of medical malpractice claims did not make a difference to referral patterns. Ketelaar et al. (2014) found that comparative performance indicators did not influence GP referral decision-making. The availability of primary care services also appears to have little influence on referral rates (van Dijk, Korevaar, Koopmans, de Jong & de Bakker, 2014).

Other studies have found that patient factors may have some bearing on variation in referral rates. Again, the evidence here is mixed. Van Dijk et al. (2014) found that being older and female increased the chance of a patient being referred. However, Forrest et al. (2006) found that referral was more likely if the patient was male. Comorbidities increasing the likelihood of referral does appear to be a common finding in many studies (Ferguson et al., 2002; Fleury, Bamvita, Tremblay & Lesage, 2010; Forrest et al., 2006; McGorm, Burton, Weller, Murray & Sharpe, 2010; van Dijk et al., 2014). O’Donnell (2000) noted that patients living in low socioeconomic areas appeared more likely to be referred, but McBride et al. (2010) noted that referral appeared less likely for patients from low socioeconomic areas. Despite patient characteristics appearing to have some influence on referral rates, Carlsen et al. (2008) felt that less than 40% of variation in referrals could be explained by patient characteristics. More recent studies have considered the impact of practice and GP case-mix on variation in referrals. Sullivan et al. (2005) found that patient morbidity explained a larger percentage of variability than factors such as age and gender, although two-thirds of variation was still not accounted for. Murchie et al. (2015) felt that variation between GPs and GP practices would likely be much less if case-mix were considered. Variation in referrals remains a poorly understood phenomenon, but policymakers often assume that variations in referrals are an indication that many referrals are inappropriate.

Inappropriate referrals are assumed to create inefficiencies within the system in multiple ways (Blank et al., 2014; Blundell, Clarke & Mays, 2010; Carlsen et al., 2008; Edwards, Evans & Aiking, 2011; Evans, 2009; Ferguson et al., 2002; Foot et al., 2010; Gjessing & Faresjö, 2009; Gran & Nordvåg, 2000; Jiwa, Chan She Ping-Delfos, Khadaroo & Dhaliwal, 2010; Rossdale

46 et al., 2007; Thorsen, Hartveit & Baerheim, 2013; Tiemeier et al., 2002). An obvious cost to the system of an unnecessary referral involves a patient receiving unnecessary review in the more expensive secondary care setting (Forrest, Majeed, Weiner, Carroll & Bindman, 2003; Martinussen, 2013; Ringberg et al., 2013; Xu et al., 2013). Further costs are considered to be due to the potential for the patient to receive expensive investigations and treatment that would have been less expensive if delivered in a primary care setting (Forrest et al., 2006; Hendijani & Bischak, 2016; McGorm et al., 2010). Administrative management of unnecessary referrals also increases cost to the system. Inappropriate referrals are thought to increase waiting times in emergency departments and outpatient departments, resulting in overcrowding of these departments (Bosch et al., 2014; Ingram et al., 2009; Liddy, Arbab-Tafti, Moroz & Keely, 2017; Measday, 2010; Perumal, Niederer, Raynel & McGhee, 2011; Thorsen et al., 2012; Turbitt & Freed, 2016). This places increasing strain on already overstretched resources (Aitken, Warwick & Davis, 2017; Akbari et al., 2008; Brennan & Houssami, 2006; Crimlisk et al., 2000; Hirsch et al., 2012; Little et al., 2004; Lucassen, Watson, Harcourt, Rose & O’Grady, 2001; Morgan, Jenkins & Ridsdale, 2007; Speed & Crisp, 2005; Watson, Austoker & Lucassen, 2001; Winpenny, Miani, Pitchforth, King & Roland, 2017). Inappropriate referrals are therefore considered drivers of costs within the health system and this could be perceived as a failure of gatekeeping.

Many studies have attempted to quantify the number of inappropriate referrals to outpatient and emergency departments; however, given the wide variety of subjects studied, it is difficult to provide an accurate average of these findings. Again, findings from studies that assessed appropriateness of referrals are mixed. For example, Hewitt, Yates and Williamson (2011) found that 65% of referrals to a foot and ankle surgical service were considered appropriate. However, on further evaluation of the remaining 35% considered inappropriate, it was found that only 5.2% of patients required no further treatment at all, leading to the observation that most of these could actually be considered appropriate (Hewitt et al., 2011). Walker, Ward and Richards (2007, p. 447) found that referrals to elective paediatric clinics were appropriate in 94.8% of circumstances. Grassini et al. (2008) found that 77% of colonoscopy referrals were appropriate before educational interventions. This closely mirrored the findings of Mariotti, Meggio, de Pretis and Gentilini (2008), who found that referrals for colonoscopies were appropriate 78% of the time. Measday (2010) found that 99.2% of referrals to a hospital outpatient department in Victoria, Australia, were considered appropriate. Similarly, Rosemann et al. (2006) found that referrals from GPs to consultants in Germany were

47 appropriate in 91% of cases. Ng et al. (2012, p. 500) found that GP referrals to an Australian emergency department were considered appropriate 89.7% of the time compared with 72.9% of referrals from a patient helpline. Kozomara et al. (2009, p. 1240) found that GP referrals of acute abdominal pain to an emergency department in Bosnia and Herzegovina were inappropriate 51.25% of the time. It is worth noting that it was difficult to tell what postgraduate training GPs here had received. Bosch et al. (2014) found that over 90% of patients referred to an emergency department could more appropriately have been referred to an outpatient department created to provide rapid investigation for serious problems. However, they did find that most direct referrals to the outpatient department were appropriate. Here it is important to note that most patients did require referral, but they were referred (in the author’s eyes) to an inappropriate place. Aitken et al. (2017) found that 45% of referrals from GPs to a genetic service were inappropriate. Speed and Crisp (2005) found that 58% of referrals to an orthopaedic outpatient department were appropriate, but the inappropriate referrals were deemed appropriate for a rheumatology outpatient clinic. Referrals to the rheumatology clinic were appropriate in 94% of cases (Speed & Crisp, 2005). The problem here is that studies of the appropriateness of referrals tend to suffer from a lack of a standard measurement of appropriateness. This will be further discussed in Section 4.3.3.

4.3.2 Quality of Referrals

The second claim made by researchers is that referrals are not only inappropriate, but also of poor quality. Referrals of poor quality may reflect poor gatekeeping by potentially increasing costs to the system through delays in accessing services. Quality of referrals generally refers to the content of written referrals. Information that may be considered important includes the presenting complaint, significant positive or negative examination findings, differential diagnoses, past medical and surgical history, allergies and medications (Nash, Hespe & Chalkley, 2016). Referrals for specific diseases should also contain information relevant to that particular disease, for example, a HbA1C when referring for management of issues in patients with diabetes (Syed & Large, 2003) or a CRP for patients with suspected rheumatoid conditions (Jack, Hazel & Bernatsky, 2012). Other data such as patient and referrer details including addresses and contact numbers were also regarded as important (Scully, O’Donnell, Peters, O’Connor & Lyons, 2016). Quality, like appropriateness, is difficult to define, and no two studies measured quality by the same standard. One study invited GPs to set quality standards for letter writing (Jiwa, Coleman & McKinley, 2005). Many studies used published standards

48 and guidelines, although no guidelines were the same (Jiwa, Arnet, Bulsara, Ee & Harwood, 2009; Patel, Doulias, Hoad, Lee & Alberts, 2016; Sales et al., 2015; Scully et al., 2016; Wanis, Oucharek & Groot, 2013). Many guidelines did, however, share similar features such as requiring a presenting complaint, differential diagnosis and medication list. Some used a proforma developed for the study (Azzi et al., 2014; Bodek, Ghori, Edelstein, Reed & MacFadyen, 2006; Campbell, Parsons & Loane, 2008; DeAngelis, Chambers & Hall, 2010; Gran & Nordvåg, 2000; Gulati et al., 2012; Jack et al., 2012; Measday, 2010; Raheja & Singh, 2001; Ramrakha & Giles, 2001; Syed & Large, 2003). One study used both measurements (Nash et al., 2016). Some studies clearly define how these proforma were developed. Campbell et al. (2008, p. 24) developed their checklist based on their own clinical experiences as psychiatrists. Similarly, Gulati et al. (2012, p. 24) developed a checklist based on agreement between specialist colleagues at the service being studied, although how this was done and who the specialists were is not detailed. Several other studies are equally vague. For example, Nash et al. (2016, p. 314) developed a nine-item list based on ‘professional consensus and similarity with prior studies’. Raheja and Singh (2001, p. 40) state, ‘Following discussion with professional colleagues the following basic standards for all GP letters were identified’. The qualifications of these professional colleagues are not articulated.

Poor-quality referrals are considered a significant issue by the authors of the studies. The most commonly expressed issue with poor-quality referrals is the potential to delay necessary investigation and treatment due to a lack of relevant information (Campbell et al., 2008; Gulati et al., 2012; Jack et al., 2012; Jiwa et al., 2009; Kada et al., 2007; Martinussen, 2013; Nash et al., 2016; Raheja & Singh, 2001; Ramrakha & Giles, 2001; Sales et al., 2015; Scully et al., 2016; Syed & Large, 2003). Further issues are associated with patient safety as a lack of important information such as allergies and current medications could endanger a patient’s health (Azzi et al., 2014; DeAngelis et al., 2010; Durbin et al., 2012; Harwood, Paoloni & Mitic, 2015). If this were true, this would indeed reflect poor gatekeeping. However, Jiwa and Dadich (2013) found in a systematic review that there is currently little evidence to suggest that the quality of referrals affects patient outcomes. A subsequent RCT aimed at improving referral quality found that even increasing quality made no difference to how patients were scheduled for appointments (Jiwa et al., 2014). Jiwa and Dadich (2013) note that although researchers assume poor quality will impact on patient outcomes, evidence to support this assumption is currently lacking.

49 4.3.3 The Problem of Inappropriateness

The findings of research into the referral process are mixed and fail to shed light on whether GPs are acting as gatekeepers. One reason could be the difficulty of defining appropriateness. Measuring appropriateness has proven complex, with three ways of measuring appropriateness evident from the literature. The first determines appropriateness based on whether the patient has further investigations or treatment because of a visit to either an emergency department or outpatients department. Ng et al. (2012) defined appropriateness by whether the patient was admitted to hospital, referred to an outpatient department, transferred to another hospital, died in an emergency department, or had any investigations performed. Likewise, Hewitt et al. (2011) determined appropriateness of referral to a foot and ankle outpatient department by whether a patient required further investigation or surgery. This definition of appropriateness demands high levels of sensitivity in referrals; that is, every patient who is referred must require something other than a non-GP specialist opinion if the referral is to be appropriate. However, diagnostic uncertainty is a key reason GPs refer patients to secondary care (Bekkelund & Salvesen, 2006; Clemence & Seamark, 2003; Foot et al., 2010; Hirsch et al., 2012; Olav Thorsen et al., 2012). Patients with an uncertain diagnosis may not require further investigation or treatment. This finding is equally useful for both the patient and the GP, and the referral could therefore be considered appropriate.

The second method used to define appropriateness considers guidelines as a suitable measure of referral appropriateness. Here, lack of adherence to guidelines is considered inappropriate. GPs are known to be sceptical of guidelines, with concerns about general applicability to patients, economic agendas influencing guideline development and threats to clinical autonomy (Carlsen & Norheim, 2008). While distrust of guidelines does not negate their value, other criticisms of guidelines suggest that assessing the appropriateness of referrals with guidelines is likely to be difficult. Common criticisms of guidelines include the existence of myriad guidelines making it difficult for GPs to remain up to date (Bayram, 2013), the single disease focus which ignores comorbidity (Lugtenberg, Burgers, Clancy, Westert & Schneider, 2011) and the differing advice contained in guidelines for the same condition (Bayram, 2013; Walker et al., 2007). Appropriateness of a referral may differ according to which guideline is being followed and which guideline is being used as a measurement. For example, Walker et al. (2007) found that the appropriateness of referrals was 45% if using American guidelines,

50 but 95% if using locally developed guidelines. Determining which guidelines a GP is to be judged by is therefore an important consideration.

The type of guideline is also important. Carlsen and Norheim (2008) recognise two types of guidelines, proscriptive and prescriptive. Proscriptive guidelines are used for regulatory purposes, restricting access to scarce resources. Certain situations may make the use of these guidelines in assessing appropriateness of referrals more valid than others. For example, adherence to guidelines when deciding which patients to refer for counselling for genetic cancer risk makes sense, given that the guidelines will hopefully exclude those patients for whom testing is a low yield activity while including those for whom testing will be useful. Referring outside of the guidelines is unlikely to provide value for the patient or value for money. However, genetic screening provides patients with a risk rather than a diagnosis, and it is difficult to assess what harm a patient who does not receive screening is likely to receive. Conversely, prescriptive guidelines contain recommended actions to be considered in the context of the patient’s presentation. In patients in whom there is diagnostic uncertainty, adhering closely to the guidelines has potential for important outcomes to be missed. For example, Baughan et al. (2011), in a study of referrals to an urgent cancer clinic, found that 7% of patients referred outside the guidelines were found to have cancer. The authors concluded that ‘there are other important factors, not captured within the national referral guidelines, which have prompted GPs to refer these patients urgently’ (p. e704).

This would likely come as no surprise to advocates of evidence-based medicine, for whom guidelines are created to be used in combination with clinical acumen. According to Sackett, Rosenberg, Gray, Haynes and Richardson (1996, p. 71), ‘The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research’. Guidelines are usually based on a combination of evidence from clinical trials and expert advice. They are developed to guide the practitioner but, except in circumstances described previously, are not designed to be used proscriptively. In assessing appropriateness using guidelines, researchers fall into the positivist trap of mistaking guidelines for fixed rules. Criticisms levelled at evidence-based medicine have focussed on the positivist adherence to limited types of evidence without consideration for contextual factors and individual experience (Goldenberg, 2006; Mykhalovskiy & Weir, 2004). The same criticisms could be levelled at those who use guidelines to assess appropriateness. Using guidelines as a tool of measurement transforms them into fixed rules that do not allow for appropriate clinical

51 acumen. Goldenberg (2006) notes the risk of EBM being used as a political tool and this caution could also be applied in this scenario. The adherence or otherwise to guidelines as performance indicators has potential ramifications for GPs.

Measuring appropriateness using guidelines without consideration of clinical context or the clinical acumen of doctors risks the creation of an understanding of medicine as a straightforward, linear process. The complexity of medicine is not captured in guidelines alone, yet assessment of GPs through use of such guidelines has the potential to produce a reductionist understanding of the practice of medicine and particularly the workings of general practice. This has significant implications for policy. If medicine is a truly linear process in which formulaic practice will produce uniform outcomes, it could be hypothesised that policy levers which focus on rewarding adherence and punishing non-adherence to guidelines would be effective. Yet Foot et al. (2010) caution against such understandings of general practice and note that policy based on simplistic interpretations of evidence are likely to fail. Further, such interpretations could have implications for patient outcomes. They note that ‘it may be difficult to decrease unnecessary referrals without increasing the number of patients who would benefit from a referral but are not offered one’ (Foot et al., 2010, p. 33).

The third way in which appropriateness is assessed is with non-GP specialist opinion. For example, in a study from Grassini et al. (2008), a gastroenterologist decided on the appropriateness or otherwise of the referrals. Gulati et al. (2012) used a variety of non- identified hospital-based specialists to determine the appropriateness of referrals to an outpatient clinic for back pain. Raheja and Singh (2001) also used hospital-based specialists to determine the appropriateness of referrals to a learning disability clinic. While having a non- GP specialist critique referrals for appropriateness may appear to be a valid form of assessment, this is perhaps the most problematic of all assessments of appropriateness. It is well documented that general practice differs from hospital-based and non-GP specialist practice. GPs see patients with largely undifferentiated illness, for whom a diagnosis may not be obvious and, indeed, may never be made (Shinkins & Perera, 2013). The predictive value of diagnostic tests is weakened because of the low likelihood of serious disease within the general practice population (Shinkins & Perera, 2013). Summerton (2000, p. 995) notes that ‘Within primary care, conditions will often be seen at an evolutionary stage when classical descriptions and classifications simply do not apply’. The general practice approach to a symptom, therefore, is likely to be quite different from the non-GP specialist approach to a symptom. The GP has

52 access to information concerning the context in which the patient presents, and this may have bearing on a decision to refer the patient. GPs understand the resources available in the community and any issues associated with these resources. A non-GP specialist who does not understand all these issues may regard a referral as inappropriate while a GP may consider otherwise. GP opinions, however, appear to have less validity than those of non-GP specialists and are not often utilised in research.

The lack of experience of non-GP specialists and hospital-based doctors with general practice has a further impact on the issue. Whereas GPs have experience of the hospital system throughout their training, the contact of non-GP specialists with general practice is often limited. The resources available to GPs, the training GPs receive, and the spectrum of disease reviewed in general practice are largely unknown to non-GP specialists. Perceptions of general practice may evolve from contact with patients in emergency departments and outpatient departments. However, referring patients, while an important aspect of patient care, is only a small part of what GPs do each day (Forrest et al., 2006). An understanding of general practice developed from such a limited exposure is likely to be fraught with cognitive bias. This could also be the case for researchers, whose lack of experience of general practice may limit their understanding of their own biases towards general practice and non-GP specialist care.

Definitions of appropriateness reveal underlying beliefs about medical knowledge hierarchies in which secondary care is considered superior to primary care and non-GP specialists considered superior to GPs. The first definition regards hospitals as places of active investigation and treatment. Patients not requiring active investigation or treatment are interlopers who have been referred inappropriately. Technology and technical skills are privileged over diagnostic skills, patients requiring investigations over patients who require an opinion. Non-GP specialists, in this environment, are regarded more for their technical skills than their diagnostic skills. Serious medicine, it is implied, is about investigation and treatment rather than history taking and diagnosis and non-GP specialists with these skills should not be burdened by patients lacking a need for the technology available. General practice, with a traditional focus on diagnostic skills over the use of high-cost technologies, is unlikely to be regarded highly in such an environment. General practice referrals are regarded as the cause of burdensome patient numbers, rather than the starting point for a productive journey through the health system. In this narrative, the increasing number of referrals suggests GPs have failed

53 at gatekeeping and GP perspectives on issues with referral are therefore likely to be disregarded.

The remaining two definitions privilege non-GP specialist knowledge over that of general practice. The privileging of non-GP specialist knowledge over GP knowledge feeds into existing beliefs about the value of general practice and GPs. The GP as the supplicant requiring non-GP specialist input to determine the correct path through medicine is a trope that many researchers would likely distance themselves from. However, it is given some legitimacy in the research on referrals. Suggestions that the problem is best analysed by non-GP specialists, and that solutions should generally involve non-GP specialists dictating their requirements to GPs, reflects this issue. In doing so, the potential input of GPs to the referral issue is, again, largely ignored. In all three measurements of appropriateness, the GP is positioned at the bottom of a medical hierarchy, to be rated and assessed by the ‘experts’. While the increasing costs associated with increased referrals to outpatient and emergency departments are regarded as a problem of primary care, it is considered that the solution to this problem will come from secondary care.

This may be because, according to many authors, the perceived failure on the part of GPs to provide subjectively appropriate referrals reflects an ignorant and inadequately trained profession (Azzi et al., 2014; Grassini et al., 2008; Jamous et al., 2014; Raheja & Singh, 2001; Robison, Kljakovic & Barry, 2012; Samant et al., 2007; van Dijk et al., 2014). According to Bodek et al. (2006, p. 599), ‘With GPs increasingly less exposed to medical instruction beyond registration, their ability to complete adequate diagnostic medical assessments is under increasing pressure’. Similarly, Watson, Austoker and Lucassen (2001, p. 133) note that, ‘If GPs are to act as efficient gatekeepers, it is important that they know which patients are likely to benefit from referral’. Increases in referrals to certain services is regarded as evidence that GPs do not understand how to manage particular conditions, while failure to refer to particular services is regarded as evidence that GPs do not understand the value of certain treatments (Samant et al., 2007). The claim of GP ignorance as the ultimate cause of referral issues is reinforced by extrapolations made from poor referrals. An assumption that a poor referral indicates a lack of knowledge concerning management of a problem appears frequently within the literature. A lack of inclusion of a CRP in a referral to a rheumatology clinic, for example, is taken as an indicator that GPs do not know how to manage rheumatoid conditions (Jack et al., 2012). Likewise, the absence of a HbA1C in a referral letter indicates a lack of

54 understanding of how to manage patients with diabetes (Syed & Large, 2003). Therefore, uneducated GPs, making inappropriate and poor-quality referrals, are responsible for increased and inefficient us of emergency and outpatient departments. Here, GP ignorance is the cause of gatekeeping failure.

The evidence for these assumptions remains unclear. Studies considering the quality of GP referrals did not review GP knowledge of the subject independently. Assessments of GP knowledge were based solely on the contents of the referral letter. This has implications for suggested policy approaches to the problem. Consider the suggestions advanced by researchers to solve this issue. The most common action suggested by researchers was the education of GPs. This mirrors the theme noted in Chapter 3 regarding ongoing calls for GP education. What form this education should take remains the subject of much discussion. Providing GPs with education around current guidelines was a common suggestion (Bekkelund & Salvesen, 2006; Brennan & Houssami, 2006; Hirsch et al., 2012; Hull, Jones, Tissier, Eldridge & Maclaren, 2002; Ingram et al., 2009; Johnson, Girgis, Paul & Currow, 2011; Little et al., 2004; Montgomery et al., 2006; Morgan et al., 2007; Oliveira, Barlow & Bayer, 2015; Ramanathan et al., 2011; Tan & Fitzgerald, 2014; Tiemeier et al., 2002; Turbitt & Freed, 2016). Further education in the form of peer review and discussion was considered useful (Evans, 2009; Kada et al., 2007). Some suggest collaboration between non-GP specialists and GPs in order to clarify expectations so as to improve the quality and appropriateness of referrals (Kada et al., 2007; Kozomara et al., 2009; Martinussen, 2013; Ramrakha & Giles, 2001; Rosemann et al., 2006; Walker, Haeney & Naik, 2005). What collaboration looks like in practice is unclear. For many, it involves non-GP specialists providing education for the GP. Others have suggested a multipronged approach which included educating patients and non-GP specialists as well as GPs (Perumal et al., 2011; Sales et al., 2015). Given the multiple suggestions for improvement, it is perhaps unsurprising that there is a call for more investigation of this topic (Halkett, Jiwa, Meng & Leong, 2014).

Researchers also suggested technology as a solution to poor referrals. The idea that emerging technologies will improve the referral process has existed for some time. For example, Ramrakha and Giles (2001) noted the potential for electronic templates to improve the referral process some time before electronic records became the rule rather than the exception. Suggestions for the use of information and communication technologies to improve the quality and appropriateness of referrals and, subsequently, to decrease costs to the health system take

55 the form of electronic referral templates and electronic system prompts. Templates and prompts are regarded as ways in which referring doctors can be prompted to include important information and to reconsider the necessity of the referral. Syed and Large (2003) claimed that newly emerging technologies may improve referrals by prompting for important clinical information. Similarly, Gulati et al. (2012) make the observation that electronic referral templates may aid decision-making and provide suggestions for clinical assessments. Scully et al. (2016) argue that technology should enable both more accurate transfer of information and more standardised referral information. Standardisation of referrals through provision of templates is also suggested by Jack, Hazel and Bernatsky (2012).

It should be noted that while most researchers focus on educating GPs and improving technology as ways of addressing the issue of referrals as a driver of costs within the health system, some researchers point to the complexity of health systems and the need to adopt a systems approach when addressing issues. Sørensen, Olsen and Vedsted (2009) noted that the availability of non-GP specialist care could affect the nature of referrals from primary care. Measday (2010) suggested that non-GP specialists and unit managers should also be involved in efforts to improve the referral process. The structural characteristics of healthcare systems, beyond the scope of GP influence, have been noted to affect the nature and frequency of referrals (Forrest et al., 2006). The failure of some secondary care services to meet the needs of the populations in their care has been considered an important issue affecting GP referral behaviour (Gucciardi et al., 2011). Sales et al. (2015) conclude that problems with inappropriate referrals are unlikely to be solved through educating GPs and will likely require a wider system response; however, what this response should be is not clarified. Blank et al. (2014) reach a similar conclusion but, once again, clear suggestions for system change are lacking.

Several systematic reviews have investigated suggestions to improve the referral process. The findings of these reviews have been limited by the paucity of quality evidence in this area. Faulkner et al. (2003) noted that some evidence suggested that education of GPs may result in certain behavioural changes; however, this did not appear to affect referral rates. They also found that providing in-house non-GP specialist advice appeared to decrease referral rates (Faulkner et al., 2003). Evidence for the cost effectiveness of such initiatives was lacking (Faulkner et al., 2003). Several years later, Akbari et al. (2008) also found that pre-referral discussion with a non-GP specialist may reduce referral rates; however, once again, the cost

56 effectiveness of such an initiative was not known. In this review, passive dissemination of guidelines was found to be ineffective, while structured referral forms may have had an impact (Akbari et al., 2008). The authors did warn, however, that studies of structured referral forms tended to consider only one problem at a time and that GPs were in danger of being overloaded with such forms (Akbari et al., 2008). No effect of payment methods on referral behaviour was found (Akbari et al., 2008). Blank et al. (2014) found that peer review in general practice could successfully reduce referral rates; however, adding other primary care staff was likely to increase referral rates. The authors expressed scepticism at the idea that a focus on primary care would improve the referral process. They suggested a systems perspective is needed to improve this process.

Hendrickson, Lacourciere, Zanetti, Donaldson and Larson (2016) suggested that the evidence for educational interventions was mixed, while the most effective interventions appeared to be the introduction of electronic templates. They also noted that referral management centres did not appear effective in improving the referral process (Hendrickson et al., 2016). Results from the latest review indicate that, once again, pre-referral discussions between GPs and non-GP specialists appear successful in reducing referral rates (Winpenny et al., 2017). The authors also note that some evidence exists for the positive impact on referral rates by the provision of feedback on referrals. Increasing GP access to investigations may also decrease referral rates; however, there is some evidence that this may expose patients to increased testing (Winpenny et al., 2017). Most of the studies in these reviews considered the National Health System in the UK and may not be applicable in other health systems. Overall, the evidence appears strongest for pre-referral discussions between GPs and non-GP specialists and providing electronic referral templates for specific conditions. The evidence remains patchy, however, and further research is required.

If referrals serve as a proxy for gatekeeping, the evidence for GPs acting as gatekeepers is at best mixed. The number of potentially inappropriate referrals could indicate that gatekeeping in general practice is not optimal or that GPs do not act as gatekeepers at all. However, the issues associated with researcher bias make the use of referrals as a proxy for gatekeeping problematic and has the potential to lead to poor policy as these biases feed into a dominant narrative about general practice. The discursive power of non-GP specialisation and secondary care is illustrated by the framing by researchers of negligent primary care as the cause of cost issues within the health system. Such framing in research perpetuates historical biases of non-

57 GP specialist superiority in medicine and the value of secondary and tertiary care over primary care. This results in expenses due to secondary care being perceived as inevitable but justified, while expenses due to general practice are not. General practice and GP agency are limited to passive absorption of non-GP specialist knowledge and non-GP specialist perspectives on the health system. While blamed for causing increased costs, GPs are rarely consulted for their opinions regarding solutions for this problem.

Understanding the problem as a failure of general practice gatekeeping caused by ignorant GPs is likely to cause difficulties with policy implementation. Policy solutions that target specific groups with clear expectations of outcomes are popular for policymakers. The relative simplicity of reducing inappropriate and poor-quality referrals by targeting GPs for education could appeal to policymakers. If such solutions fail, having a target group to blame is also beneficial. If educating GPs fails to decrease costs to outpatient and emergency departments, the blame could reasonably be placed on a recalcitrant general practice that is unwilling to learn. That general practice is recalcitrant and in need of education has already been suggested by the research detailed above. The nature of the problem then becomes cyclical. The complex nature of the referral process requires multiple solutions at multiple levels of the health system, but this is difficult to recognise if general practice remains the punching bag for issues within the health system. Recognising the value of general practice by seeking GP opinions and developing an understanding of the way general practice operates would be a more reasonable starting point. Determining enablers and barriers for and to the general practice gatekeeping role would help to identify areas for targeted policy in this area. Targeting general practice to reduce costs and overcrowding of outpatients will fail unless this is done.

4.4 Conclusion

The purpose here is not to argue that inappropriate referrals are not an issue; rather, it is to note that claims made about problems with referrals are heavily influenced by assumptions about general practice competency and non-GP specialist expertise. In this way, it reflects a tension in GP consultations caused by GP assumptions about our patients. For example, GPs may expect a patient to react to news in a certain way, either because it is how the GP would react or based on underlying assumptions about a person’s age, race, gender or social class, among others factors. GPs struggle to recognise these assumptions and this may have a significant impact on the GP–patient relationship and interaction. Likewise, assumptions in research could potentially lead to researchers asking the wrong questions, using inappropriate measurements,

58 or promoting ineffective solutions. A well-educated GP may still refer ‘inappropriately’ because of time or patient pressures, or for other reasons which may be unfathomable to research subjected to a non-GP specialist-centric gaze. The general practice perspective on referrals would assist with developing a deeper understanding of the referral process, and this in turn could lead to the development of effective solutions. Such solutions are likely to be more complex than those currently proffered. This may appeal less to policymakers and, therefore, it is important for research to communicate such complexity in a way that is understandable for policymakers.

59 Chapter 5: Policymaker Claims

Chapters 5–7 provide contextual information regarding the policy environment in which decisions about general practice are made. How policymakers perceive general practice and the role of the GP in the health system influences the types of policies which are promoted. This in turn impacts how GPs’ practice. To understand the context, it is important to understand the claims that various stakeholders make about the health system. Defining problems and apportioning blame or responsibility creates a context that serves as justification for policy initiatives. The claims stakeholders make indicate who they believe is responsible for both problems and solutions within the health system. As noted in Chapter two, this step involves a deductive analysis of media releases considering the situational, attributional and action claims made by various stakeholders. This chapter considers the claims made by the three health ministers concerning what is wrong with the health system, who is responsible and what should be done. The health ministers discussed here were those who served in the role during the time under discussion. The media releases were available on the health ministers’ websites. These media releases contain information that health ministers wish the public to hear and provide arguments for various policy directions concerning primary care. By analysing these claims, it is possible to determine if policymakers have an expectation of general practice gatekeeping and, if so, what type of gatekeeping is expected. This chapter considers the impact of these claims on general practice. In doing so, it reflects the history taking aspect of a general practice consultation: What does the patient think the problem is? As history taking moves us towards a diagnosis, so understanding these claims can move us towards a diagnosis for problems within the health system.

5.1 Mr Dutton

5.1.1 Situational Claims

The three health ministers from September 2013 until July 2017 were Peter Dutton, Sussan Ley and Greg Hunt. Mr Dutton took over the health ministry from the previous Labor Government when the Coalition came to power in September 2013. He had previously been the shadow minister for health and aging when in Opposition. Mr Dutton served as health minister from September 2013 until December 2014, when he took over the Ministry for Immigration and Border Protection. During his tenure as health minister, Mr Dutton made

60 several claims about the current situation in healthcare. Healthcare, from Mr Dutton’s perspective, was in urgent need of review. According to Mr Dutton, ‘the public know not all is well with our health system’ (Department of Health, 2014b). Mr Dutton’s primary argument was that Medicare, in its current form, was unsustainable. He claimed that ‘Medicare is at risk of collapsing under its own weight, undermining its ability to go on providing quality healthcare to those most in need’ (Department of Health, 2014j). Arguments for the lack of sustainability of Medicare centred on economic forecasts that predicted issues caused by increasing costs to the system and a diminishing tax base. This situation was, according to Mr Dutton, the result of an ageing population and an increase in the number of people with chronic diseases.

Mr Dutton referred to the overall cost of healthcare, asking his audience to consider how the government could sustain such spending in the future:

Total health expenditure was $140.2 billion in 2011-12 or 9.5 percent of GDP [gross domestic product]. That puts our country fractionally above the OECD average health spend, but with better outcomes compared to many comparable populations. The trouble is given the cost growth across Government outlays in health, nobody can give an assurance of sustainability over the coming decades. (Department of Health, 2013)

Ten years ago we were spending $8 billion on the MBS; today it’s $19 billion, and in ten years’ time, it’s forecast to be more than $38 billion. (Department of Health, 2014c)

The rise of certain diseases was considered proof that costs in healthcare were likely to spiral out of control. Obesity, diabetes and dementia all posed a future threat to the health system, according to Mr Dutton (Department of Health, 2014b, 2014c). While the rise of these diseases was attributed, in part, to an ageing population, Mr Dutton felt it was important to also emphasise that, ‘These diseases, including cardiovascular disease, diabetes, cancer and mental health issues, are heavily linked to lifestyle decisions’ (Department of Health, 2014m). Adding to the cost of healthcare was an increase in the amount of medical technology used to combat diseases. New medical technologies affect everything from investigations through to treatment. Mr Dutton was particularly concerned with what he referred to as ‘genomic testing’. Genomic testing, according to Mr Dutton, results in medical therapy targeted to the individual and such technology, while desirable, will significantly increase future healthcare costs (Department of Health, 2014h, 2014n). Paradoxically, when talking to researchers, Mr Dutton did admit that such individualised medicine could result in cost savings (Department of Health, 2014c). Other

61 new discoveries such as life-saving medicine could also potentially increase costs to the health system (Department of Health, 2014k). Mr Dutton made multiple claims that new medical technologies have already increased costs to the health system (Department of Health, 2013, 2014k, 2014l, 2014m). He did not clarify what these technologies were or what he envisioned them to be in the future.

5.1.2 Attributional Claims

The increased costs of healthcare were, according to Mr Dutton, exacerbated by irresponsible use of resources. Mr Dutton began his tenure by claiming that increased spending was the result of the Federalist separation of powers between states and the central government, which created a system that was ‘riddled with inefficiency and waste’ (Department of Health, 2014b). This wastage and inefficiency was most obvious, to Mr Dutton, in states governed by the Labor Party (Department of Health, 2014b). However, federalism and recalcitrant state governments were not the only entities accorded blame by Mr Dutton. He increasingly claimed that certain patients accessed medical care at rates significantly higher than the rest of the population: ‘Indeed, a small group of patients account for a large proportion of MBS expenditure. In 2012- 13, ten percent of patients accounted for 46 per cent of MBS expenditure’ (Department of Health, 2014b).

According to Mr Dutton, patients overused the health system. One of Mr Dutton’s most controversial claims was that Australians visit a doctor an average of 11 times a year (Department of Health, 2014a). This statistic, from a report by the Productivity Commission, was derived from the number of Medicare item numbers billed within one year. Although many argued that Medicare item billing could not be directly correlated with doctor’s visits, as several Medicare item numbers could be billed in one session, Mr Dutton claimed that such arguments were missing the point. A visit to the doctor resulting in the billing of multiple Medicare item numbers was, according to Mr Dutton, only the start of an expensive process that could not be sustained by Medicare:

Now, when you go to a doctor, it’s not just about the item number that the taxpayer provides support to. It’s also about the pathology that’s ordered, it’s about the diagnostics, the X-ray or the CT scan that’s ordered. It’s about the referral off to the specialist, it’s about the script, so there’s expense under the PBS. It is not just about a $31 or a $36 level B or A consultation or whatever it might be with a GP. (Department of Health, 2014a)

62 General practice, for Mr Dutton, made the system expensive by instigating a cascade of expensive medical episodes. GPs, according to Mr Dutton, were leaving the gate wide open.

However, patients, according to Mr Dutton were the instigators of this effect. This message was reinforced throughout Mr Dutton’s tenure and was to become a primary argument for his health policy initiatives. Patients were problematic for Mr Dutton. Not only were patients embracing lifestyles that increased their chance of developing a chronic disease and increasing Medicare spending through inappropriate use of the health system, they were also placing unrealistic demands on the health system. The expectation of ‘free’ healthcare, according to Mr Dutton, further cemented his claim that patients were to blame for problems in the system (Department of Health, 2014e). Thus, Mr Dutton felt that patients overused services and exacerbated sustainability issues through adopting poor lifestyle choices and through high expectations of government supplied services. GPs failed to do anything to prevent this. Mr Dutton felt that the practice of ‘six-minute medicine’, an epithet describing short, basic consultations, was rife within the system. Such practices would lead to poor care for patients with complex health issues, resulting in increased admissions to hospital and increasing costs to the health system (Department of Health, 2014f, 2014o). That six-minute medicine existed was considered indisputable by Mr Dutton, though he did not provide evidence for these practices or the current effect of such practices on the health system. The government’s responsibility was to discourage such behaviour to reduce reliance on government-funded medical care. This idea is repeated in various forms throughout Mr Dutton’s media releases (Department of Health, 2014a, 2014c, 2014e, 2014f, 2014l, 2014o, 2014p). Mr Dutton’s ideal health system, it seemed, functioned best sans patients.

5.1.3 Action Claims

In response to perceived patient demands, Mr Dutton sought to encourage an environment in which people could contribute to their own healthcare (Department of Health, 2013). To do this, according to Mr Dutton, the government must promote a situation in which the private sector can thrive. Such a situation would, according to Mr Dutton, provide healthcare more cheaply and efficiently than currently provided: ‘The commercial sector may be able to provide a better service to Australians at a lower cost to the taxpayer, if so patients, doctors and the Government will reap the benefits and savings’ (Department of Health, 2014g).

63 Therefore, in Mr Dutton’s view, the responsibility of policymakers is to encourage individual responsibility for health while providing an appropriately unfettered market in which private healthcare can flourish. In such an environment, the fees charged by GPs would more appropriately reflect market demand and reduce the need for government subsidisation. Market forces would regulate irresponsible behaviour, resulting in less inappropriate use of the system.

Solutions, for Mr Dutton, involve economic reform of the primary care sector (Department of Health, 2014b). The first solution Mr Dutton offered involved instituting a co-payment for general practice and pathology services (Department of Health, 2014e). This solution addressed the perceived problems of increased government spending on health and overuse of the health system by patients: ‘By asking people to make a modest $7 contribution to the cost of their own healthcare, we’re in a much stronger position to safeguard our health system from collapsing under its own weight’ (Department of Health, 2014m). Addressing concerns that a co-payment would adversely affect vulnerable segments of the Australian population, Mr Dutton suggested that the implementation of a co-payment would be at the discretion of GPs (Department of Health, 2014l).

Doctors, according to Mr Dutton, were best placed to deal with the issue of troublesome patients. As Mr Dutton was primarily concerned with the impact of patients on health costs, this meant requiring doctors to implement government cost-saving measures. GPs, to whom Mr Dutton’s policy initiatives applied, were considered responsible for policing Mr Dutton’s idea that ‘people should take more responsibility for their own health, including through modest contributions to the cost of care’ (Department of Health, 2014k). Mr Dutton justified his claim by suggesting, ‘what doctors charge their patients is ultimately a matter for doctors and not government’ (Department of Health, 2014j). Paradoxically, he noted that the government was interested in policies that would ensure doctors considered the impact on poor and vulnerable patients when making decisions about fees: ‘doctors will have incentives to charge only the low gap, and only up to a cap of 10 services per year’ (Department of Health, 2014k).

This policy initiative was unpopular with stakeholders, and Mr Dutton added a second incentive to make the proposition more appealing. This incentive took the form of the establishment of the Medical Research Fund. According to Mr Dutton, the research fund would not only place Australia at the forefront of medical research but would also address another situational claim of Mr Dutton’s, that of the rising incidence of chronic disease. This policy

64 initiative would be funded by the co-payment initiative with $5 from every co-payment being co-opted into the fund (Department of Health, 2014p). It appears Mr Dutton hoped to persuade stakeholders that the introduction of the co-payment model was not an attempt by the government to cut spending. This was unsuccessful and the co-payment model was eventually discarded because of lack of support in the Senate. The Medical Future Fund was to remain with funding coming from other sources.

The third initiative introduced by Mr Dutton involved cutting the Medicare rebate for GPs. Mr Dutton offered this initiative as a solution to the problem of doctors failing to spend time with their patients: ‘The Medicare rebate paid to doctors for some consultations will be reduced by $5 and the troublesome issue of “six-minute medicine” will be addressed by encouraging doctors to spend more time with patients’ (Department of Health, 2014o). The rebate was dependent on the amount of time doctors spent with their patients and targeted a frequent criticism of the Medicare system that Medicare encouraged quantity of service over quality of service (Department of Health, 2014o). In effect, this would have forced most GPs to charge a co-payment and was considered even less acceptable than Mr Dutton’s co-payment initiative. This initiative was eventually scrapped by Mr Dutton’s successor without any attempt at implementation.

Although these three initiatives were the hallmarks of Mr Dutton’s time in charge of the health portfolio, Mr Dutton did suggest other solutions that were not enacted in policy during his tenure. Mr Dutton was a strong proponent of private health insurance involvement within the primary care sector (Department of Health, 2014b). Introducing private health insurance into the primary care arena was Mr Dutton’s solution to the perception that a visit to the GP instigated a chain of more expensive health events. According to Mr Dutton, primary care needed reworking:

That will mean as I said before the election and indeed since, the Government is totally committed to re-building general practice. No hair brained super clinic programs for marginal seats thought up on a Government jet, but providing greater support to our primary care network. (Department of Health, 2014c)

It is important to note that Mr Dutton’s solutions to the ‘problem’ of general practice focussed largely on economic initiatives, despite attempts to claim to the contrary (Department of Health, 2014c). Yet none of his economic initiatives involved increasing funding of the health system. Indeed, Mr Dutton was generally opposed to increasing government spending on

65 health: ‘Putting more money into the system was largely successful until the Rudd/Gillard years, where in some areas more money actually produced poorer results and patient outcomes. But this shouldn’t come as any surprise’ (Department of Health, 2014b).

In summary, while Mr Dutton regarded health as something better managed by the private sector, he felt that the government should use punitive policy levers to alter the behaviour of wasteful patients and doctors within the public system. These punitive measures against doctors indicate a belief that doctors were, in part, responsible for managing costs within the system. Therefore, it can be concluded that Mr Dutton did have some expectation of GPs serving as financial or closed-gate gatekeepers within the system.

5.2 Ms Ley

5.2.1 Situational Claims

The Coalition found itself faced with the impossibility of passing Mr Dutton’s initiatives in the Senate. Mr Dutton’s successor, Sussan Ley, had to contend with the ongoing task of convincing sceptical stakeholders of the merits of Mr Dutton’s claims. She initially persevered with the same situational claims about the health system. She agreed that the rise of chronic conditions, an ageing population and improvements in medical technology were placing pressures on the system: ‘Last year’s Intergenerational Report highlights the challenges facing us now: an ageing population; a shrinking workforce as a proportion of the population; and technology that comes with a price tag’ (Department of Health, 2016i).

Indeed, according to Ms Ley, ‘managing chronic conditions and their impact on Australia’s health system remained one of our greatest health challenges’ (Department of Health, 2016b). These factors were again considered proof of the claim by both ministers that ‘Medicare will not survive in the long term without changes to make it sustainable’ (Department of Health, 2015e).

As with her predecessor, Ms Ley also offered as proof of her claim the apparent rising costs of the system:

It is essential to review chronic disease health care because the use of Chronic Disease Management Medicare items had grown by almost 17 per cent in 2013-14 compared to the previous year, with over $587.6 million worth of benefits paid for over 5.6 million services. (Department of Health, 2015m)

66 Ms Ley repeated Mr Dutton’s claim that the practice of six-minute medicine was common and supported by the current Medicare system (Department of Health, 2015e). However, Ms Ley made a new situational claim which was to become the basis of most of her policy initiatives. The system, Ms Ley claimed, was inefficient. Inefficiency was to become the keyword for most of Ms Ley’s initiatives within the health portfolio. Inefficiencies within the system were caused by several factors other than the practice of six-minute medicine. The MBS, with over 5,700 item numbers, was considered inefficient because it potentially subsidised outdated procedures and treatments (Department of Health, 2015o). Inefficiencies existed in the ability of patients with chronic diseases to access several different GPs for their medical care (Department of Health, 2016f). Doctors ordering inappropriate tests or performing unnecessary procedures, either through a lack of knowledge or for fraudulent purposes, were inefficient, as was poor information transfer between medical practitioners (Department of Health, 2015n). A lack of a unified electronic health record, Ms Ley claimed, was a barrier to more efficient patient management (Department of Health, 2015n, 2016e).

Proof offered by Ms Ley for her assertions came from several government reports including the Australia Health report, the Professional Services Review report and the 2015 Intergenerational Report published by the Treasury (Department of Health, 2015k, 2015n, 2016b). Ms Ley also cited anecdotal evidence from discussions she undertook with members of the medical profession and members of the public (Department of Health, 2015a, 2015c). She further cited an Australian current affairs program to justify several policy initiatives focussing on waste within the health system: ‘Last night’s sobering Four Corners episode exposing a real – not perceived – waste in health spending demonstrates the need for a peaceful and constructive national conversation about how to fix the system for health professionals and patients’ (Department of Health, 2015d). Ms Ley’s claims about the current situation in health added to Mr Dutton’s claims that the system was unsustainable by not only reinforcing the idea of spiralling expenses, but also introducing the idea of inefficiencies within the system adding to these expenses.

5.2.2 Attributional Claims

Ms Ley’s attributional claims were to change throughout her tenure. Like Mr Dutton, Ms Ley noted the poor choices many individuals had made which resulted in increased costs to the system (Department of Health, 2015f). She also supported the claim that patient demand was contributing to spiralling costs in the system (Department of Health, 2016i). Like Mr Dutton,

67 Ms Ley felt that patients should be encouraged to contribute to health costs (Department of Health, 2015i). However, as Ms Ley’s claims changed from unsustainable spending to claims of inefficiencies within the system, so too did her claims about who was to blame for problems within the health system. For Ms Ley, the cause of the problem was now doctors. Doctors, according to Ms Ley, were inefficient because of failure to practice evidence-based medicine. Another way in which doctors were to blame was considered more deliberate. Ms Ley claimed that abuse of Medicare by GPs wasted health system resources through the misuse of chronic disease item numbers (Department of Health, 2015a). However, she did note that ‘ambiguities in the rules made it harder to track and prove non-compliance by “less scrupulous” practitioners and that these referrals to the PSR may be just the “tip of the iceberg” ’ (Department of Health, 2015k).

Having established that doctors were more to blame for rising health costs and inefficiencies within the system than patients, Ms Ley was now able to claim that doctors shared a responsibility for addressing the issue. Like Mr Dutton, her solution was a punitive approach and took the form of maintaining the Medicare freeze until health reforms had been implemented (Department of Health, 2016c). However, she was also eager to assure doctors that their input was considered necessary for policy development (Department of Health, 2015h). The role of the government, according to Ms Ley, was one of facilitation of policy development through discussions with experts. The government would facilitate doctors and patients working together to contribute to policy. However, it would also create an environment that fostered efficient practice from doctors. For example, ‘The Government is committed to encouraging doctors to spend more time with patients where appropriate, whilst ensuring that taxpayers’ dollars are effectively targeted’ (Department of Health, 2015e).

5.2.3 Action Claims

These ideas influenced Ms Ley’s claims about solutions. The policies that defined Ms Ley’s tenure were the Healthier Medicare initiative, the My Health Record electronic record and the Health Care Homes initiative. The Healthier Medicare initiative consisted of three parts: a review of the MBS, a review of primary healthcare and attempts to tighten Medicare compliance. The My Health Record was a continuation of the previous government’s attempts to create a unified electronic health record. The Health Care Homes initiative encourages patients with chronic illnesses to have their care managed by one GP or practice. The solutions offered by Ms Ley addressed the claims of inefficiency Ms Ley had made about the system:

68 the MBS Review, combined with rolling out the Turnbull Government’s Medicare Health Care Homes and the revamped My Health Record, aimed to cut down on low- value use of MBS items through a greater focus on integrated care and stronger rules, education and compliance. (Department of Health, 2016g)

These initiatives also offered solutions for other problems noted within the system. The Health Care Homes initiative offered an alternative model of care for patients with chronic diseases to ensure that care was restricted to one or two doctors. This addressed perceived problems associated with patients attending multiple doctors (Department of Health, 2015l). The payment model associated with Health Care Homes addressed issues associated with fee-for- service and six-minute medicine (Department of Health, 2016h).

The MBS Review aimed to address the problem of inefficient and outdated medical practices. However, reducing government spending on health was not, according to Ms Ley, the aim of the review:

I’ve made it very clear to all of the clinicians that I’ve spoken to that this is an exercise primarily for the patients and the doctors, because it does make sense to have an MBS that really reflects what I call the right care, at the right place, at the right time for patients. (Department of Health, 2015g)

Ms Ley claimed that stakeholder support for the MBS Review was high (Department of Health, 2016g). Evidence for this was based on an online survey of over 2,000 doctors and discussions in various stakeholder forums (Department of Health, 2016g). Such support provided legitimacy to Ms Ley’s efforts to reform the system. However, there appears to have been less support for efforts to improve Medicare compliance, the third part of the Healthier Medicare initiative. How this was to be done remained undefined, and efforts to reform the Professional Services Review are currently stagnating. The same could be said of the review into primary care. Ms Ley’s primary care review resulted in the publication of a report from the Primary Health Care Advisory Committee. This report focussed on different models of remuneration for the work of GPs, but the recommendations of this report have not yet been adopted. Ms Ley’s targeting of GPs for reform indicates that she, like Mr Dutton, had an expectation that they would act in the interests of the health system. That costs were increasing indicated that GPs were not acting in ways which met these expectations. Her claims also reflected an understanding that well-practised medicine would be inexpensive.

69 5.3 Mr Hunt

5.3.1 Situational Claims

Ms Ley’s removal from the portfolio left several initiatives inadequately implemented, especially the need for closer attention to compliance with Medicare. Perhaps because these reforms were met with some resistance from the medical profession, there appears to have been little ongoing political will to implement these changes. Her successor, Mr Hunt, sought a more conciliatory approach with medical stakeholders, and it is likely that policy with potential punitive consequences for doctors fell (briefly) out of favour. Mr Hunt inherited the health portfolio six months after an election in which the Coalition Government’s majority in the House of Representatives had been severely diminished. As previously noted, analysis of the government’s near loss suggested that perceived threats to Medicare were a significant consideration for voters opting for the opposition. This is perhaps one reason that Mr Hunt’s situational claims differed somewhat from those of his predecessors. Nevertheless, Mr Hunt did agree with his colleagues in two areas. The first area of agreement was that chronic diseases are on the rise in Australia. Like his colleagues, Mr Hunt felt the current system was not supportive of good chronic disease management (Department of Health, 2017t). The second area of agreement concerned that of Medicare spending. Mr Hunt noted, like his predecessors, that costs to Medicare were increasing (Department of Health, 2017h). However, unlike his predecessors, Mr Hunt did not regard this as problematic, claiming this was evidence that the government had a continued interest in supporting Medicare. Here, Mr Hunt differed markedly from his predecessors by claiming that Medicare required more, rather than less, funding. Sustainability, according to Mr Hunt, ‘means actually the ability to reinvest into the system’ (Department of Health, 2017s).

Mr Hunt claimed that ‘Universal access to medical services, public hospitals and medicines through Medicare and the Pharmaceutical Benefits Scheme is something that Australians hold dear’ (Department of Health, 2017q). Such access, according to Mr Hunt, was increasingly at risk because of a rise in the cost of living which made private billing of healthcare a prohibitive expense for many patients (Department of Health, 2017l). Success of government policy in this area, according to the Mr Hunt, could be measured by the number of patients being bulk billed for consultations with their GPs (Department of Health, 2017k). Indeed, Mr Hunt felt that bulk billing rates could be used as a proxy measurement for access to healthcare. According to Mr Hunt, better access to medical care was the result of greater levels of bulk billing, which in turn

70 was the result of better government funding (Department of Health, 2017h). Mr Hunt also claimed that access to medical care was being impeded by a drop in the number of Australians taking out private health insurance (Department of Health, 2017g). Private health insurance alongside bulk billing were considered the basis of a sound health system, and threats to private health insurance were regarded as threats to the overall sustainability of Medicare (Department of Health, 2017m). Therefore, Mr Hunt, while agreeing with his predecessors that chronic diseases were on the rise and causing increased costs to the health system, did not agree that this was the primary issue; rather, he regarded the possibility of diminished access to healthcare because of potential falls in bulk billing and reduction in the number of patients with private health insurance as the prevalent problem in health.

5.3.2 Attributional Claims

In apportioning blame and responsibility, Mr Hunt avoided his predecessors’ choices of patients and doctors. Instead, he chose to focus on state governments and the Opposition (Labor) as the cause of problems within the healthcare system. According to Mr Hunt, the cause of spiralling costs within the system was public hospitals redirecting private health insurance funds:

The important thing, the biggest single component of that is the fact that some of the state governments are pulling private health patients into the public hospitals, increasing the cost of the premiums by taking those funds and adding the cost, and also putting pressure on public patient waiting lists. (Department of Health, 2017a)

This was at a time when most states were controlled by Labor governments. According to Mr Hunt, the Labor Party also shared the blame for the Coalition being unable to pass legislation: ‘We tried to do it with savings; those savings were just wildly and widely blocked by the Labor Party’ (Department of Health, 2017j).

This is not to suggest that Mr Hunt ignored the role of individuals in creating the healthcare crisis. Like his predecessors, Mr Hunt did suggest that patient lifestyle choices were perhaps to blame for the rise of chronic diseases. However, this rhetoric was not towards the forefront of Mr Hunt’s attributional claims. Neither were attributional claims about the role of doctors in causing the situation in healthcare foremost for Greg Hunt. Like Ms Ley, Mr Hunt was eager to promote a consultatory approach to health policy (Department of Health, 2017b). For Mr Hunt, stakeholder support was a primary consideration and claims of stakeholder agreement are a regular feature of Mr Hunt’s rhetoric (Department of Health, 2017b, 2017d, 2017e, 2017k,

71 2017o). Ultimately, Mr Hunt felt that the responsibility for solving the problems within the healthcare system rested within himself and his department (Department of Health, 2017k). In this way, Mr Hunt differed from his predecessors; rather than considering GPs as responsible for costs within the system, Mr Hunt barely considered them at all.

5.3.3 Action Claims

The solutions that Mr Hunt offered also differed from those of his predecessors. The first point of difference concerned funding. Unlike Mr Dutton and Ms Ley, for whom an appearance of good economic stewardship was important, Mr Hunt’s solutions sought to demonstrate the government’s interest in ensuring access to healthcare. Mr Hunt began by announcing a long- term health strategy involving ‘four pillars’:

What’s my task? My task is to deliver a long-term National Health Plan, out to 2030, and that’s about strengthening Medicare and working with the doctors, strengthening the hospital systems and working with the states and the private health insurers, third, the pillar is mental health and preventive health, for the first time elevated to the top level, and fourth, strengthening medical research in Australia. (Department of Health, 2017r)

Strengthening Medicare involved, for Mr Hunt, an economic investment rather than the search for efficiency (which had defined Ms Ley’s tenure). Responding to the perceived public criticism that the Coalition Government was not interested in healthcare, Mr Hunt was quick to reassure the public that this was not the case: ‘Our commitment to Medicare is rock-solid with funding increasing each and every year from $23 billion in 2017-18, to $24 billion, to $26 billion to $28 billion in 2020-21’ (Department of Health, 2017p). Mr Hunt announced an end to the freeze on Medicare rebates (Department of Health, 2017k), although this was to be done incrementally in a way that was to save the government large amounts of money, rather than abolished immediately (Department of Health, 2017i). Mr Hunt was clear that the government remained committed to promoting ‘sustainability’ of the system through careful spending.

Mr Hunt was also anxious to promote individual responsibility for health through various education programs. These included the ‘Take back your Life’ campaign, aimed at users of methamphetamine, and the ‘Girls make your move’ campaign, aimed at encouraging women to participate in sporting activities for fitness (Department of Health, 2017f, 2017o). These programs, Mr Hunt felt, were more likely to be effective in improving health than other suggested policy solutions. Mr Hunt was especially eager to note that the government preferred

72 solutions promoting individual choice over those seeking to address the issue with a more legislative approach. This was noticeable in his disagreement with a proposed ‘sugar tax’ aimed at increasing taxes on high-calorie foods to provide a purchase disincentive: ‘Obesity and poor diets are complex public health issue with multiple contributing factors, requiring a community-wide approach as well as behaviour change by individuals. We do not support a new tax on sugar to address this issue’ (Department of Health, 2017u). The interference of government in such a way was not considered in alignment with Coalition policies. Mr Hunt’s claims were notable for their lack of attention to primary care. While using GP bulk billing rates to promote a perception that the government was interested in health, he did not regard GPs as instruments for controlling waste.

5.4 Discussion

Mr Dutton Ms Ley Mr Hunt Situational Claims Health care costs are Health care costs are Health is an important spiralling out of spiralling out of government concern control control Costs are increasing Chronic diseases are The system is Chronic diseases are on the rise inefficient on the rise Chronic diseases are on the rise Attributional claims Costs are due to Costs are due to State Labor people ageing, new inefficient use of the governments are technologies and system by doctors contributing to patients abusing the inefficiency in the system system Poor decisions by patients are causing lifestyle diseases Action Claims Solutions include Solutions include Solutions include patients paying for changing payment increased funding of more of their health methods, an electronic Medicare and care health record, an MBS encouraging the Doctors moderating review and greater uptake of private who will pay and who accountability in health insurance will not Medicare Encouraging individuals to take responsibility for lifestyle choices.

Summary of Claims

Several areas of agreement exist regarding the situational claims of policymakers. That healthcare is increasingly expensive and an increasing burden for the government is generally agreed on. However, there is little agreement on the cause of increased costs. Mr Dutton

73 believed that increased costs were the result of new technologies, an ageing population, the rise of chronic diseases, increasing patient expectations, and patient and doctor abuse of the system. While Ms Ley shared these beliefs, she considered inefficient use of the system by doctors as the most prominent cause of increasing expenses. Mr Hunt, while acknowledging the increasing cost of medical care, was less likely to regard this as a problem and saw health as a positive investment for the government. The rise of chronic diseases was regarded by all three policymakers as having an important impact on the system, and all three considered this rise to be the result of poor individual lifestyle choices. Patients, however, were not the only people to blame for increasing costs. Doctors, especially GPs, were seen to increase costs by universally bulk billing, by failing to spend time with patients, through a lack of knowledge of evidence-based medicine or through abuse of the Medicare system. The fee-for-service model of Medicare was also considered blameworthy. Other system issues, such as the impact of federalism on policy implementation, were also considered problematic.

The solutions suggested by policymakers focussed on payment models, market manipulation and modification of stakeholder behaviour. Several policy measures contained elements of all three. The co-payment model suggested by Mr Dutton, for example, considered a different payment model intended to impact patient demand for medical care, exerting a perhaps punitive effect on patients (who were perceived as overusing the system) and GPs (who allowed such overuse). The Health Care Homes model promoted by Ms Ley offered a payment model that reduced reliance on fee-for-service and encouraged doctors to spend more time with patients. The MBS Review also considered new methods of payment and attempts to alter doctor behaviour through modification of the existing system. Mr Hunt’s push for private coverage of primary care again introduced a potential modification of existing payment models and an attempt to increase the role of the private sector in health. While policymaker claims are similar in content, the acceptability of their claims among other stakeholders was variable. There are several reasons for this. The first is because stakeholders were variably convinced by the evidence used to justify these claims. This is discussed further in Chapter 6. The second reason was the way each policymaker framed their arguments, which impacted on the acceptability of these arguments. This is discussed further in Chapter 9.

5.5 Conclusion

The claims made here have implications for the concept of gatekeeping in general practice. Mr Dutton noted that a visit to the GP could result in a cascade of health costs, Ms Ley insinuated

74 poor practice within primary care, and Mr Hunt disregarded the contribution of general practice altogether. For Mr Dutton and Ms Ley, these claims indicated an expectation that the role of the GP should, in part, be to constrain costs within the system. This indicates an expectation of general practice engaging in financial or closed-gate gatekeeping and the perception that general practice is failing to fulfil this expectation. This is akin to the concept of “closed gatekeeping” detailed in Chapter 1 where GPs are expected to restrict access to more expensive care. However, general practice was and remains, for the most part, ignored by policymakers. Mr Hunt especially appears to have little expectations of GPs, and the role of general practice in the health system remains vague for Mr Hunt. Claims from all three policymakers diminish the value of general practice, and this is reflected in the framing of issues discussed in Chapter 9. How this compares to how other stakeholders and GPs perceive their role in the health system is discussed in Chapters 6 and 7 respectively.

75 Chapter 6: Advocacy Stakeholder Claims

Policymakers have an advantage over other stakeholders within the health system in their ability to develop and implement policy. However, ignoring other stakeholder claims can lead to policy failure as powerful stakeholders influence policy acceptability. This influence can wax and wane, dependent on the ability of stakeholders to promote their agenda. The plausibility of stakeholder claims determines the acceptability of their claims among other stakeholders. Stakeholders must battle with each other and policymakers for supremacy of their arguments and ideas. This chapter considers the situational, attributional and action claims made by three advocacy stakeholders with the Australian health system and considers areas of agreement and disagreement with policymakers. In doing so, this chapter provides further contextual history, important for assisting with the diagnosis of issues concerning gatekeeping.

6.1 Australian Medical Association (AMA)

6.1.1 Situational Claims

During the period under discussion, the AMA often found itself at odds with policymaker claims. Most notably, the AMA contradicted the government claim that the health system was unsustainable. To prove sustainability, then-President of the AMA Associate Professor Brian Owler referenced a Commonwealth Fund report ranking health systems in 11 developed nations (Davis, Stremikis, Squires & Schoen, 2014). This report, according to the AMA, demonstrated that ‘Australia has a sustainable health system with the lowest level of expenditure on health as a percentage of GDP [gross domestic product] across all the countries included in the comparison’ (AMA, 2014e). The AMA further disputed the government assertion that costs to the system are spiralling out of control. The AMA noted that the ‘Health budget is 16.13 per cent of the total Commonwealth budget, which is down from 18.22 per cent in 2007-08’ (AMA, 2014f). Also disputed was the government claim that future health costs are rising fast, with the AMA noting that the predicted growth in expenditure had failed to occur (AMA, 2015h). Although costs associated with general practice are increasing, the AMA notes GP output has also increased significantly over the last decade, resulting in greater value for money (AMA, 2016b). General practice, the AMA claims, is the most efficient part of the current health system (AMA, 2014f, 2015b, 2017c).

76 This is not to suggest that the AMA does not recognise problems within the system. The AMA appears to have tacitly conceded that there may be inefficiencies within the system regarding investigation ordering and prescribing. This concession can be seen in the release of a position statement regarding the use of health resources (AMA, 2016f). The AMA also agrees with the government about the rise of chronic diseases increasing pressure on the health system (AMA, 2015a). The rise of these diseases, the AMA claimed, placed significant pressure on general practice, however, not because of the management issues highlighted by the government. In 2016, then-President of the AMA Dr Michael Gannon claimed that ‘BEACH [Better evaluation of care and health] data shows that GPs are managing more chronic disease. But they are under substantial financial pressure due to the Medicare freeze and a range of other funding cuts’ (AMA, 2016d). The AMA concurred with the government claim that the MBS is currently not equipped to adequately manage the rise of chronic diseases (AMA, 2016h). However, for the AMA, this is because of the freeze on indexation rather than the government claims of outdated and unproven procedures (AMA, 2016h). The AMA also does not regard the concept of six- minute medicine as problematic for chronic disease management:

experienced family doctors were often able to provide quality care in less than 10 minutes, and the focus needed to be on the outcome of care, not how long it takes. Often, a GP will spend seven, eight or nine minutes with one patient, and then need to spend 17, 18 or 19 minutes with the next patient … Providing quality care is not about watching the clock. It is about giving each patient all the attention and care they need. It is about what care is provided, not how long it takes. (AMA, 2015f)

What is problematic for the AMA was rising out-of-pocket costs for patients. Citing the Commonwealth Fund report, the AMA notes that Australia performs poorly compared to other countries regarding patient expenses (AMA, 2014e). This, the AMA claimed, was contrary to the spirit of Medicare and the wishes of the Australian public who strongly supported Medicare and the ability of citizens to access health services without fear of cost (AMA, 2015k). Agreeing with Mr Hunt, the AMA claimed that ‘people want confidence that they can see their doctor or get to a hospital when they or their loved ones need health advice or care’ (AMA, 2016i). Unlike Mr Hunt, however, the AMA was quick to lay blame for out-of-pocket costs squarely on the government.

6.1.2 Attributional Claims

Problems in the health system, according to the AMA, were the fault of poor government policy (AMA, 2015g). The AMA agreed with Ms Ley that there was inefficiency within the health

77 system. However, inefficiency, from the AMA’s perspective, is the direct result of poor government funding limiting the ability of medical practitioners to practice in an efficient manner: ‘The Government is simply ripping $1.3 billion out of primary health, and trying to dress it up as some sort of measure to support quality care’ (AMA, 2015f). For the AMA, patients and doctors shared no part of the blame for problems within the health system, with one notable exception. The AMA did alter its attributional claims briefly during the tenure of Ms Ley. During this time, the AMA were open to the suggestion that doctors may have a role to play in managing inefficiencies within the system (AMA, 2015d).

The MBS Review posed a conundrum for the AMA. It claimed to be based on evidence-based principles, a concept fully supported by the AMA, yet some of the surrounding rhetoric was accusatory, with claims of doctors’ unprofessional conduct (Department of Health, 2015d). The AMA was quick to defend members, claiming that the problem was due both to an ageing system and a lack of government understanding of patient care. Although this disagreement caused a rift in the working relationship between Ms Ley and the AMA, it appears to have been somewhat resolved with the AMA cautiously observing the following year, ‘Individual doctors affect health care expenditure through their clinical recommendations and decisions regarding patient treatment’ (AMA, 2016f). Such an acknowledgement appears to support Ms Ley’s argument that doctors are responsible for economic waste within the health system; however, the AMA argument focussed more on the role doctors should have in reform of the system (AMA, 2016d).

The doctors who have the most significant contribution to improving waste and efficiency are, according to the AMA, GPs (AMA, 2015j). General practice, according to the AMA, is not only responsible for efficient care but is the solution to problems of economic waste and inefficiency. According to the AMA, quality general practice is efficient. The government role, according to the AMA, is to establish policies that support the ability of doctors to practice quality medicine. This support takes the form of providing adequate funding for GPs to do their job (AMA, 2015e). Therefore, according to the AMA, while policymakers are to blame for the current situation in healthcare, doctors, especially GPs, have a role to play in providing solutions for these problems. Thus, policymakers should follow the advice of doctors regarding policy and commit to the necessary funding required for successful policy implementation.

78 6.1.3 Action Claims

These understandings of roles and responsibilities are echoed in the action claims made by the AMA. The AMA’s understanding of the government’s role as the funder of healthcare is reflected in the claim that removing the freeze on Medicare rebates was a basic requirement for improving healthcare (AMA, 2015c). Lifting the freeze would show government support for primary care and general practice, something the AMA felt was decidedly absent from previous government policies (AMA, 2015i). Investment in general practice was a key responsibility of the government and, again, this investment was largely considered a matter of funding. How such funding was to be used was considered the domain of doctors. The AMA, for example, supported the idea of introducing a co-payment, but considered the government’s co-payment initiative as deficient. The AMA proposed their own version of a co-payment that they considered fairer to patients and doctors (AMA, 2014b). Likewise, the AMA provided conditional support for the Health Care Homes concept with the caveat that such an initiative needed to be suitably funded (AMA, 2016d). The AMA was reluctant to support any initiative that threatened the current fee-for-service remuneration which doctors were receiving for patient care (AMA, 2015b). However, as the government moved towards trialling the Health Care Homes concept, the AMA strove to ensure the centrality of doctors to both formation and implementation of the policy (AMA, 2016g).

While the Health Care Home initiative was the subject of much criticism, some government suggestions did receive support. The introduction of private health insurance into the primary care sector, suggested by both Mr Dutton and Mr Hunt, was encouraged by the AMA (AMA, 2016c). The AMA was also supportive of programs to help educate patients and encourage people to live healthier lifestyles (AMA, 2016a). The Choosing Wisely initiative received qualified support with the AMA, which stressed the importance of practitioner contribution to the initiative (AMA, 2015d). Where policymakers appeared to accept medical practitioner input and agree to funding demands, the AMA was likely to be supportive. However, unsurprisingly, initiatives that appeared to have been developed without practitioner input, cut funding, or appeared critical of doctors were met with opposition. While refusing to allow doctors to take the blame for rising health costs (which, according to the AMA, did not exist), the AMA did offer up general practice as a cost-effective solution for any economic woes. However, this was not in the form of gatekeeping necessarily; rather, it hinged on the touted efficiency of the specialty.

79 6.2 Royal Australian College of General Practitioners (RACGP)

6.2.1 Situational Claims

The RACGP shared some situational claims with the AMA. Like the AMA, the RACGP disputed government claims that the cost of health was spiralling out of control. Citing a report by the AIHW, the RACGP claimed that health spending had slowed (RACGP, 2014d). In 2016, the RACGP claimed the previous budget overestimated spending by A$177 million (RACGP, 2016f). In 2017, it noted that spending in health had remained stable, leading the RACGP to claim that ‘there is no budget emergency in health’ (RACGP, 2016b). Conversely, like the AMA, the RACGP noted that out-of-pocket expenses for patients were increasing (RACGP, 2014d). The same claim was again made in 2017 (RACGP, 2017b). At the same time, the RACGP disputed government claims that increases in bulk billing statistics are an indicator of how many patients access free medical care. According to the RACGP, the rise in out-of-pocket expenses prove that bulk billing rates are a flawed measure of access to the health system (RACGP, 2016h).

The problems in health, according to the RACGP, were poor communication and lack of service coordination. Challenges to coordination of patient care arise, according to the RACGP, from antiquated systems that fail to recognise new ways of practising medicine and new ways in which patients interact with healthcare (RACGP, 2016i). Like policymakers, the RACGP regarded chronic disease as a pressing issue for the current health system. The rise of chronic diseases along with an ageing population was perceived as the most challenging scenario for general practice. Preventing chronic diseases through provision of preventative healthcare was an important task of general practice, and the current MBS was not regarded as supportive of such care (RACGP, 2015h). The RACGP claims that this lack of support has:

led to fragmentation of care, which results in the duplication of patient services and testing, unnecessary care, loss of coordination, and poorer health outcomes for patients. The consequences are unnecessary hospital presentations and admissions, costing our health system more than $3 billion per year. (RACGP, 2015h)

The RACGP repeated the historical claim noted in Chapter 3 that remuneration was affecting the way GPs practised medicine. The current fee-for-service model was considered problematic because it encouraged high-volume throughput while discouraging care that requires greater time investment (RACGP, 2015h). However, fee-for-service was still regarded as an efficient payment method for acute presentations in general practice (RACGP, 2016d).

80 6.2.2 Attributional Claims

Despite claims regarding the negative impact of fee-for-service, government policies attempting to alter the way general practice visits are paid for have been strongly opposed by the RACGP. These include the co-payment model and Medicare rebate reduction proposed by Mr Dutton and the ongoing Medicare freeze. Unlike the AMA, the RACGP was reluctant to support any co-payment model (RACGP, 2014e). Likewise, reduction of the Medicare rebate was also opposed by the RACGP, with concerns it would adversely affect patient care and inadvertently increase costs to the system (RACGP, 2013). The RACGP considered reduced government spending on primary care and general practice to be the exact opposite of what was required to improve healthcare. According to the RACGP, reductions in spending were likely to worsen access to health and, in turn, worsen health outcomes (RACGP, 2015g). This was most noticeable regarding the Medicare rebate freeze (RACGP, 2016e), but this was not the only instance of government spending with which the RACGP took issue. Government spending on hospitals while ignoring primary care was an area the RACGP found increasingly frustrating (RACGP, 2017d). Spending on general practice was, according to the RACGP, the most appropriate way to reduce government outlay and improve health outcomes (RACGP, 2017d). Thus, the RACGP shares with the AMA the claim that the government is largely to blame for the current crises within the Australian health system due to lack of support for general practice.

6.2.3 Action Claims

Another example of the lack of support for general practice, according to the RACGP, is the amount of administrative regulations associated with new or suggested models of care (RACGP, 2014a). This is contrary to the RACGP’s perception of the government’s role within the health system. According to the RACGP, the government should be providing an environment in which unpaid paperwork is minimised. As part of this role, the government should be considering models of care more suited to the Australian health situation (RACGP, 2016g). Developing new models of care requires collaboration with stakeholders, the most important of which, from the RACGP’s perspective, is general practice. According to the RACGP, GPs can offer policymakers insight into the health system that is not available from other sources. These insights, according to the RACGP, will result in savings for the government (RACGP, 2015a, 2017a).

81 The RACGP was not opposed to every government initiative. The RACGP supported the Health Care Home concept, although, like the AMA, the funding of Health Care Homes and practitioner input were considered key to success of the program. The RACGP regarded the Health Care Homes concept as one that would address many of the problems causing increased costs to the health system (RACGP, 2015h). The RACGP also supported the MBS Review. This support came with the caveat that new item numbers that better reflected the care provided by GPs be created and outdated item numbers retired (RACGP, 2015b). While the RACGP was open to different methods of funding for GP services, the sanctity of fee-for-service remained paramount, and the RACGP was quick to reassure members that any policy supported by the RACGP would retain this feature (RACGP, 2016d).

The RACGP was also supportive of technological efforts to address problems within the health system. Support for adding item numbers for telehealth was strong (RACGP, 2015e), as was support for linked electronic health records to address problems associated with a lack of information. Such a system would greatly benefit GPs and patients (RACGP, 2015a). This support was conditional, as the RACGP was concerned that GPs would be expected to implement the system without sufficient training or remuneration (RACGP, 2015a). A final area in which the RACGP advocated was that of preventative healthcare. The RACGP regarded government policy initiatives as more concerned with the treatment and management of chronic diseases than the prevention of such diseases (RACGP, 2016f). The RACGP considered general practice as the ultimate provider of preventative healthcare. Therefore, failure to invest in general practice was a failure to invest in preventative care.

In return for adequate funding and the opportunity to participate in policy formation, GPs were willing to take on the responsibility of monitoring and managing waste within the health system: ‘every part of the health system can make cost efficiencies and we as GPs will take ownership and governance within our specialty’ (RACGP, 2016c). However, this should not be taken to mean that general practice accepts responsibility for much of the current waste within the health system (RACGP, 2016c). Indeed, inefficiencies within general practice are considered by the RACGP to be minor, and the government is considered responsible for policing these inefficiencies (RACGP, 2014b). Overall, despite the challenges of the twenty- first century and the issues associated with the MBS, the RACGP considers general practice to be the most efficient part of the Australian health system (RACGP, 2015a, 2015c, 2015e, 2017e).

82 Proof of this efficiency is offered in several ways. GPs are efficient because, ‘Collectively, GPs see more than 80% of Australians each year but general practice spending represents less than eight per cent of the overall Government healthcare budget’ (RACGP, 2015b). General practice, according to the RACGP, offers more for less (RACGP, 2015e). However, efficiency is not only measurable by the amount of spending or the number of patients seen. General practice is also efficient because it prevents ill health, saves lives, and reduces costs to the hospital system (RACGP, 2016a). The reason for this efficiency and overall benefit to the health system is because, ‘GPs are the gatekeepers to cost-efficient health care and prevent the unnecessary escalation of care and coordinate patient management, at a fraction of the cost of hospital and other specialist services’ (RACGP, 2016c). Therefore, GPs contribute to the health system by helping to rein in inappropriate spending. According to the RACGP, GPs are willing and able to be gatekeepers within the health system, by overseeing and preventing cost escalations due to inappropriate care. In this sense, the RACGP version of gatekeeping reflects more the “closed” understanding of gatekeeping desired by policymakers.

6.3 Consumers Health Forum of Australia (CHF)

6.3.1 Situational Claims

The CHF shared areas of agreement with both the AMA and RACGP regarding situational claims. Like the AMA and RACGP, the CHF was concerned about the rise of out-of-pocket costs for patients: ‘In a country which is thought to have a universal health system, out of pocket health costs represent a barrier for many of those most in need and often least able to speak out, particularly the chronically ill’ (CHF, 2014m). Citing the Australia’s Health 2014 report, the CHF claimed that up to 30% of all expenditure on primary care in Australia comes directly from patients’ pockets (CHF, 2014o). The CHF also cited evidence from the Commonwealth Fund report, noting that Australia has high out-of-pocket expenditure compared with other developed countries (CHF, 2014o). These out-of-pocket expenses result in a situation where patients are delaying seeking healthcare because of cost (CHF, 2014j). For some, the CHF claims, this also means, ‘having to decide whether they pay their food and power bills, or pay for the health care they need’ (CHF, 2013). This situation, according to the CHF, is undermining an essential expectation of the Australian public, that of universal access to healthcare for Australian citizens.

83 According to the CHF, ‘The principle of universal access that Medicare is meant to underwrite is becoming frayed’ (CHF, 2016n). This is important because, ‘Universal access to health care is what Australians value’ (CHF, 2015g) and, ‘Australians support our national health system because it is meant to provide access to quality care and medicines to everybody regardless of income’ (CHF, 2016d). This is a claim frequently repeated in CHF media releases (CHF, 2016c, 2016e, 2016i, 2016j). However, such a situational claim is difficult to prove. The CHF used as evidence the fact that ‘Health is a top issue in this federal election because most Australians are concerned about the future health care of themselves and their children’ (CHF, 2016n). While Medicare and universal access to healthcare are considered the foundation of the Australian health system, the CHF does recognise that issues exist within the system. Mirroring the claims of policymakers, the CHF considers the rise of chronic disease and the inadequacy of Medicare for dealing with this as important factors currently impacting the health system.

While the rise of chronic diseases may be contributing to the rise in healthcare costs, the CHF joined the AMA and RACGP in questioning the extent of cost rises. Citing a report from the Parliamentary Budget Office, the CHF downplayed government rhetoric about spiralling costs:

The projections released by the Parliamentary Budget Office show that Medicare and PBS spending is projected to slow below real GDP [gross domestic product] growth. That challenges the alarmist rhetoric of the National Commission of Audit finding that health care spending represented the Commonwealth’s single largest long-run fiscal challenge. (CHF, 2014g)

The CHF and government do agree that the rise of chronic diseases necessitates a review of Medicare as the status quo does not adequately manage these illnesses (CHF, 2016h). A key claim about Medicare, supporting the claim by Ms Ley, is that the current system of reimbursement through Medicare item numbers supports care of acute illnesses rather than chronic disease (CHF, 2015d). Fee-for-service payments in Medicare are not the only issue. The CHF supports Ms Ley’s assertion that waste in Medicare is due to inefficiencies within the system. These inefficiencies occur when unnecessary investigations are ordered or unnecessary procedures are performed (CHF, 2015c, 2015k, 2016g). They also occur when there is duplication of investigations because of poor communication between various segments of the health sector: ‘A common plea we hear from consumers is the frustration they feel when they have to repeat key information about themselves, their medical history, and current medications to multiple clinicians’ (CHF, 2015h).

84 However, duplication of investigations is only one aspect of poor communication within the health system. Poor communication results from poor information and communication technology infrastructure that does not allow clinicians to communicate the required information rapidly. Poor communication contributes to the occurrence of duplicate programs addressing the same issue, an overall result of the division of responsibilities between federal and state governments, a source of significant waste within the system (CHF, 2017c). In summary, therefore, the CHF claimed that Australians want a universal healthcare system and that this is being threatened by government policies that raise out-of-pocket expenses, especially for patients with chronic disease. Further, inefficiencies in the system exist because the system is outdated, communication is poor, and federal and state health initiatives often overlap, leading to a lack of service coordination.

6.3.2 Attributional Claims

The CHF, AMA and RACGP are mostly in agreement that the government is to blame for most, if not all, the current problems within the health system. Throughout the period under discussion, September 2013 until July 2017, the CHF made various claims about government practices and how these affected system issues. During Mr Dutton’s tenure, the CHF claimed that government policies were likely to increase costs to the system by discouraging patients from seeking help early in their illnesses (CHF, 2014o). Not only were consumers being discouraged from seeing their GP, GPs themselves were being placed in untenable positions by government policies. These policies, from the CHF perspective, placed undue pressure on GPs to police consumer spending in health (CHF, 2014a). Mr Dutton was not the only health minister to come under fire for their treatment of GPs and primary care; both Ms Ley and Mr Hunt were criticised for their apparent disregard for the importance of primary healthcare (CHF, 2016j, 2017a). The idea that government manipulation of GPs could lead to difficult adverse consequences was a concern: ‘We are concerned that many GPs will have to start charging patients a gap fee and once they have systems installed to charge extra, it will be difficult to reverse’ (CHF, 2016j).

The CHF believed the government was contributing to inefficiencies through support of redundant programs. Wasteful practices, according to the CHF, were being ignored while the government pursued its detrimental policy agenda (CHF, 2015j). Here, GPs shared some of the blame, with the CHF noting the wide variation in patient treatment as a potential signifier of poor medical management (CHF, 2014b). The studied differences in GPs’ prescribing and

85 management practices were an indication for the CHF that evidence-based medicine was not always being followed, leading to further inefficiencies within the system.

Another way in which the government was to blame for problems within the health system was its failure to consult with consumers about policy. The CHF felt that the government valued the opinions of doctors over those of patients (CHF, 2015a). The CHF saw the role of the consumer not as a passive recipient of medical care but as an active contributor to health policy (CHF, 2016m). According to the CHF, consumers needed to take a more active role in their own healthcare, a position that appeared to support the attributional claims of policymakers (CHF, 2015b). GPs also have a role in this situation by educating patients about their health (CHF, 2014k). GPs are perceived as the leaders of primary care initiatives and, according to the CHF, should take a leading role in addressing problems within the Australian health system (CHF, 2015f, 2016j). These roles, however, involve different responsibilities to those of gatekeeping. A role of the government in addressing issues within the health system is, according to the CHF, facilitating consumer and general practice cooperation to develop improved models of care that support doctors and patients (CHF, 2016p). Such facilitation would ensure the government also fulfils what the CHF regards as the government’s primary role within the Australian health system, maintaining access to universal healthcare (CHF, 2014i).

6.3.3 Action Claims

With a focus on maintaining access to universal healthcare, it is unsurprising that the CHF has much to say about the funding models presented by various stakeholders. These action claims contend that various models are likely to improve health system outcomes. The CHF strongly opposes the fee-for-service model currently in place and promoted by the AMA and, to a lesser extent, by the RACGP. The CHF opposed fee-for-service on the basis that it encouraged quantity over quality (CHF, 2014c). Other funding models proposed by policymakers were also strongly opposed. The co-payment model suggested by Mr Dutton received abundant criticism from the CHF: ‘The Medicare co-payment is a barnacle on the Budget which would drag the health system down and needs to be scraped off completely’ (CHF, 2014e). The CHF argued that co-payments would create barriers for patients trying to access healthcare (CHF, 2014i), increase costs to the system by increasing emergency department presentations (CHF, 2014a), increase the administrative burden on doctors (CHF, 2015e) and worsen health

86 outcomes (CHF, 2014i). Co-payments also threatened the idea of universal access (CHF, 2014e).

The CHF regarded other policies as equally threatening to universal healthcare. The freeze on the Medicare rebate and the attempt by Mr Dutton to reduce the Medicare rebate were heavily criticised by the CHF for this reason (CHF, 2014a, 2014j, 2016j). The CHF also opposed suggestions to introduce private health insurance into the primary care arena, claiming that this would erode universal access to healthcare by creating inequality of access (CHF, 2014d, 2014l). The CHF was alone in criticising private health insurance for primary care, with the AMA and RACGP being open to the initiative. While the CHF opposed many of the funding models suggested by policymakers and other stakeholders, it was open to the concept of the Health Care Home. The CHF felt that this concept could address issues associated with access to healthcare for people suffering from chronic diseases (CHF, 2016a). Support for this concept was reportedly high among CHF members (CHF, 2015f). However, like the AMA and RACGP, the CHF were sceptical of the levels of funding the government was willing to invest in the initiative (CHF, 2016j, 2016n). Investment in primary care was a key action claim for the CHF which suggested that such investment would improve health and help to restrain spending. Attacks on primary care were considered poor policy.

Other policies the CHF believed supported primary care reform included the MBS Review and attempts to end the duplication caused by the disconnect between the federal and state governments (CHF, 2014e). The introduction of the electronic health record was considered important. Digital technology, according to the CHF, could address the issue of poor communication and improve patient control of their own healthcare. Empowerment of consumers is the foremost concern for the CHF, and digital technologies are regarded as playing a role in such empowerment. According to the CHF, digital technologies help patients make intelligent decisions about healthcare (CHF, 2014f).

Health literacy is also improved through the adoption of digital technologies. However, according to the CHF, it is important that patients can access suitable information. The Choosing Wisely program is considered a good option for improving health literacy (CHF, 2016b). While patients are encouraged to work in partnership with doctors and other health professionals, programs that support individual efforts to maintain health are also considered useful. The CHF supports initiatives that encourage these efforts (CHF, 2015i). These programs are considered by the CHF to be preventative health measures best performed in primary care

87 (CHF, 2015i). In summary, the CHF supports the Health Care Home initiative, the MBS Review and various patient education measures. It is opposed to the introduction of co- payments, retainment of the Medicare Freeze or any measure that makes out-of-pocket expenses more likely for the patient. The CHF holds universal healthcare to be important and patient empowerment to be the purpose of health systems. Of note, the CHF disapproves of doctors being asked to take responsibility for resource management. Doctors, according to the CHF, should be able to practice without this responsibility. The CHF, therefore, is not enthusiastic about doctors assuming the role of gatekeeper.

6.4 Discussion

AMA RACGP CHF Situational Claims Health care costs are Health care costs are Health care costs are not spiralling out of not spiralling out of not spiralling out of control control control Out-of-pocket Out-of-pocket Out-of-pocket expenses are expenses are expenses are increasing increasing increasing GPs are underfunded MBS is not supportive Chronic disease is not of chronic disease well-managed management Remuneration affects behaviour of GPs Attributional claims Poor government Poor government Poor government policy has led to poor policies are making policies are making funding of primary things worse, things worse, care especially the co- especially the co- GPs are the most payment policy payment policy efficient part of the Government spending Lack of health system on general practice is communication poor between levels of GPs are the most government is efficient doctors in the inefficient health system Failure to consult with consumers is inefficient Australia has poor health literacy

Action Claims Medicare rebate freeze Improve remuneration Different funding should be lifted for GPs models should be Fee for service should Involve GPs in policy explored remain planning Fee-for-service should Private health Different payment be ended insurance should be models should be Health literacy must introduced in primary explored but fee-for- be improved care service should remain Consumers must be consulted on policy Summary of Claims

88 Among these three stakeholders are broad areas of agreement. The AMA, RACGP and CHF all agree with government claims that chronic diseases are placing pressure on the Australian health system. They also agree that the government claim of spiralling health costs is overstated and indicative of an attempt to cut health spending. All agree that patient out-of-pocket expenses are increasing and that the government has failed to adequately address this issue. The Medicare rebate freeze is considered the prime cause of the rise of out-of-pocket expenses, and all three stakeholders agree with the necessity of lifting the freeze. Another area where all three stakeholders agree concerns the lack of support shown by policymakers for primary care and general practice. This is considered a significant oversight as all stakeholders suggest that general practice is the most efficient part of the health system. Poor policy, it is felt, is the root cause of the problems within the health system and is the result of a lack of consultation with relevant stakeholders.

The AMA, RACGP and CHF also share similar action claims. All agree that the concept of the Health Care Home is sound, but consider the lack of funding will make this idea unworkable. Electronic health records are regarded as important for improving the health system. The MBS Review receives less enthusiastic support, especially from the AMA and RACGP. However, the Choosing Wisely campaign, which reflects a similar concept, is supported by all three stakeholders. The most marked divergence in stakeholder claims centres on the advisability of co-payments and the introduction of private health insurance in primary care. The AMA is the only stakeholder that supports the co-payment concept, with both the RACGP and the CHF claiming this is likely to increase disparity in health outcomes. Conversely, the RACGP agrees with the AMA that private health insurance in the primary care sector could provide a suitable funding solution for primary care woes, while the CHF claims that this would also cause inequitable health outcomes.

The fee-for-service model of care was also an area of disagreement. While the AMA strongly supported fee-for-service, the RACGP was more supportive of alternative payment models and the CHF regarded the fee-for-service model as a cause of health system failure. There was also divergence regarding who was best placed to inform policy. Not unexpectedly, each stakeholder felt that their own members were likely to contribute the most meaningful insights for good policy formation. All agreed that policymakers ignoring the input of stakeholders was the reason for failures of policy implementation. Failures of implementation led to failures within the system, and all stakeholders agreed that the system needed refining with

89 modifications designed to address new health concerns. It is interesting to note that evidence for often contradictory claims sometimes came from the same source. This evidence and the different interpretations of it are discussed in Chapter 8.

While the AMA, RACGP and CHF were united in their opposition to government claims of out-of-control spending, claims of inefficiency proved harder to counter. While all three stakeholders promoted the efficiency of primary care in seeming opposition to inefficiency claims, subsequent support of government initiatives appeared to undermine these claims. Stakeholder support of these initiatives gave tacit legitimacy to the government’s claim that doctors have a role to play in managing waste within the health system. A focus by the stakeholders on funding exacerbates this issue. Implicit in stakeholder claims and support for government policy is the idea that funding initiatives will change the way doctors manage patients and this, in turn, will solve health system issues.

Ultimately, it appears that claims made about the healthcare system by stakeholders mirror historic claims of lack of appropriate funding. The cause of problems is over- or under- spending, and the role of policymakers is to fund and that of stakeholders to use funds appropriately. Action claims involve the awarding or withdrawal of funds or the management of funds in different ways. As with historic claims, funding, if delivered in the right way, apparently has the power to alter doctor consultation, prescribing and ordering practices. The exception appears to be support of the electronic health record, although this is still touted to reduce inefficiency within the system. Gatekeepers, according to the AMA and RACGP are necessary in this system to keep the gate closed against such waste and inefficiency. The CHF, however, does not support the role of doctors in restricting patient access to aspects of the health system. For the CHF, a “closed gate” system would be detrimental to patient care and oppose patient autonomy.

6.5 What Does this Mean for General Practice?

Despite the advocacy role of the AMA, RACGP and CHF, and strong support for general practice, many of these claims create a quandary for general practice. While the argument that general practice is the most efficient part of the healthcare system may appear appropriate to supporters of general practice, the challenges of such a claim need to be addressed. Claiming that general practice is the most efficient part of the health system could lead to misinterpretations of the role of general practice within the system. It is possible that ‘efficient’

90 could be misread as ‘cheap’, leading to an expectation of good outcomes produced on a minimal budget. This was the fate of the Primary Health Care concept, with the result that primary healthcare initiatives were grossly underfunded. This led to disappointment in the concept and primary healthcare still battles an image of ‘poor care for poor people’ (Cueto, 2005).

The promotion of general practice as the most efficient part of the health system also implies an active attention to efficiency on the part of GPs. The RACGP was the only group to explicitly mention gatekeeping however the AMA implied that efficiency should be policed and maintained through general practice. The CHF, while supportive of efficient practices, resisted the concept of GPs making decisions about treatment based on cost. There were various levels of enthusiasm for different levels of funding. However, the implication that models of funding are the only factors influencing general practice decision-making is inappropriately reductionist. So too is the idea that problems within the health system will be solved through injections of funding alone. The complexity of GP decision-making and practice and the role of general practice in the health system is minimised where such claims about the health system exist.

6.6 Conclusion

While attempts to promote the value of general practice by highlighting the economic advantages of good primary care may appear to serve general practice well, this strategy may ultimately prove disadvantageous. Expectations of primary care financial gatekeeping held by policymakers are reinforced by other stakeholders attempting to describe the value of general practice in terms of economic efficiency. This could prove restrictive for GPs as assumptions are made about GP priorities and the way they practice medicine. The next chapter considers how individual GPs regard these issues and considers the similarities or otherwise between their views and those of other stakeholders.

91 Chapter 7: General Practice Claims

GPs arguably form part of the smallest unit of the health system—the doctor and patient. As such, GP perspectives represent a ground-level view of the health system. These micro-level views can provide practical insight into the functioning of the health system. GPs’ claims about economic waste in the health system help to identify who or what they believe are responsible for cost containment within the system. This, in turn, provides insight into how or if GPs consider gatekeeping a function of their everyday practice. It also provides insight into features of the health system that may act as barriers and facilitators of gatekeeping. Nineteen GPs were interviewed for this study. The GPs interviewed worked in diverse situations from remote Australian practice to inner city practice. The relevant demographic details are outlined in Appendix A. The GPs are quoted extensively throughout this chapter. This ensures that a true GP voice is heard, an important consideration where GP voices are rarely encountered outside of advocacy representation. These GP interviews provide a ground level perspective that is not found in prepared media artefacts and is often missing from quantitative analysis of general practice. GPs are human and fallible, yet their stories are powerful and provide important detail for policy formulation. Stories from GPs that could not be included within the text are included in Appendix B and showcase the everyday experiences of general practice.

7.1 Situational Claims

The most frequently noted area of waste was that related to the ordering of pathology and radiology investigations.

Douglas, Laverty and Healthscope, which is the one that we had was in-house at our practice. I’ve called those three, occasionally, if they’ve said an area, I might call like—I can’t remember their name—I can’t remember the name of those other ones, but I might call that. And if I get to that point, then I’ll say, ‘We’ll do them again’. (GP 1)

There are inefficiencies of if you can’t rapidly get the results, you’re more likely to just test them again, just in case. (GP 2)

And often patients will sit down and say, ‘Right. I saw radiology two days ago and they said it was going to be ready within three hours’—they always say that, it never is. You know that. And then I have to waste time chasing it because they’re sitting in front of me looking irritated. (GP 5)

92 In fact, you know on an average of four or five patients a day I go chasing down results. (GP 7)

To chase a test takes me two or three minutes because you know you’ve got talk to them, get the details. (GP 14)

It’s easier for me to just rewrite, say, a blood test or a CT scan than to call up the radiology or call up the pathology lab, be on hold for two or three minutes. You know writing out a test takes me 10 seconds. To chase a test takes me two or three minutes. (GP 15)

I spend a significant proportion of my time trying to chase hospital results. (GP 16)

I think sometimes it happens because information isn’t available to a GP or another health provider so sometimes it’s easier to do another test rather than to track down where the last tests were done. (GP 18)

One failure of GP gatekeeping highlighted by Ms Ley (see Section 5.2.1) and researchers (Chapter 4) is the overuse of investigations. As noted in the insights detailed above, the GPs interviewed here present a different perspective for this problem. According to GPs, poor access to pathology and radiology results produced frequent duplication of investigations. Accessing pathology and radiology investigations within the Australian health system is difficult for several reasons. Pathology and radiology results are usually sent to the doctor who ordered the tests. Results may be sent to another doctor if the ordering doctor requests it. This often occurs if a patient is under the care of a non-GP specialist who will copy in the GP or vice versa. However, as patients can opt to see any doctor of their choice, GPs may find themselves outside of this treatment loop. To gain access to results, a GP must ring the appropriate laboratory or radiology service and request the results, which are usually then faxed through to the GP. The location of the GP’s practice determines the number of possible laboratories and radiology services available to patients. In Sydney, New South Wales, for example, patients have a choice of at least 10 laboratories, while in the whole of the Northern Territory the choice is limited to two. This creates issues for GPs, especially those with myriad pathology provider choices when trying to follow-up a patient’s results and can lead to duplication of testing as GPs weary of the time spent searching for previous tests.

Some GPs noted that duplication of test results occurred when patients were reviewed by non- GP specialists. Some patients had tests repeated by hospitals and non-GP specialists who presumably were aware of previous results. Poor information and communication infrastructure is often blamed for this phenomenon.

93 So, the lack of interoperability now for IT systems means that results get repeated; that, to me, is one of the really big things. And so, I do a blood test - when they go to casualty, I do a blood test for their abdo pain. Even though I write the blood test in the referral letter, the abdo pain gets to casualty and they immediately order another test because they can’t see the private pathology agencies. We can’t see the hospital; they can’t see the privates. (GP 7)

And even if you do send things in, particularly to hospitals with blood tests, even if you do send them in, they repeat them all themselves, anyway. (GP 17)

Poor communication was a frequently mentioned problem for GPs. This claim reflects that of the CHF (see Section 6.3.1). However, while the CHF points to the problems associated with poorly demarcated boundaries of responsibility aggravated by the federal system of government, for GPs, poor communication is much more localised and has a daily impact on consultations. Poor communication with regards to investigations is exacerbated by poor communication in the form of absent or late discharge summaries. GPs claim that poor communication between public and private non-GP specialists and hospitals makes clinical practice difficult. In many cases, GPs struggle to get any information at all from hospitals and discharge summaries are considered poor:

The discharge summaries take a long time to get to us even though it’s all electronic. And yeah—and then plus the results that you’re chasing after, often hard to get. (GP 10)

I think when they’re only writing discharge summaries for 47% of their patients, you’re not going to receive half of them because it’s simply not done. That’s in the public system. The private system’s different again because you get a computer- generated nursing discharge which isn’t particularly helpful and then you might get a clinical letter which comes several weeks later from the clinician involved. (GP 16)

Oh, well, the thing is, and I mean I was last in the public hospital system in 2015 so it’s not that long ago that I was there, a lot of the typing pools are well over three months behind with outpatient letters, and a lot of the discharge summaries are late/never arriving. (GP 17)

Failure to receive discharge summaries is reflective of the larger problem of a lack of integrated records. This is not only evident between primary and secondary care, but also between general practices:

There are whole inefficiencies of course if a patient’s going to multiple clinics then their medical records aren’t linked, so there’s time inefficiencies of having to obtain a medical history, there are inefficiencies of if you can’t rapidly get the results. (GP 2)

94 Thus, according to GPs, issues within the system encourage inefficient practice, acting as a barrier to efficient investigation ordering. These issues exist beyond the control of the GP and while a GP may have good intentions regarding the use of investigations, systemic barriers prevent good intentions being translated into efficient practice.

Of course, not all inappropriate testing occurs because of poor communication with other health providers. Another cause of inappropriate testing is patient pressure. Patients, according to GPs, often pressure doctors to order inappropriately:

I guess, the minority of patients will kind of come in and say, ‘I need a full body MRI’, which I did have one like that last week. (GP 11)

Patients expect tests. They want to know what it is. They’re not happy with being told, well, it will probably go away in three weeks. (GP 17)

But there are just a minority who come in saying, ‘Right, I’m here for this’, and they keep insisting on sort of doing those screening tests more often than they should. (GP 18)

According to GPs, patients tend to pressure them for investigations due to poor health literacy:

So, there’s a real challenge in educating patients about the fact that’s not indicated. And that can be a hard thing, because people want everything done. They think that then that will give them a clean bill of health and they’ll not have to worry about anything. (GP 1)

There’s a person who reads it and says: ‘It’s me’, and the other person reads enough articles to think they are now a medical expert. And that’s the person who’s come in and decided, ‘That’s my diagnosis’, or, ‘that’s my sister’s diagnosis and you need to treat her. If you don’t, I’ve read all the articles, we’re going to another doctor’. (GP 3)

They frequently come and ask for tests, whether it’s they’ve been sent in by the physio for a request for imaging, or whether it’s a naturopath with a list of 20 different blood tests, yeah, I probably get that on a daily basis. (GP 16)

Poor health literacy not only leads to inappropriate requests for pathology, treatment and referrals, but can also lead to patients being trapped in a cycle of non-GP specialist visits:

If they’re new patients and they’ve moved from Sydney and they’ve been seeing all these very important specialists well, then, yes, they definitely trust them more. I think if they are long-term patients and we’ve looked after them reasonably well and they can see that they’re getting pretty comprehensive care and that we ask for an opinion when needed, then it can be a slightly easier conversation, but it still is hard. (GP 6)

95 So, one thing, for example—I don’t know. I see a lot of patients where they’ll go back and see their … so, they’ve had a heart attack, say, 15 years ago. They’ll go back to see their cardiologist every year for a consultation and it’s literally, Oh, yeah, no, you’re good. You’re on these medications. Good. Continue to stay on them and see me in 12 months’. And I’m like—I think to myself, ‘Like why you see them? Like I could do the exact same thing here’, you know what I mean? (GP 15)

This is also seen where poor health literacy is complicated by a lack of understanding of the Medicare system making certain patients vulnerable to poor advice and exploitation from allied health and complementary medicine practitioners:

They’re telling the parent, ‘Take your kid to get a GP management plan from the GP’. And then they come in, it’s like, ‘My kid has a problem with their handwriting. They need to see an OT—for a GP management plan’. (GP 11)

allied health professionals pushing it, you know, just go to the GP and get a care plan or just go to your GP and get a mental health care plan without actually having an understanding of what the rules surrounding that are. (GP 17)

but they’ll say, you know, my naturopath has asked me to have this, and sometimes it will be a test that they might have already had or it might be another test which the naturopath asked them to get. (GP 18)

One GP noted that sometimes the actions of GPs could also give patients the wrong idea about test ordering:

Because I guess a lot of what I’m seeing now is that a lot of I guess some misinformation with patients is perpetuated by us. So, for example, if I say, ‘Okay. We’ll just do the back X-ray, you know, for your peace of mind’, even after I’ve explained it’s not going to show a whole lot—you know, you’ve still got pain— they’re kind of saying, ‘Oh, well, the doctor said, “Yeah, she’ll just get it”. So, it must be the right thing’. (GP 1)

GPs appear to tire of addressing these issues and are frustrated by the systemic pressures which prevent them from doing so:

but still for both of you it would be more efficient to do all of that medical care and work it within a 30-minute consultation. It’s cheaper for the patient and it doesn’t financially penalise the doctor, but if you’re in a bulk bill setting and its bulk bill across, yet you still want to get all that work done, but keep the turn through or maybe the practice has a policy and it’s very hard to get in longer than you know, it’s just like the policy is you’ve got a turn. (GP 2)

96 And I think, once again, that’s where the inefficiency is if you’re encouraging short episodes of medical care through low rebates, you’re more likely to go, well, go and see a specialist and go and have a few tests rather than sorting it out. (GP 6)

A further problem is that of remuneration. However, unlike the claims made by other stakeholders (see, for example, Section 6.3.3) the arguments for and against fee-for-service are more nuanced:

Now, the fee-for-service, I disagree that the more patients you see the more money you make. I see 40 patients and I make more money than the other doctors who see 60 patients. (GP 8)

No, I think the system, fee-for-service, has a potential downside of encouraging volume and it’s not necessarily saying there isn’t value in that volume, but the value hasn’t been determined and that’s what we need to do. (GP 18)

These claims reflect the ongoing argument noted in Chapter three that fee-for-service arrangements result in poorer medical care. Despite the AMA and RACGP insisting that fee- for-service remains the best funding arrangement for general practice it appears that GPs themselves are ambivalent about the concept.

This ambivalence results from scepticism not only about fee-for-service but also about the effectiveness of other forms of payment. A common claim was that Medicare initiatives, such as GP management plans and Aboriginal Health Checks, aimed at addressing this problem are prone to misuse:

And again, we are almost forced into doing it. So, they sit down, and they go ‘Right, this is a requirement. I want my referral; I’ve had it for more than six months’. We’re forced into doing it and I feel so guilty claiming that Care Plan Item Number; I really do. And I feel it’s so wrong. And the only reason I’m claiming it is because they’re wanting their rebate. (GP 5)

I think there’s so much inappropriate use of GP management plans. Not so much mental health care plans. You don’t see too many of them that are complete nonsense ones, but like, I see a lot of like patients who have had a GP management plan, a team care arrangement plan for someone who doesn’t qualify for it. (GP 11)

Chronic disease management plans appear, to GPs, less than ideal. One GP noted however:

So, I mean the whole point of introducing those item numbers was to get people to do more of them, so now people are doing more of them and they’re told ‘ah, they’re wasting money’ and that when they need to be stopped, but that was the whole point. So, it’s the perfect example of introducing an incentive and then when providers

97 follow it, they say, ‘ah, well, you’ve done the wrong things’, but the results of the incentive have actually been exactly as [intended] … they’re not unintended. (GP 18)

Even if the plan is considered appropriate, there is some doubt as to whether these initiatives are addressing the health needs of patients:

But for the moment just commenting on the health check itself, we definitely cover enough stuff to cover the Medicare items, but yeah, I worry that it doesn’t fully grasp, like it doesn’t really—you can go through it without really engaging the patient still. (GP 9)

While the use of management plans may appear dubious to many GPs, being held to account for poor plans is not a concern. This lack of accountability in Medicare in general is an issue:

And I think there’s a real risk that Medicare is an open blank cheque book that there’s no criteria for somebody just going back and back and back. (GP 6)

You know the faster you can push them through the most money. As long as you don’t crack your 88—was is it, 86 or whatever it is? (GP 7)

Ah, the trouble is that the audit thing, well I don’t know, nothing seems to act, no one enforces any of these guidelines. (GP 17)

As one GP noted, accountability is difficult when criteria are broad and guidelines vague:

So even before we talk about accountability, I don’t even think we have the guidance. How can you hold somebody to a standard that’s not actually being articulated? (GP 19)

Other health system issues present challenges for GPs and impact heavily on the ability of GPs to perform a gatekeeping role. Notably, the ability of patients to see other doctors if a GP refuses to fulfil a request is a problem. Again, this can result in inappropriate use of resources:

my supervisor at that time was like, ‘There’s no point fighting with patients about this, because they’re just going to go to someone else down the road’. And then we’ve cost the government that consult fee, as well. (GP 1)

potentially, and that’s … but I think that’s the challenge in our system where there’s no restriction so obviously if you’re restricted to a doctor within a practice. (GP 18)

This creates a quandary for the GP, torn between satisfying patient requests, applying evidence- based medicine and working within Medicare guidelines. Different GPs approach the problems in different ways:

98 but I’m quite particular with that you know and so it’s like, ‘well if you want that test of course I will order it for you, but I’m not ordering it under Medicare’, so you order it and you just write ‘no Medicare’ so it’s just private. (GP 2)

I would be more inclined to do it because aside from anything it’s going to alleviate their stress and worry about that and so mental health is—caring for their mental health is also my responsibility as a doctor. (GP 2)

If I had enough red flags. I’d still need a flag. I wouldn’t do it because the person said: ‘I’m scared I’ve got ovarian … I’ve read a story and I might have it’. I’d take the history. (GP 3)

So I’ll kind of say—I won’t even look at the list and I’ll say, ‘Look, if you want to talk to me about your symptoms, that you can figure out what it is actually and could be necessary and I’m happy to do that’. In terms of ordering a list of tests, no I’m not going to just sign [up] something without giving a medical reason, of course those are the ones that are not necessary. But then if they do want to go to those other ones, they’ll kind of say, ‘You can get in trouble for that. You’re going to have to pay— you’re going to do it privately’. But I try not to do that because it’s a waste. (GP 11)

I tend to … look in the long-term patients it’s actually pretty easy. I’ll sit through, I’ll just go through it with them and they’ll all be pretty good at saying, ‘well, this was done six months ago, or we checked your thyroid and that’s been fine’. I’ll explain why they don’t need some of the testing. (GP 16)

It is important to note that while GPs try to manage these scenarios in ways that attempt to follow evidence-based practice and Medicare guidelines, multiple factors may influence their behaviour within each consult:

Going through it again, it’s a lot easier just to sign a piece of paper. Yeah, so I guess sometimes your—how you’re feeling at that time could sway it, or if you’re running late and—‘cause it’s so much easier just to sign a piece of paper and give it to them than to try to indicate about why we shouldn’t do something. (GP 1)

But anyway, she’s lovely but she’s very aggressive and she maximises all her pathology and everything, even the completely unnecessary and won’t take ‘no’ for an answer. So, what do you do if you don’t agree and the patient is being highly aggressive and standover? What do you do? I don’t know. I’m not sure. (GP 5)

But yeah, so overall I don’t think it’s really patient-driven in that sense; it’s me sort of having a sense of … I guess, to be honest, I sometimes feel quite anxious—that I might be missing something with my patients and maybe that does drive me to over- investigate possibly. (GP 9)

99 I suppose it depends on how stressed I am at that day as to how much I feel like having a fight with a patient then and there about the fact that they do or don’t need them. (GP 17)

Time constraints, fear of being wrong, fear of displeasing the patient, fear of litigation and fatigue are all factors that might affect GP behaviour. These factors affect different doctors differently. For example, fear of litigation was not common to all GPs:

I think that most of the populations I’ve had tend to be nicer but, you know, they’re not … country … Indigenous patients, country ones, don’t tend to be the suing type. They’ll shout at you maybe, but they don’t tend to be the ones that sue. (GP 17)

GPs also feel that these pressures tend to dissipate with experience and that more experienced GPs were less likely than their counterparts to order inappropriate tests:

But you can be surprised. But yes, I think that with time you get confident like with enough patients that you see. And I guess it’s knowing that most things can wait. (GP 10)

GPs were aware, however, of less-than-desirable behaviour in some of their general practice colleagues:

yeah, mindless medicine is to see the person, you do a few repeat scripts, you do a couple of quick you know—maybe a practice nurse has already checked their blood pressure or you do the blood pressure and wait, you might do a quick examination or a few tests or you don’t even bother, you just refer to the specialist and so one of the comments, for example I’ve had from a few specialists is I love it when I get a referral from you because I know the patients been properly worked up. (GP 2)

GPs were mostly comfortable with how they practiced medicine, despite the seeming contradictions between how they wished to practice and how they did practice. This has significance when considering gatekeeping. It appears that an almost infinite number of scenarios are possible in general practice. For example, a GP may see a new patient, be short of time, have already argued with three people that day and be anxious about litigation. Or they may see a patient, have ample time and feel the need to reassure the patient. The idea that GP consultations follow a linear process which could be regulated by more guidelines or education ignores the complexity of human interactions. Furthermore, multiple barriers exist that prevent GPs from acting in a way that could truly be described as financial or closed gate gatekeeping. This will be discussed further below.

100 Despite GPs acknowledging inefficient practices in primary care, all were adamant that levels of inappropriate investigation, treatment or referral ordering in general practice compared favourably with those of their non-GP specialist colleagues. Compared with GPs, non-GP specialists and hospitals were, according to GPs, over-ordering or duplicating tests results at a much greater rate than themselves:

The same with specialists as well. Like I’d order all the appropriate tests, send it to them and then they’ll repeat it a month down the track, and you’re like, ‘What the hell? I’ve just ordered these tests. Like what do you want to know? Has something changed in the last month? No’. You know? (GP 15)

So, even little old us would just sort of watch and wait whereas a specialist goes bang, bang. Every single patient who walks through their door automatically gets an MRI no matter what, no matter how. (GP 17)

The relationship between general practice and other specialities was complex. While GPs were mostly appreciative of non-GP specialist input, frustration with certain behaviours from colleagues was evident. On the list of non-GP specialist trespasses was the practice of not offering feedback on the appropriateness of a referral. This was seen regarding various procedures as well as with pathology and radiology:

For instance, you might say, for instance, say, if you’re referring this patient with a history of bloating and abdominal pain, a good consultant may well say, ‘As you are aware, you know a gastroscopy is actually a low-yield investigation for this sort of work. What I would recommend instead would be et cetera, et cetera, et cetera’. Instead of saying that, they just go, ‘Thanks for referring this patient in for an upper and lower gastroscopy/colonoscopy. We’ve done both tests, so we’ve charged the government, and there was nothing abnormal defined’. End of story. (GP 14)

And I think the business models out in Australia now are that pathology companies aren’t going to tell you not to order tests, and specialists are not going to tell you when you send them a crappy referral because it’s all business as far as they’re concerned. (GP 14)

GPs also felt that non-GP specialists interfered with the training of potential GPs. This results in younger GPs ordering inappropriate tests and increasing costs to the health system:

I think they have learnt it from the hospital. In hospital a patient goes, they just automatically go through a huge number of tests and which many times aren’t necessary. (GP 8)

And I mean like I guess one of my theories is that … so, I remember being a junior doctor and being in charge of ordering bloods for the patients on the list. And if you

101 didn’t order something that the boss wanted you would get yelled at. But if you ordered extra things nobody ever said anything because they would just, you know, ‘What’s the potassium? What’s the CRP?’ whatever, and then, ‘What do you mean you haven’t ordered a CRP?’ But if they didn’t ask that then they wouldn’t know if you ordered it or not. (GP 10)

They write you off—if you say, ‘I’m going to be doing General Practice next year’, they go, ‘Okay, oh, good’. And they’re no longer interested in giving you the time of day or setting you up with a higher threshold of expectation for yourself … But the impression of that is, ‘Well, you’re no longer going to come through us and you’re not going to be training with us. You’re not dangerous, so you pass’. They’re not saying, ‘Gee, you know, you really ordered some pretty dumb tests there. That’s not good enough’. (GP 14)

While attention to rational investigation ordering is not considered a priority of hospital medicine by older GPs, several GP registrars noted that they had received some training in rational ordering and prescribing:

a lot of our training has been about evidence-based medicine and doing what the evidence says is the—for example, the best practice first-line treatment, best practice investigation given for something. (GP 1)

and to me that’s really important, like it’s the JMOs that are ordering all these tests on behalf of the consultants and, yeah, so I mean it’s good to teach it at the university level, which is what I experienced at [university]. (GP 19)

The underlying belief that non-GP specialists encourage wasteful practices is likely to have implications for educational activities which focus on non-GP specialists imparting information to GPs.

The complicated relationship with non-GP specialists is illustrated by the final situational claim made by GPs that general practice is not well understood. This leads to misunderstandings concerning GP behaviour. Many GPs are sceptical when it comes to non-GP specialists and hospitals understanding their role and qualifications:

I totally—because I did four years of hospital before I started GP training. And there are these awkward moments, to tell the truth, in the hospital because I just—let’s say you were in Emergency, where you’re just like, ‘Oh, that GP. Why is he referring this person?’ But on the other side of it now I completely understand it so much better. (GP 9)

I think sometimes the hospital still really they’re—unless the people travelling out to communities and actually seeing what you’re up against in a small community—they don’t really have any idea. (GP 13)

102 GPs feel it is important to recognise the difference between their own practice and those of non-GP specialists:

And I don’t think people understand that effectively we are specialists in undifferentiated illness and that’s the one bit of the health system that does that apart from [Emergency Departments] up to a point. (GP 6)

And the third thing is that the GPs are multitalented doctors, they manage everything. (GP 8)

we deal with everything from simple colds and flus, depression to heart attacks and to anything. So, we are trained for all this. (GP 8)

Some of this difference concerns the value of evidence-based medicine to everyday practice:

You can rely on evidence, but it doesn’t always work because the patient may have a psychological, or a cultural, or a religions barrier to accessing the best practice. There could be something stopping you from doing the best for that patient, whether it’s a language barrier, a cultural barrier. (GP 3)

So, I think this is one of the challenges we face in general practice, is that just because there’s no evidence doesn’t mean … just because there’s a lack of evidence doesn’t mean that something is not efficacious. (GP 18)

Some GPs are concerned that this lack of understanding of what GPs do clouds the perspectives of policymakers. Importantly, many GPs felt that policymakers do not appreciate the value of general practice:

I think it’s a lot more complicated and doctor behaviour; prescribing, investigations, treatment how and why we do things is a lot more complicated. (GP 5)

And, you know, I mean all the international data and Starfield, the data which has been replicated right around the world which demonstrates that primary care is efficient it actually lowers mortality. Specialist care mortality is much the same if not higher because they’re dealing with more proportion of the population, they’re doing more intensive procedures on them which is what you’d expect, just the actual [sieve] of primary care is pretty efficient. (GP 6)

I think there’s an attitude amongst politicians that medical costs are blown out by GPs spending large amounts of taxpayers’ money, and we’re the cause of costs and we’re a large part of the core—cost blow outs in medicine. (GP 13)

I think because it’s very difficult to prove the value of general practice interventions because patients are complex. General practices involve multiple interventions and valuing them isn’t easy and it’s not something that funders, that complexity doesn’t

103 seem to be funders … something that funders are willing to sort of cost into the system. (GP 18)

The complexity of relationships here makes attributing blame for system issues complicated.

7.2 Attributional Claims

While the behaviour of certain individual GPs is considered questionable, GPs are more likely to point to problems within the system that promote this poor behaviour. The same consideration applies to patients. However, GPs do accept a level of responsibility for issues within the system. For example, GPs regard patient education as primarily the responsibility of general practice:

I think health literacy actually has everything to do with the doctor you’ve got because I think that we are actually the best people to teach people how to think about their health. (GP 15)

I’ll say, ‘Look, if you want to talk to me about your symptoms, that you can figure out what is actually happening and what test could be necessary and I’m happy to do that’. (GP 11)

So, there’s a real challenge in educating patients about the fact that’s not indicated. And that can be a hard thing, ‘cause people want everything done. They think that then that will give them a clean bill of health and they’ll not have to worry about anything. (GP 1)

GPs varied in their perspectives on the responsibility of GPs to contribute towards cost management within the health system:

So, when I think about it; if you should see some waste when it’s my responsibility just to the Commonwealth? No. it’s to the business that I work with, it’s to the other practices around, it’s to the patient. (GP 2)

I don’t think I have that role. I don’t see that as a role because we’re not dealing with a lot of the expensive stuff as far as I was aware, but I don’t know what you’re talking about. (GP 4)

at least I practice that way, that if I see a patient many times I don’t charge because I regard it as that it is our responsibility to regulate Medicare as well. (GP 8)

I don’t think we should be solely responsible; I think everyone should be responsible for it [constraining costs]. (GP 15)

104 This is not to suggest that responsibility to the system was an all or nothing consideration for GPs. Despite a lack of consensus about the level of responsibility GPs have towards health system expenses, it is interesting to note that the GPs interviewed claimed to be generally thoughtful about investigation ordering and referrals. However, the prime motivation appears to be professional conduct and best practice, rather than thoughts of cost.

I think it’s up to us to practice good medicine, and yet within the realms of the fact that we’ve got a limited money supply. I totally accept that, but you would hope that if the test was necessary it’s going to either treat something early before it gets more expensive, if you want to look at it that way, or avoid something that you don’t need a hospital admission. (GP 3)

Because the healthcare dollars are a finite resource … all the doctors should be aware of that. (GP 9)

7.3 Action Claims

Given that multiple issues within the Australian health system are regarded as having more than one cause, it is not surprising that a varied range of required actions were suggested by GPs. These actions can be divided into financial actions, educational actions and actions required to address structural issues within the system. However, the diverse nature of general practice is illustrated by the general lack of consensus on these actions. Financial actions recommended by GPs include introducing a co-payment for consultations or pathology, reviewing payment models and considering models such as capitation, better funding for primary care, better funding for allied health, less funding for secondary care and different Medicare item numbers. None of these suggestions had unanimous support from the GPs interviewed. The introduction of a co-payment was surprisingly popular, given the RACGP opposition to the government’s proposal. However, GPs did not regard co-payments as a tool for preventing unnecessary visits to the doctor. Unlike the government, GPs did not feel that patients visited the doctor more than necessary:

Having said that, those that are time rich but cash poor, you have a sub-group of those who will you know, doctor shop, will overuse the system, people who—but in some respects, part of the reason why they’re not working is because they actually have high medical needs, either physical and or mental, so the same reasons that are preventing them from engaging in either part time or full time employment are the same reasons why they’re needing to see a doctor more regularly and have higher unmet needs or ground. (GP 2)

105 From our point of view, it [unnecessary visits] is, but from their point of view they worry about everything today, it’s a different psychology. (GP 4)

There can be some patients who come for very minor ailments but it’s not a large number, I would say I would see probably one patient a day who if he doesn’t come will not affect him much. But that is out of 40 patients, one is—so it’s about 2%, that’s not much. But then you end up doing preventative health on them so eventually it leads to better health to those people. (GP 8)

Co-payments were considered a way to educate patients about costs to the system and the value of self-care:

I think co-payments have to come in, there’s got to be something. The government can’t be expected to pay for every cent of everybody’s care anyway, I don’t think. (GP 3)

The patient needs to contribute something to the test. I don’t think there’s any problem with people contributing to their costs directly so that they know if I’m going to have this, Medicare’s there, but they’re going to have to contribute to it. They do find the money I think. (GP 4)

I guess what I’m trying to say is, you have to be smart with the people who live completely on the breadline, but you also have to give them some responsibility to pay. So, they do get some government money, I accept that, and if they can part with just a little bit for pathology, I still think even those people living on the breadline have to part with something. (GP 5)

Many GPs felt that a co-payment on pathology and radiology investigations may reduce requests for unnecessary testing:

And I think part of it is when a patient, when you don’t pay for something you don’t cherish it or you don’t perceive it as … say, for example, if each patient paid for their tests, whatever amount, small, tiny amount, they’re not just going to ask you to order every single test under the sun. They’re not going to ask you to order a test every single week to track them. (GP 15)

So, I would say, you know, if people had to pay $3 to see the GP and $5 to have pathology, I think it would make a big difference. (GP 19)

However, while doctors felt that there may be a role for co-payments, they also felt that co- payments should be used with caution:

But I do agree with the fact that some people, if there’s any cost that they’re going to have to pay, they just won’t go. And so, things will end up really bad until they

106 actually present. So, I think that’s a big thing for a lot of people is that if they have to pay anything, they just won’t go. (GP 1)

One GP opposed co-payments altogether:

But the thing is that it will lead to adverse situations, it will lead to further deterioration of the health of the poor. And in this area, 50% of people are—I wouldn’t call it, there’s no one poor in Australia—but with Australian standards, yes, they will delay their consults and seeing the doctor and eventually they will become worse. And for saving a consult with a GP you will end up in hospital and requiring a huge amount of expense in the hospital. So overall it would be bad. (GP 8)

Other payment models had more support. The Health Care Homes concept, although in its infancy at the time of interviews, received more approval than the co-payment option. The ability of patients to sign-up with a practice was considered an important step in reducing the number of doctors patients saw, thereby improving continuity of care:

It’s much better for somebody to be able to see a doctor, or no more than say two doctors, because one doctor may not always be available so you have to have another doctor who is able to access the information or whatever. (GP 4)

I came from a New Zealand system where I had patients registered with me, registered with the practice. It was easy to sort of keep tabs on them. (GP 16)

I think it would be a good idea if patients had to register with a practice and stick with a practice and, you know, if they went somewhere else then maybe the Medicare rebate was on 70 or 80% because I think that would result in less jumping around and better continuity of care. (GP 17)

Not all GPs were convinced the concept would improve patient care:

I mean you’ve got a Health Care Home system and you get paid a capitation amount per patient, but then you set the GP up in a conflict of interest really to say, ‘I’m going to do the cheapest job possible because it will benefit me more than it benefits you’. (GP 14)

So, if you set a like Health Care Homes what you’ll find is people won’t want to sign people up with borderline personalities. Like I see borderline patients all the time. You’ve got to choose whether you’re in my budget, you know? Where I’m going to pick and choose who’s easy and I’ll get the most money out of. Do you know what I mean? (GP 15)

The amount of funding required for this concept was a concern, and many GPs expressed a belief that such funding would not be forthcoming from the government:

107 Oh, look, I think the funding is terrible, but I think the concept is good. (GP 10)

Though I think—I suppose that would make it difficult if they’re trying to like sneak stuff in so they didn’t have to pay for it, and then, you’re financially worse off. (GP 12)

My opinion, personally, is I think the initial suggestions and what the RACGP was proposing actually has a huge amount of merit to it. It’s entirely about the funding and implementation of that and you can’t … if it’s not funded adequately it’s never going to work so I think it comes down to the funding. (GP 16)

Reaction to other models of care, such as the US-style health maintenance organisation or the UK National Health Service fund holding models, was mixed:

I wouldn’t feel comfortable with someone, particularly if it’s an insurance company—you know, someone who’s not directly or indirectly involved in patient care, really, to be saying, ‘Well, you can’t go to that, because it’s too expensive’. (GP 1)

And a similar thing, we can probably take more of the best bits of the American health system which is their reliance on data and some pretty tight feedback controls in some of the HMOs. Some of the HMO stuff is done very well but the bad side of that is just to cost containment on the one hand of gatekeeping and inordinate levels of administration and ridiculous funding incentives for some and particularly procedural work which we see here as well. (GP 6)

Well, that’s probably the opposite end of the spectrum, which is totally, totally dollar- driven and not care’s-driven. Having said that, there’s some really interesting and quality stuff that comes out of the HMOs. When I look at it as the overall thing it drives up the cost of healthcare, so that’s a [driver] there. I’ve just had a friend of mine who’s a paediatrician in Washington and I went to [city] for a wedding a couple of weeks ago. And when you talk about the sums of money and the investigations and the tests, it’s not fun working with the HMOs; they actually get in the way of good care. (GP 7)

I don’t think that ideologically I am up for that sort of developing two-tiered system that we start getting paid huge amounts of money from private health insurers and then I abandon my bulk billing patients and start looking after them. (GP 8)

Outcomes-based or pay-for-performance funding was generally considered a poor model of funding:

so outcome-based funding doesn’t work in my mind because I can’t get you the same diabetes outcomes in [outer suburb of Sydney], because I may not have enough Spanish-speaking dieticians, I may not have enough Polish-speaking podiatrists. Do

108 you know what I mean? I think unless the resources give us a level playing field then outcome-based funding doesn’t work. That’s my theory. (GP 3)

having worked in the UK, is with their quality outcomes framework, which was called their pay-for-performance programme but which measured sort of a hundred different processes that happened in what was thought to be high-quality care. So if you have your HbA1C measured, have your blood pressure measured, if you’ve got hypertension and just the results seem to show that although you get increased recording of what you say people need to record, you don’t get any more than a short- term change in the quality of care and that you actually get worsening care for the things that you’re not measuring. (GP 18)

Several GPs interviewed were paid a salary and admitted that this may affect the way they practice medicine:

Yeah, I mean, and I guess, again, it’s difficult because where we’re paid in a salary basis at the moment, and I really kind of am aware of once we finish and we become contractors, or we get paid off of the patients we see, not on the time we’re at work, and whether that will actually change the way I practice, because at the moment, it doesn’t, because I don’t have that pressure. (GP 1)

I mean, I guess it’s one of the things I should have looked at, but I just get paid a weekly rate for what I do. (GP 13)

Several other payment models for GPs were suggested:

My idea is that you should be allowed to go to the doctor 10 times a year and after that you pay. There are a number of options, but then you pay. Otherwise, you contribute a certain amount but it’s not free for everybody, but everybody’s used to it being free. It can’t be sustained, no. (GP 4)

I think that the remuneration system in terms of time is incorrect. It skews it towards just tipping over into the next category of timing system but then doesn’t reward the additional time needed. I think it should be a flat rate, yeah, in a way that the legal services do. So, you know if you think a GP is worth this much an hour you pay them on a time basis in units of time, so make it five-minutely or two-minutely. I reckon if you cut it down into smaller slices you actually get more efficiency because people don’t try and stretch—there’s no benefit to stretching it out to the next level. (GP 14)

While the current payment model is agreed to be less than ideal, other payment models appear to be problematic for many GPs.

Educational solutions to systemic healthcare issues are less divisive than economic issues. The requirement for more focussed training while registrars are in the hospital system is generally agreed on:

109 A lot of it’s about education; the more fearful you are, the more ignorant you are probably the less confident you are in a test or a single blood test. As I say to my registrars, ‘This patient is our patient, he’ll come back next week. It’s fine to just do a full blood count this week. If he’s anaemic, we can do an iron study next week. So, don’t think that you have to do everything including the bone marrow biopsy on your first path form’. So, education is part of the key. (GP 7)

So, I think, yeah, well, I’d argue that maybe there’s more of a need to even more so to support through education for the juniors. (GP 9)

Many GPs admitted that they were unaware of the costs of investigations and some treatments. Awareness of costs was considered helpful by some as a means of avoiding expensive tests:

Actually, that’s something else that needs to be fixed; we don’t know costs of our pathology at all. (GP 5)

And I mean, I think it would be important to me to know—and I would actually love to know all these—like the routine blood tests, how much they cost each time and when you start adding on the transport costs, from—whether we’re talking about the Bush bus and then flying things to [nearest capital city] and what it actually costs the taxpayer in terms of getting a full blood count, or an ELFT is done and things like that. (GP 13)

Continuing medical education is important for GPs and feedback on practice is considered helpful here. Feedback may come from different areas such as government initiatives, colleagues, and medical students:

Look, I mean I think some of the prescribing feedback you get from NPS is very helpful, and particularly the comparisons that you get with your … you know, how you sort of ranked in your percentile, I think that’s very helpful so it sort of helps you reflect on where you might be against your peers and sort of lets you reflect if you are outside the average. Is that warranted variation or unwarranted variation? (GP 18)

Software could also assist with the education of both GPs and patients:

I think if the software is licenced to have logic built into it; so if you ordered a lumbar spine X-ray, the following indications are currently acceptable under best practice or evidence and if you can’t tick one of them you can’t order the X-ray. (GP 3)

I’ve been referring patients to the Health Ed; there’s a beautiful … actually I was reading it this morning. There’s Health Ed, you do Health Ed Insulin, Google it. There’s a beautiful article actually; I want to distribute it to all doctors especially at the practice. Not many people at the practice do it but where you do a completely unnecessary test, and then you get patients coming in. But it’s nice to be able to show them that. (GP 5)

110 You know requiring, for instance, open-access colonoscopies and requiring that in their results, if they’re electronic, to automatically provide the internet link to the National Bowel Cancer Screening Program protocols. It would be a really simple way to get GPs to go, ‘Oh, I’m not really familiar with what the protocol is. Click it’. (GP 14)

I think having a pop-up on the patient’s things, so the patient realises, you know, cost of test, this much; today you are … this cost is being covered by the government or something or your tax or something. (GP 17)

Educational messages from government sources would also be useful for both GPs and patients:

I think patients find it really difficult to work out what to trust. I think they do find that a difficult to try and work out for themselves what to rely on, and they look things up, like what sites are reliable and I think more education and advertising, I guess, from the government or coming from—you know, you said that’s helpful. One of the bodies that people go, ‘oh, I can trust that’ would make a huge difference, because rather than us spending, you know, five, 10 minutes of the consult trying to educate someone about health literacy, some part of it, if that’s happening, if they’re seeing that on TV, if they’re seeing that when they read the paper, that would make a huge difference. (GP 1)

The Choosing Wisely thing that the NPS does—these are the things that are completely unnecessary and those things that you’re just doing to make everyone feel better in terms of investigations and that sort of thing. I guess that’s sort of— awareness raising of like, people don’t need these tests to do that, that sort of thing. And also, I guess having a bit more awareness of how much is it going to cost if I do this scan for those ones that don’t need it. (GP 11)

Finally, GPs suggested a number of system changes that could either enhance or complicate their practice. These changes involved the introduction of guidelines like that of the UK NICE arrangement, the introduction of electronic health records, changes to how primary care communicates with other segments of the health system and better funding for allied health professionals:

But yeah, I don’t know; there’s got to be some gatekeeping beyond the GP, I suppose. I guess it’s a bit like when you fall back on the driving guidelines and you can show a patient, ‘Look, I can’t give you your unconditional licence because it says here in black and white. These are the rules’. (GP 10)

I mean, I think guideline support, I think information’s very helpful. One of the things sort of, like, which I found really helping with the referral pathways is the development of health pathways put through lots of the PHNs where you’ve actually got an evidence-based resource and knowing what services and what treatments are

111 available locally for issues, understanding when you might and might not refer, so I think that’s an actually really helpful program. (GP 18)

Others felt that guidelines could be problematic: ‘For things like diabetes, osteoporosis, hypertension the guidelines do vary a bit. You get one guideline, then in another 12 months it will be slightly different’ (GP 4).

Restricting the MBS criteria was considered a potential option:

I think if the software is licenced to have logic built into it; so if you ordered a lumbar spine X-ray, the following indications are currently acceptable under best practice or evidence and if you can’t tick one of them you can’t order the X-ray. (GP 3)

I feel there probably should be, in terms of sort of like time limits on how often you can order a test. Say, for example, right, like some tests you only need once a year or once every six months or once every 12 months. Like for example, the PSA is a good example, right? You really don’t need anything more than once every three months. (GP 15)

In fact, I think my GP supervisor told me the UK had a good method for some things like TFT—if they’d been done within the last six weeks they would just send you the old … the lab would send you the old result and inform you that if you wanted them actually done again you’d have to give a clinical reason for it. (GP 17)

However, restricting items on the MBS could have unintended repercussions:

I think it’s quite reasonable but I guess I would just like to mention that they’ve done their sums right because the question would remain how many—what’s the cost of the cat scan, so how many of those people having a back X-ray will now end up having a cat scan? So actually, will they end up saving? If it’s really just for a budget reason, a cost-saving reason, how many people are now going to have an unnecessary cat scan instead? I’m pretty sure that attracts a high Medicare rebate. (GP 2)

Restriction of ordering rights was not highly regarded. Some GPs had experienced this in other health systems, while some felt that current Australian restrictions were already causing issues:

Because I don’t want to take away the GP’s autonomy to do stuff, and I hate the idea that specialists can order—like all specialists. Like, why should dermatologists be able to order an MRI? (GP 10)

GPs considered electronic health records necessary to reduce the incidence of duplication of pathology and radiology investigations. As previously noted, GPs spend a significant proportion of their time searching for results. Time constraints can often lead to investigations being repeated as GPs are unable to find these results. The electronic health record, now known

112 as My Health Record, first introduced by the Labor Government, was newly online during the time of interviews. Many GPs had not had experience with the record, but those who had were generally unhappy with the format:

No, I found that it’s been very clunky, I really just haven’t had the time to engage in it, so and also you know again, it’s mainly just about—well its really for those sort of where that is a value like a hospital, if they’re moving to the hospital staff and yeah, because most of the GP’s aren’t putting all their patients and particularly those that are moving around, coming back to your question of patients that are seeing multiple doctors. Well as if for particularly those patients that you’re only seeing once or twice, you’re going to be then going and uploading that into their personally controlled electronic medical record. (GP 2)

And I’m 100 per cent for it and it’s a brilliant idea but I can’t possibly trust it because no one—it’s not a universal thing. So, there’s no point if I can’t trust it, so I’m just not doing it. It’s not done for everybody. And then just say you’ve got an unwell elderly patient, goes off to Queensland, goes off to places, sees several doctors. One doctor uploads it, the other three don’t; it’s very difficult to use. (GP 5)

Disaster. What do they say, ‘A camel is a horse invented by a committee’. Well, the PCEHR [Personally Controlled Electronic Health Record] is invented by an enormous committee. (GP 7)

I am happy with that, that’s the eventual way to do it but it does not have radiology and blood results in it. It has only medical conditions, medications and allergies. So, I think the best would be that whatever the patient has tested it should go into a pool and it should be formatted in a standard way. We’re going to Mars and we are going to, I think recently something went to Mercury or something, not Mercury, one of the other, Jupiter and the delay was some milliseconds or, I think, 1.2 seconds when the thing connected and all that. I mean when we can do all that and we can’t just do this? I can’t understand this. (GP 8)

It’s very user-unfriendly. Oh, when you do find useful information there, but that’s if you’re persistent enough to actually find what you’re looking for. (GP 13)

One remote doctor with experience of the Northern Territory electronic health record found the My Health Record useful, but did note an unexpected downside:

Actually, I think like there’s good and bad. So, I like it because of those health barriers, like so communication barriers. So, if you are unsure of something and the patient can vaguely tell you that they’ve been in hospital fairly recently, so it’s really helpful to be able to just look at their Health Record if you can see it and find out what’s happened. But I think there’s also another aspect to it that I feel a bit sad about because I’ve had a number of patients, when I ask them about their medical history or what medications they take will simply say, ‘It’s on your computer’. (GP 9)

113 One reason for the apparent dislike of the electronic record may be because investigation results were not available when the My Health Record was first online, and GPs consider availability of results most important to their everyday practice:

I think electronic health records are a huge thing, because a lot of waste from duplication would not happen. And I think that’s a big thing is that patients might have had the same thing investigated four times in the past two years. They’ve had all the same tests done, but we just don’t know about it. (GP 1)

So, I would like to see those barriers to be removed so that we have access to hospital tests and results and the hospital has access to other pathology. I mean the best way is to have access to the GPs—the GPs but many patients don’t have GPs, many patients have few GPs. So, I think there is a need to have a pool of pathology and radiology results somewhere. (GP 8)

And I suppose what I mean by that is if, say, some of the pathology companies don’t upload to it then I’d probably not routinely look at the ‘My Health Record’, whereas if they all are, which is what we hope will happen, then I think it will improve the problem. (GP 18)

Thus, the My Health Record was not meeting the needs of GPs and was considered yet another bureaucratic timewaster.

7.4 Other Initiatives

The GPs interviewed for this study had received little information about the MBS Review. The review is a good example of a top-down approach to policy where those at whom the policy is aimed have had little to do with policy formation. This is despite government claims that policy initiatives were based on discussions with people in the profession. It is possible that policymakers regard discussions with stakeholder representatives such as the RACGP and the AMA as equivalent to discussions with grassroots professionals. GPs had mixed feelings about these representative bodies:

Yeah. The RACGP. I seem to see him popping up a lot. I think it’s always at the good GP campaign going, as well. So, but I still feel like, on the whole, no. I feel really quite …I feel like a lot of doctors aren’t really saying a lot. Yeah. (GP 1)

I feel like no one’s listening to us and getting our opinion about these sorts of things. And I guess—is the knowledge of that, like I’ve never had a politician come and work—talk to me about any of these things. (GP 11)

114 look I still think the RACGP’s probably got more of a profile. I really can’t stand their advertising. I’ve written very strongly worded emails to them about that. Whereas I’m not just a GP. I thought we’d left that behind about three years ago— and then, ‘Nobody knows you like your GP’. It’s like, ‘What?’ It makes me cringe. (GP 13)

One action many GPs were eager to see was structural change within the system to enable general practice to take on more responsibility. Treatment of many conditions in a hospital setting was regarded as a waste of resources, though GPs felt that primary care would require better funding to be able to treat these conditions. However, this was expected to lead to substantial savings in the future:

So, we know that primary care and good strong, efficient, effective primary care is what keeps the health bill down. We know that from national studies and comparative research, so what’s logic? They should be putting more money into primary care and really cutting it on secondary care, but of course they can’t because you can’t take the candy away from the baby without the baby crying. (GP 2)

So I thought with that that almost all of the diabetic patients, bar a few that are really quite complex, could have actually been managed in primary care so I think there’s probably a lot when you start looking at the hospital system that could be managed effectively in primary care. (GP 16)

sometimes patients just don’t realise what GPs can do so I think it’s … I think it’s up to GPs to treat and manage what they can and then refer to the appropriate service. What they then need help with, but then I think there also needs to be better communication back because there’re lot of things that GPs could manage if they were sent a clear plan from the specialist. (GP 17)

It is interesting to note that rural and remote GPs were less likely to refer due to a combination of travel, accessibility and expense for patients: ‘you essentially you have to go into [capital city] if you wanted a doctor on the weekends. So, drive half an hour, it kind of weeds out all of those unnecessary business I think, but, yeah’ (GP 11).

GPs with experience in different settings often noted various concerns and solutions. One GP felt that a GP liaison in the hospital would improve many of the communication issues:

But I would have robust GP liaison in the hospital, like more than one of them in some pointless .1[one day/week] position. I would have GP liaisons who are on every ward that would do Discharge Planning rounds that would look at the patient and look at what could be done in the community and could actually liaise with that patient’s GP and ring them up and say, ‘We’ve got Mrs Bloggs in hospital. You know, did you know? Who’s had this and this and these are the…’ well, even at the initial admission it would be great so that they could get an up-to-date history of what’s been going on

115 with her lately and what blood tests she’s had done and ‘Could you send us through those results and the scans’ and that kind of thing. (GP 10)

Another GP with experience in palliative care felt that attention to end of life practices was likely to yield important cost savings:

look, I think better end of life planning is really important, when you look at the amount of health dollars that are spent on people in the last month or two of their lives, which is inappropriate. I think that, I think that’s an area where we really should be looking very closely, and I would be hoping that that’s an area with my health records, that we’d be able to do things like upload advanced healthcare directives and other information like that, so they’d be accessible to ED [Emergency Departments]. So, somebody like my 95-year-old that gets carted off to Emergency, with some acute condition and he doesn’t want to be resuscitated, that they can accept that, rather than putting him in Intensive Care. (GP 13)

This highlights the importance of consulting GPs with regard to policy.

7.5 Discussion

GPs’ claims about the health system differ from those of representative interest groups. These claims present a coalface perspective, which has potential positive and negative implications. Coalface perspectives have been criticised for the potential for representative bias (Scott, Soon, Elshaug & Lindner, 2017). However, a coalface perspective can provide policymakers and other stakeholders with a deeper understanding of the nature of general practice. It may challenge perspectives and provide insight into potential policy levers for improving the system. Given that GPs are often the focus of health policy, understanding the general practice perspective of current problems in health can aid implementation of policy. This analysis of GP claims finds that, for GPs, the world is more complex than that represented by the view of policymakers. This is notable in GP discourse. Perhaps because GPs negotiate complexities daily during work hours, they are less likely to make sweeping generalisations about the health system and more likely to detail multiple and at times conflicting claims about issues. By providing substance and clarity to claims, GPs can bring nuance to health policy discussions.

GPs make claims about the health system based on their everyday interactions within the system. As the main healthcare service providers within the Australian health system, GPs are perhaps best placed to offer what Lipsky (1971) calls a ‘bottom-up’ approach to policy formation. GPs are acutely aware of health system issues that make their lives and their patients’ lives harder. These issues contribute to waste within the system by altering GP

116 behaviour in ways that could negatively impact health spending. One example of this is the problems GPs face with time constraints. Most GPs agree that a significant proportion of their time is spent searching for information regarding patient treatment. Current structural issues cause problems in accessing this information and GP frustration at this situation is evident. GPs find themselves making choices between maintaining their appointment schedule or ensuring that duplication of investigations does not occur by attempting to navigate a disconnected system. While spending time looking for results is good for the patient and the system, it could be frustrating for the next patient forced to wait and for the GP faced with a restive waiting room and unwanted overtime. Faced with such a choice, it is not surprising that GPs often choose the path of least resistance by repeating the investigations. GPs freely admit that these factors may lead to less than ideal practice, but most are confident that they are working within appropriate boundaries. These findings have implications for the GP as gatekeeper. If GPs are aware of issues regarding waste within the system yet feel powerless to address these issues because of systemic problems, they are unlikely to fulfil expectations of gatekeeping. Similarly, if GPs do not regard themselves as primarily responsible for such waste, then they are unlikely to take actions to address this issue.

7.6 Conclusion

That GPs have insight into less than ideal actions may contradict government claims that wastage occurs because of GPs’ ignorance or wilful abuse of the system; rather, GPs’ actions are a response to acknowledged pressures that require consideration of multiple factors when making decisions. GPs must make these choices within a limited timeframe and this requires complex decision-making skills. That GPs felt they are doing their best in a less than ideal situation may make educational and punitive actions unacceptable and unsuccessful if these pressures are not first addressed.

GPs are frustrated that primary care is the most often targeted healthcare sector for government intervention. This appears unfair to many GPs who regard inefficiencies as more of a problem for the secondary and tertiary care sectors. A further concern is the lack of appropriate funding for the primary care sector and the apparent over-funding of secondary and tertiary care. Lack of consultation and a top-down policy approach exacerbate this issue. These issues appear to reflect a lack of respect for GPs and their work. This lack of respect is mirrored in the day-to- day problems faced by GPs due to poor discharge summaries, poor access to investigation results and poor remuneration.

117 The issues of training, funding and respect reflect the historical issues faced by general practice discussed in Chapter 3. While these issues do appear to be an ongoing concern among GPs, attempts to address these issues through policy continually fall short. Infrastructure weaknesses and systemic issues such as health literacy, a top-down policy approach and poor communication require an approach that involves more than funding and feedback to ensure quality general practice. GPs regard leadership from policymakers in this area as lacking. According to GPs, until these factors are addressed, their ability to act as gatekeepers of the health system will be limited.

118 Chapter 8: What is the answer?

This chapter examines the evidence for the claims stakeholders have made about the Australian health system to consider the validity of the situational claims and the advisability of action claims. Many questions arise from these claims. Why, for example, is there disagreement between stakeholders regarding the sustainability of Medicare and the existences of a fiscal emergency in health? One could assume that such disagreement could be swiftly resolved through attention to facts and figures. That stakeholders disagree indicates that there is more at play here than a bald interpretation of facts. This chapter considers the evidence for claims using the proof offered by stakeholders along with further available evidence. Not every claim is discussed here. Those that are discussed are those that are shared or debated by stakeholders. These claims are listed in Table 1. As noted in Chapter two, while qualitative research is perhaps more reflective of general practice than quantitative research, GPs do appreciate empirical information when consulting patients. This chapter attempts to provide some empirical information about the claims made by various stakeholders. This chapter also mirrors two parts of a GP consultation. The first is that of examination. Here, GPs look for physical evidence of patients’ historical claims. For example, does a patient with palpitations have an irregular pulse or heart murmur? Secondly, the GP will consider the evidence for further investigation and treatment. Should the patient have an ECG, a Holter monitor, or is no investigation required? Much like the evidence for these decisions, the evidence for many stakeholder claims is less obvious than may be expected.

119 Table 1: Claims About the Australian Health System Type of Claim Claim Evidence Situational claim Costs are spiralling out of control Equivocal Ageing populations increase expenditure Equivocal Chronic diseases are poorly managed Equivocal Medicare item numbers for chronic Equivocal diseases are being abused Six-minute medicine is a problem Refuted Out-of-pocket expenditure is increasing Justified Poor discharge summaries are common Justified

Attributional Australia has poor health literacy Justified claim Patient pressure increases investigation Equivocal ordering Duplication of investigations because of Equivocal system features is a problem Doctors practising low-value medicine is Equivocal a problem GPs are ordering inappropriate tests Equivocal Action claim Co-payments will reduce costs to the Refuted system Changing payment methods will change Equivocal doctor behaviour A national electronic health record will Equivocal improve efficiency Private health insurance will reduce Refuted government spending on health

8.1 Situational Claims

8.1.1 Are Costs Spiralling Out of Control?

The first question to consider is whether health costs are spiralling out of control. Both Mr Dutton and Ms Ley claim that this is the current situation in the health system. This claim is disputed by the AMA, RACGP and CHF, while GPs are divided on this subject. The health ministers used the biennial Australia’s health reports from the AIHW and the Intergenerational

120 Report as proof of their claims. The AMA used the Commonwealth Fund report and Parliamentary Budget Office report to counter these claims, while the RACGP and CHF used the AIHW report to do the same. According to the AIHW’s (2014) report, Australia’s health 2014, spending on health was approximately 1.7 times that of a decade ago. This expenditure included government and private expenditure and considered the whole health system, of which Medicare is a significant part. Primary healthcare services accounted for 36.1% of all healthcare expenditure, the second-highest area after public hospitals (AIHW, 2014, p. 49). The ratio of health expenditure to gross domestic product (GDP) also appears to be increasing, with current spending at 9.5% compared with 6.8% two decades ago (AIHW, 2014, p. 47). Thus, health expenditure is outstripping economic growth (AIHW, 2014).

The Intergenerational Report, Australia in 2055 (The Treasury, 2015, p. xvi) predicted that this situation would continue unless government policy were to change. This was used by both Mr Dutton and Ms Ley as proof of their claims. The AMA countered with the Commonwealth Fund report (Davis et al., 2014) which appeared to show that health spending was relatively stable, and that Australia remained below the OECD average regarding the ratio of spending to GDP. However, the Commonwealth Fund report was primarily concerned with the performance of the US health system, and while Australia is doing well comparatively, this is not the complete picture. Nor is the Intergenerational Report (2015) a reliable indicator of spiralling health costs, suffering as it does from the usual problem afflicting economic crystal gazing: the near impossibility of predicting a future impacted by multiple variables (The Treasury, 2015, p. 33). Comparisons over a decade, such as those found in reports from the AIHW, also suffer from the impact of confounding factors. For example, the rather swift increase in health spending reported in the first decade of the twenty-first century was likely the result of government policy which saw a one-off increase in remuneration for GPs, increased expenditure for a bulk billing incentive and an increase in the number of GPs (Parliamentary Budget Office, 2015, p. 15). At the same time, the 2007–2008 global financial crisis saw a drop in government revenues and health spending took some time to adjust to this situation (Parliamentary Budget Office, 2015, p. 15). Using the past decade as a model for predicting future health spending is therefore fraught with difficulties. The slowing growth of government health expenditure, claimed by the AMA, CHF and RACGP to contradict the government’s claims, appears correct (AIHW, 2018a, p. 56). However, these claims are also problematic given that much of this could be attributed to government policy such as the freeze

121 of the Medicare rebate (The Treasury, 2015, p. ix). While government healthcare costs do seem to be increasing, the idea that they are spiralling out of control is difficult to prove.

8.1.2 Does an Ageing Population Increase Health Expenditure?

An ageing population and the rise of chronic diseases are factors that all stakeholders agree on. An assumption is made by policymakers that ageing will lead to increasing health spending. However, as the AIHW (2014, p. 55) notes, the relationship between ageing and expenditure is complex. Early predictions of the catastrophic effect of population booms related to increased life expectancy have failed to materialise (Bloom, Canning & Fink, 2010). Healthcare expenditure appears to increase only in proximity to death, suggesting that the intensity of healthcare increases just before a person dies, confirming the suspicion of GP 13 (see section 7.4) that costs in this area are high (Shang & Goldman, 2008). Likewise, much research suggests that ageing has contributed only minimally to the identified increases in health expenditure over the past 20 years (Breyer, Costa-Font & Felder, 2010; de Meijer, Wouterse, Polder & Koopmanschap, 2013; Reinhardt, 2003; Seshamani & Gray, 2002; Werblow, Felder & Zweifel, 2007; Zweifel, Felder & Meiers, 1999). Several researchers have hypothesised that this is because advances in medical care resulting in increased life expectancy have also resulted in healthier ageing and a potential reduction in pressure on health systems (Werblow et al., 2007). Others suggest a complex link between increasing life expectancy, increasing income and increased health expenditures (Breyer et al., 2010). For this hypothesis, increases in health expenditure result in increased life expectancy. The longer we live, the more we are likely to earn, and the more we earn, the more we are likely to spend on healthcare (Breyer et al., 2010). Werblow et al. (2007, p. 2) note that understanding this complexity is important as a focus on ageing as a cause of healthcare expenditure could lead to inappropriate health policy and maldistribution of resources.

The rise of chronic diseases, however, suggests that ageing in Australia may not follow the pattern indicated by previous research. Ageing may not be as healthy as previously thought. Claims about chronic diseases suggest that they are on the rise and one in two Australians has a chronic disease (AMA, 2015a; CHF, 2016h; Department of Health, 2014b, 2016b, 2017t; RACGP, 2015h). This is consistent with data from the national health survey of 2014–2015 which found that 50% of people surveyed had at least one chronic health condition (Department of Health, 2017c). An earlier national health survey found that 77% of people surveyed reported one or more chronic conditions (Australian Bureau of Statistics, 2006). Taken at face

122 value, this would appear to indicate a decrease in the prevalence of chronic conditions; however, problems with deciding what constitutes a chronic condition make comparisons of data unreliable. For example, in the earlier health survey, eyesight difficulties were reported in 52% of patients and reported as a chronic condition (Australian Bureau of Statistics, 2006). Eyesight difficulties were not included in the later survey (Australian Bureau of Statistics, 2015). Difficulties with defining what constitutes a chronic illness have been discussed elsewhere (O’Halloran, Miller & Britt, 2004). It is therefore difficult to assess the rise or otherwise of chronic diseases and the impact this has on health expenditure. However, it is likely that current presentations to medical services represent different health issues to those that presented frequently when Medicare was first introduced.

8.1.3 Are Chronic Diseases Poorly Managed?

Difficulty managing chronic diseases because of the antiquated structure of Medicare is another situational claim agreed on by all stakeholders. Poor management of chronic diseases is, again, something that could be measured in multiple ways. An increase in deaths due to chronic diseases may indicate problems with management, but it would be confounded by several variables including the increased incidence of such diseases. According to the World Health Organization (2020), 90% of all deaths in Australia in 2002 were due to chronic diseases. However, this is perhaps more an indication of the success of measures to reduce infectious diseases and injuries than a reliable indication of poor management of chronic disease. Australia performs very well in measures of perception of health, with a slight rise (0.6%) in the number of people reporting ill-health, while the number of people reporting good health has remained relatively stable at around 85% (OECD, 2018). Australia also performs well comparatively as seen in the improvement in healthcare rankings in the Commonwealth Fund report (Schneider et al., 2017). However, Australia’s rates of admission of patients with asthma and chronic obstructive pulmonary disease are the highest of the OECD countries (OECD, 2017b). These diseases are considered better managed in primary care and hospital admissions, therefore, indicate a failure at the primary care level. Again, the evidence remains unclear and appears to have been cherry-picked for political expediency.

8.1.4 Are Medicare Item Numbers for Chronic Disease Management Being Abused?

GPs and policymakers claim that initiatives aimed at addressing problems in chronic disease management are open to abuse within the system. GPs further claim that these initiatives do

123 not adequately address the problems for which they were designed. Medicare data indicates an increasing uptake of chronic disease management plans, which were developed to encourage coordination of care for patients with chronic diseases. Given the high admission numbers of asthma and chronic obstructive pulmonary disease, these plans may not be preventing more expensive care. The Professional Services Review, an organisation charged with the oversight of Medicare compliance, has reported an increase in the number of doctors referred to the review because of potential misuse of the chronic disease management item numbers (Australian Government, 2015). Thus, chronic disease management does appear less than ideal; however, the exact extent of the problem is not yet well understood.

8.1.5 Is Six-minute Medicine a Problem?

Policymakers claim the practice of six-minute medicine is common and leads to poor management of chronic disease. The evidence suggests that this claim is incorrect. Bettering Evaluation of Care and Health (BEACH) data shows that the average length of a GP consultation in Australia is 14.8 minutes, an overall increase in consultation time from 10 years previously (Britt et al., 2014, p. 31). Short consultations accounted for only 3.3% of all timed consultations in one BEACH study (Britt, Valenti & Miller, 2014, p. 2). Indeed, the BEACH data showed that GPs were managing more conditions and performing more procedures than 10 years previously, placing doubt on claims that GP behaviour was causing overcrowding of emergency departments (Henderson et al., 2016). GPs were also more likely, according to BEACH data, to bill a standard level of consultation when a long consultation was more appropriate. This suggests that accusations that GPs are abusing the system are overstated. It further suggests that GPs’ claims of trying to do the right thing by the system are substantiated.

8.1.6 Is Out-of-pocket Expenditure a Problem in Australia?

According to the AMA, RACGP and CHF, the rise of chronic diseases is exacerbated by rising out-of-pocket expenditure. Out-of-pocket expenditure was thought to comprise 20% of all expenditure on health in Australia in 2013 (OECD, 2015). According to the latest report from the AIHW (2018b), 50% of patients incurred out-of-pocket costs for non-hospital medical care in the years 2016–2017. This did not include dental or most allied healthcare. Although more regional patients experienced out-of-pocket costs than urban patients, the total out-of-pocket costs were less than urban patients (AIHW, 2018b). There was marked variation in how much patients were spending, with the highest expenditure noted in higher socioeconomic areas and

124 lower expenditure in lower socioeconomic areas (AIHW, 2018b). Rising out-of-pocket expenditure may not be a problem if this expenditure is borne by those in higher socioeconomic circles whose income can presumably absorb the shock of such expenditure. However, rising out-of-pocket expenditure may cause patients from lower socioeconomic strata to reconsider seeking medical care. This, in turn, could potentially lead to increased costs to the system as patients present later and require potentially more expensive care. Data here is again difficult to interpret due to different methods of expressing the data. For example, the 2013 OECD health report did not report on lack of access to healthcare due to cost (OECD, 2013). The 2015 report noted that 21% of patients from lower socioeconomic areas and 14% of patients from high socioeconomic areas missed a consultation because of concerns about costs (OECD, 2015). The 2017 report noted that 16.2% of patients skipped a consultation for the same reasons (OECD, 2017a). This compares with 8% of patients who reported delaying seeking medical care because of the associated costs according to the latest report from the AIHW (2018b). The difference in the data is difficult to explain given that the OECD data is sourced from the AIHW data. It is possible that the AIHW data is the latest data yet to find its way into OECD reporting.

8.1.7 Are Poor Discharge Summaries a Problem?

The perception of poor access to discharge summaries is substantiated by the literature. GP claims here are consistent with the available evidence. An early Australian study of communication between hospitals and GPs found that only 35.4% of discharge summaries were received by treating GPs, and only a small percentage of these were considered useful (Wilson, Ruscoe, Chapman & Miller, 2001). A later international literature review determined that an average of 25% of discharge summaries never arrive, and only 53% of discharge summaries arrive within one week of patient discharge (Kripalani et al., 2007). Although a more recent Australian study indicates that more discharge summaries are being received, timeliness and quality of discharge summaries remain an issue, with only 55% of discharge summaries being received by GPs before the first post-admission patient encounter and summaries often missing important information such as test results (Belleli, Naccarella & Pirotta, 2013). Information regarding discharge summaries from private hospitals remains elusive (Wong, Yee & Turner, 2008). Reasons for the ongoing problems with discharge summaries range from a lack of medical school education regarding the importance of clinical handover to the lack of integrated information and communication technology (Belleli et al., 2013; Kattel et al., 2016). This problem may be adequately addressed by the My Health Record, although here too

125 information may be operator dependent. Discharge summaries not written at the point of discharge may still take time to appear on the electronic record.

8.2 Attributional Claims

8.2.1 Is Poor Health Literacy a Problem?

GP perceptions of their patients’ poor health literacy and similar claims by the CHF are reflected in the available data. Data extrapolated from the 2006 Adult literacy and life skills survey suggests that only 48% of Australian adults possess the skills to successfully utilise health information and services to improve their health (Australian Bureau of Statistics, 2009). Further complicating this is the rise in the use of the internet as a source of health information, with data from the BEACH study suggesting at least half of all patients consulting GPs had consulted the internet prior to their visit (Wong, Harrison, Britt & Henderson, 2014). The use of the internet has not necessarily improved patient health literacy as the extent of information available can lead to less than ideal information-processing strategies (Metzger & Flanagin, 2011). A large portion of online information has been assessed as having low readability, leading to the possibility of misinterpretation of information, resulting in poor health choices (Cheng & Dunn, 2015). The impact of poor health literacy on pathology and radiology investigation costs is unknown, although poor health literacy is considered likely to cause expense to the health system through poorer health outcomes (Nutbeam, 2008). The perception that poor health literacy leads to inappropriate requests for pathology testing is therefore difficult to validate and is a matter for further investigation.

8.2.2 Does Patient Pressure Affect Investigation Ordering?

Pressure from patients is a known factor affecting both investigation ordering and prescribing behaviours of GPs (Keitz, Stechuchak, Grambow, Koropchak & Tulsky, 2007; van Bokhoven et al., 2008, p. 142). Keitz et al. (2007, p. 451) found that doctors acceded to patient requests for investigations about 77% of the time, while van der Weijden et al. (2003) found that GPs were more likely to order tests in response to patient requests and to reassure patients. However, attempting to quantify such influence is difficult as multiple factors influence GP behaviour in any single consultation. Evidence for patient expectations within the Australian context is limited. Data from the BEACH study suggests that investigations were initiated by patients about 15% of the time; however, the appropriateness or otherwise of these tests was not

126 discussed (AIHW, 2003). Bayram (2013, pp. 227, 234) noted that in cases of full blood count investigations, patients initiated tests only 6% of the time, while in cases of lipid investigations, patients initiated tests only 11.2% of the time. It is possible that Australian GPs may overestimate the effect of patient pressure on their ordering habits, or that they are particularly good at rejecting patient requests. However, this is only speculative and further research in this area is important.

8.2.3 Is Duplication of Investigations a Problem?

Globally, assessment of duplication of pathology results has been difficult as duplication is often considered with other inappropriate testing. Van Walraven and Raymond (Intergenerational Report, 2015) analysed laboratory data and estimated that approximately 30% of tests had been inappropriately duplicated. These were mostly duplicated in hospital emergency departments (van Walraven & Raymond, 2003). Bridges, Papa, Norris and Chase (2012) analysed inappropriate duplicate testing in hospital inpatients in Florida and estimated that approximately 7.7% of tests were repeated unnecessarily. A Canadian study of six common tests showed a duplication rate of approximately 16%, with a cost to the Canadian health system estimated to be about US$160 million (Morgen & Naugler, 2015). Jha et al. (2009) estimated that eliminating redundant tests would save around US$8.2 billion; however, how this amount was arrived at and how many tests this involved was unclear. Little is known about the duplication of tests results in the Australian health system. The current lack of integrated computer records makes assessment difficult. However, Bayram (2013) does note that new patients to a general practice were more likely to receive blood tests and this may be an indication of duplication due to lack of records and the GP’s desire to fully understand the patient’s history. If, as GPs suspect, duplication is occurring at significant rates, then addressing this issue could achieve important cost savings for the Australian health system.

8.2.4 Is Low-value Care a Problem?

Ms Ley made the claim that low-value care was causing inefficiency within the Australian health system. This was based on the work of Elshaug, Watt, Mundy and Willis (2012) who found potentially 150 low-value care items covered by the MBS. While this study is often quoted when referencing the prevalence of low-value care within the health system, the study’s authors considered the study as a ‘launchpad’ for further exploration of the concept (Elshaug et al., 2012, p. 556). Determining what defines low-value care has proven problematic.

127 Distilling the contextual appropriateness or otherwise of potential low-value procedures or treatments remains an ongoing concern (de Vries, Struijs, Heijink, Hendrikx & Baan, 2016; Duckett, Breadon, Romanes, Fennessy & Nolan, 2015). A procedure that is low value in one circumstance may not be low value in another. A study in the Australian public hospital system found that the occurrence of low-value care was uncommon (Badgery-Parker et al., 2019). Studies of low-value care in general practice are required to establish the extent of such care.

8.2.5 Do GPs Order Inappropriate Tests?

That radiology and pathology investigations are overused has become a matter of common understanding in health policy. Papers discussing the overuse of pathology investigations state figures of overuse as high as 56% (Smellie, 2003). Such figures lend weight to health policies targeting waste and inefficiency at the practitioner level within health systems. Much research has been devoted to the ways in which recalcitrant doctors can be encouraged to reduce the amount of pathology they order. Closer examination of over and underutilisation of pathology and radiology investigations reveals several issues with the evidence. Many assumptions underly the evidence. For example, poor outcomes are often assumed to result from over- ordering of investigations despite a lack of evidence for this. Further, the idea of appropriate testing has merged with the idea of less testing so that less testing is now regarded as appropriate (Bayram, 2013). This is problematic as underutilisation of investigations may prove worse for patients. Finally, much of the research has been undertaken in hospital settings rather than primary care. A systematic review of studies in this area found that most studies were based in the US health system and performed in a hospital-based setting (Zhi, Ding, Thiesen-Toupal, Whelan & Arnaout, 2013). This study found that underutilisation of tests was greater than overutilisation of tests, although the criteria used to determine inappropriateness for the tests studied was thought to be a confounding factor in the results (Zhi et al., 2013). Despite the authors’ reservations about the wider applicability of results because of this, Cappelletti (2016, p. 92) notes that this study is now frequently cited as evidence for inappropriate use of investigations.

Evidence for the pathology and radiology ordering habits of Australian GPs comes from the BEACH program. Data from this program is perhaps the most detailed review of general practice ordering habits available. This data provides a much clearer picture of the investigation ordering habits of GPs in Australia, but interpretation of this data remains complex. Bayram (2013, p. 321), in her extensive analysis of BEACH data regarding six common clinical

128 problems, determined that GP investigation ordering within the Australian context overall aligned well with available guidelines. GPs were thought to have ordered appropriate tests approximately 77.8% of the time, with 16% of tests considered inappropriate. However, as with the problem of referrals explored in Chapter 4, there were issues with defining appropriateness. Measuring appropriateness of investigations has proven surprisingly difficult. Understandings of appropriateness have changed over time and consensus regarding appropriateness has been difficult to achieve (Cappelletti, 2016, p. 92). Australian guidelines often have precarious evidence bases. Buchan et al. (2010) found that only 29% of Australian guidelines referred to evidence for the information within the guidelines. Bayram (2013, p. 96) noted the problem of multiple guidelines with differing advice in her review of general practice ordering of full blood counts for hypertension. Guidelines have also been criticised for the lack of applicability of advice in scenarios of comorbidities (Lugtenberg et al., 2011). Guidelines may also prove inappropriate for the general practice context where patients and clinical presentations differ significantly from those in secondary and tertiary care (Bayram, Britt, Miller & Valenti, 2009). The current definition of what is appropriate, ‘prescription of the right test, using the right method, at the right time, to the right patient, with the right costs and for producing the right outcome’ (Lippi, Bovo & Ciaccio, 2017), is also problematic, with a potential for broad interpretation leading to underestimation of inappropriate utilisation (Zhi et al., 2013, p. 6).

8.3 Action Claims

8.3.1 Will Co-payments Reduce Costs to the Health System?

Mr Dutton, the AMA and some GPs make the claim that co-payments could reduce expenses within the system. While Mr Dutton claims that co-payments would reduce the number of inappropriate visits to the doctor, GPs regard co-payments as a way to educate patients about the cost of healthcare, specifically investigation ordering. For GPs, co-payments on pathology and radiology investigations could reduce patient pressure to order inappropriate tests. The evidence suggests that while inappropriate visits to doctors and inappropriate utilisation of services can be reduced through co-payments, appropriate visits and appropriate utilisation of services will also be reduced (Remler & Greene, 2009). This could, as the RACGP, CHF and some GPs noted, inadvertently increase costs to the system as patients present late with conditions now requiring secondary or tertiary care. As Remler and Greene (2009, p. 307) note, co-payments are a ‘blunt instrument’ for constraining health costs. Attempts to model the

129 effects of Mr Dutton’s co-payments in the Australian context have concluded that co-payments are likely to cause harm to vulnerable patients, thus supporting the claims of the RACGP and CHF (Elkins & Schurer, 2017; Laba et al., 2015). Keane (2015), however, argues that studies of co-payments are impacted heavily by ideological considerations and should therefore be considered flawed. He argues that the negative consequences of co-payments should be compared with negative consequences of overloaded systems and long waiting lists to clarify the true negative potential of co-payments (Keane, 2015). Such research has not been performed and further investigation of his claims is needed.

8.3.2 Will Changing Payment Methods Change GP Behaviour?

While chronic disease management plans have been a primary focus of management of chronic diseases in general practice, there have been some efforts to introduce pay for performance to improve management of these diseases. GPs have been able to claim various item numbers for management of asthma, diabetes and screening for cervical cancer since 2001 (Greene, 2013, p. 1415). The success of these item numbers is reportedly limited, with GPs claiming that the increased paperwork generated by these item numbers is a significant barrier to participating in the program (Greene, 2013). A further criticism is that while these programs may improve ordering of tests, there is currently no evidence that this improves health outcomes. It appears that all payment models have problematic aspects and finding a model that all GPs agree with is unlikely. As one GP noted:

the most logical thing would be to pilot test the whole variety of different models in Australia and see which one’s work, take a realists review and look at not only does it work, but why does it work, under what circumstances? How does it work? When does it work? (GP 2)

All stakeholders make claims about payment methods affecting the behaviour of doctors. Policymakers, the CHF and some GPs claim that fee-for-service encourages quantity over quality, while the RACGP claims that fee-for-service is not adequate for assisting GPs to appropriately manage chronic disease. The AMA and some GPs feel that fee-for-service remains the most appropriate way of paying for health services. The evidence here is also mixed. In an early systematic review, Gosden, Pedersen and Torgerson (1999) noted that fee- for-service encouraged a high volume of consultations, but other factors such as professional standards appeared to temper physician actions to ensure clinical actions were appropriate. However, they did find that salaried doctors were less likely to order tests and make referrals

130 than doctors working for fee-for-service or under capitation systems. Carrin and Hanvoravongchai (2003) noted that fee-for-service was unlikely to contribute to cost containment in health systems, while capitation may have some effect and a system in which doctors were salaried was likely to have a high effect. In a later Cochrane review, Gosden et al. (2000) again noted that fee-for-service produced a higher volume of consultations, but also resulted in greater continuity of care and greater compliance with guidelines. Referrals and investigations continued to be higher in areas where doctors worked within a fee-for-service model (Gosden et al., 2000). However, as Scott and Connelly (2011) note, these reviews do not establish if the higher volumes and test ordering established with fee-for-service is a result of over-servicing, or if different payment methods lead to different health outcomes. Peckham and Gousia’s (2014) systematic review found that salaried and capitated doctors were more likely to refer and that market forces altered how fee-for-service affected doctor behaviour. While claims about fee-for-service encouraging quantity appear correct, it is less clear whether this is a problem or whether similar problems are likely to occur from other payment models. It does appear that the desired outcome needs to be clearly established before payment methods are discussed. Policymakers may find themselves deciding between cost containment or good health outcomes when choosing a suitable payment method.

8.3.3 Will a National Electronic Health Record Reduce Costs and Improve Efficiency?

There is currently little evidence for the benefits or otherwise of electronic health records integrated at the national level. Much of the evidence for electronic health records concerns the introduction of electronic records within individual practices. Interestingly, while improved efficiency, reduction in medical errors and improved patient outcomes were predicted to result from the introduction of practice electronic health records, these do not appear to be substantiated. For example, Hillestad et al. (2005) predicted that introduction of electronic records within the US health system would result in an US$81 billion saving every year due to increased efficiencies and reduction in medical errors. However, Nguyen, Bellucci and Nguyen (2014) found mixed results from a systematic review which suggested that gains in some administrative efficiencies were negated by losses from added administrative challenges. In another literature review, Ludwick and Doucette (2009) found no evidence to suggest that electronic records impacted either positively or negatively on patient care. Again, this was for individual practice electronic records. Further review is required to determine the effectiveness of the Australian My Health Record initiative.

131 8.3.4 Will Private Health Insurance Reduce Government Spending on Health?

When Medicare was established in 1984, the Hawke Labor Government had little interest in the survival or otherwise of medical insurance funds (Boxall & Gillespie, 2013, p. 120). However, later governments have expressed interest in the potential of private health insurance to reduce public health spending, with various incentives offered for taxpayers who chose to take up private insurance (Ellis & Savage, 2008). Both Mr Dutton and Mr Hunt claimed that private health insurance was necessary for the successful functioning of the Australian health system. Mr Dutton claimed that the private insurance market would bring new efficiencies to the health sector, while Mr Hunt claimed that private health coverage improved patient choice and waiting times and reduced the burden on the public system. Proponents of private health insurance reiterate the claims of these policymakers. The theoretical benefits of private health insurance include efficient and innovative reactions to market demand, as well as providing patients with a wider choice of goods and services (Colombo & Tapay, 2004). However, Colombo and Tapay (2004) note that evidence for these claims is limited. Indeed, countries with the highest levels of private health insurance also appear to have the highest spending on health (Colombo & Tapay, 2004). Multiple barriers prevent private health insurance from fulfilling these expectations. Evidence suggests that private health insurance may increase utilisation of health resources, thereby increasing costs to the system (Colombo & Tapay, 2004; Debnath, 2015; Kiil & Arendt, 2017).

This could be due to several reasons. Private health insurers in systems with strong public health insurance can experience the problem of adverse selection (Debnath, 2015). Here, healthier patients opt out of the private system, leaving only sicker patients which increases costs for insurers and subsequently leads to higher premiums and more customers opting out of insurance (Debnath, 2015). The problem of moral hazard, where patients are more likely to utilise health services if they are covered by private insurance, is also an issue for both insurers and the government. Patients are more likely to utilise both public and private health in this scenario (Debnath, 2015). This is especially important in situations where chronic disease is on the rise. Patients with chronic disease could be expected to utilise more healthcare and more expensive care, which would place increased pressure on private insurers and on the public health system. Therefore, private health insurance may not necessarily reduce costs. Vonk and Schut (2019) claim that achieving cost control with private health insurance in systems with universal access is complex and requires both extended government regulations and active

132 input from insurers. According to Vonk and Schut (2019), this is because private health insurance and public health insurance are ideologically opposed. Free markets do not ensure universal access, and government regulation is therefore required if universal access is a goal of health provision. Such governmental regulation is inherently anti-free market, leading to an ideological conundrum (Vonk & Schut, 2019).

A concern for the CHF was that the introduction of private health insurance into the primary care sector would produce an inequitable two-tiered system of medical care. There is some evidence to support this hypothesis. Chawla (2007) notes that unregulated private health insurance can result in increased costs of healthcare, which has a significant impact on the uninsured. Private rebates for healthcare providers may be higher in private health systems, and this may lead to providers ignoring the public system in favour of the private system (Debnath, 2015). While this may ensure that privately insured patients have better access to timely care, this can lead to extended waiting periods for publicly insured patients, potentially leading to inequitable health outcomes (Debnath, 2015). Again, while the theoretical benefits of an action claim may appear to justify the claim, the evidence is less clear and requires further evaluation.

8.4 Conclusion

Evidence for most claims made by policymakers, stakeholders and GPs is mixed. Opposing claims of fiscal concerns within the system are often justified using the same sources of evidence, albeit with an opposing interpretation of the facts. Evidence, it seems, is selected to support an argument, rather than an argument developing from the presented evidence. Other claims, such as those surrounding private health insurance, appear to be ideologically driven. Some facts appear to be embedded as facts through repetition rather than through solid evidence. GP claims, however, were mostly validated by what evidence was available. For example, GPs’ claims about poor health literacy and the duplication of results, are supported by evidence, although further research would be beneficial. GP perspectives, therefore, provide valid insights into the health system. The absence of clear evidence for any of these claims, however, does not come as a surprise to a GP. In general practice, the complexity of patient presentations often precludes the development of good evidence for individual consultations. As policymakers and other stakeholders tend to choose the evidence that best suits their argument, so too do GPs tend to choose the evidence which best suits their requirements. The lack of clarity in evidence for policy reflects the lack of clarity in evidence for general practice.

133 Just as policy development cannot be said to be a linear process based on the available evidence, neither can decision-making in general practice. This has implications for gatekeeping. Expectations that GPs will act according to evidence may be disappointed simply because the evidence is vague and open to multiple interpretations. The failure of evidence to provide a clear pathway for complex decision making should be given much consideration when determining expectations of general practice.

134 Chapter 9: Framing the Issue

Diagnosis and treatment in general practice develops not only from consideration of context, history, examination and evidence but also by determining how patients understand their symptoms and what beliefs they have about health and healthcare. This assists doctors with personalising an acceptable pathway for the patient. Gaining such knowledge usually comes through getting to know the patient over time. For new patients, GPs must become experts at detecting how patients understand health and their beliefs about health care through consideration of how patients frame their discussions about health. Likewise, understanding stakeholders in the policy space requires not only assessment of claims and evidence, but also an assessment of underlying perceptions of health and healthcare which impact on these claims. This chapter considers these factors though an analysis of the framing of arguments within this space. It demonstrates how policymaker frames are constrained by an ideological position on healthcare. It also demonstrates how the AMA, RACGP and CHF frames are constrained by the dominant discourse of policymakers. Such constraints result in discussions about health defaulting to discussions about money, and this has negative consequences for those claiming a gatekeeper role.

9.1 A Review of Framing Analysis

The origin of framing is found in the work of Bateson from the 1950s (Vliegenthart & van Zoonen, 2011, p. 101). Bateson’s observations of animal behaviour prompted ideas about the nature of meaning and the different ways in which human beings could interpret the same situation (Van Hulst & Yanow, 2016, p. 94). Bateson’s ‘framing’ concerned the way in which meaning was developed by interactions between individuals in social situations (Van Hulst & Yanow, 2016). Much of Bateson’s work concerned the non-verbal communication of meaning, and his work on framing was further developed by Goffman (1974) for whom frames represented the many ways, both verbal and non-verbal, in which people negotiated situational meaning.

Goffman postulated that people use various strategies and sets of understood rules to classify and characterise lived experience (Hill, 2014). People’s frames were transformed by events which Goffman (1974, p. 78) described as ‘keying’. These he divided into Make believe (such as the influence of plays or movies), Contests (sports), Ceremonials or social rituals, Redoings

135 (rehearsals or practice of certain social situations) and Regroundings (where situations are reworked for differently agreed purposes) (Goffman, 1974, pp. 48–75). Also of influence for Goffman were fabrications, deliberate attempts by social actors to change scenarios to give a ‘false’ sense of reality (Goffman, 1974, p. 83). These factors all led to the development of a primary framework through which the individual interpreted day-to-day activities. Several theorists have built on Goffman’s work, resulting in a variety of quite disparate interpretations of framing analysis.

Framing analysis has been used in both analysis of, and analysis for, health policy. Issues where policy is potentially contentious, such as climate change, or issues which require changes in behaviour, are common targets of framing analysis (Hawkins & Linvill, 2010; Korn, Gibbons & Azmier, 2003; McCright, Charters, Dentzman & Dietz, 2015; Patchett, Yeatman & Johnson, 2016). A recent review of the use of framing in health policy research found that framing analysis had been used to analyse health policy across a variety of disciplines including policy studies, political science, sociology, psychology and media studies (Koon, Hawkins & Mayhew, 2016, p. 805). However, this study also found that while many articles referred to framing, many could not be regarded as having performed a framing analysis and the definition of framing was unclear (Koon et al., 2016, p. 807). These difficulties in adequately defining framing are found across disciplines and several understandings of terms and processes exist.

Framing has been described in several ways. According to Johnston (1995, p. 217), frames are a ‘mental structure that organized perception and interpretation’. According to Ryan and Gamson (2006), a frame is ‘a thought organizer, highlighting certain events and facts as important and rendering others invisible’. Chong and Druckman (2007, p. 104) refer to framing as ‘the process by which people develop a particular conceptualization of an issue or reorient their thinking about an issue’. According to Dekker (2017, p. 127), framing ‘is about making a difference between what is important and what is not, regarding a particular issue or situation. Frames arise when people are encountered with a situation and ask themselves: “What is going on here?” ’ According to Koon, Hawkins and Mayhew (2016, p. 83), frames are ‘considered to be an optimal unit of analysis in ideas-based policy research, as it constitutes either a package of ideas or a central organizing idea’. This definition differs from the previous three in that it suggests the possibility of discovery of a static concept that will explain variations in stakeholder perceptions. This variety of ideas has been recognised as problem, and several theorists have attempted to address it.

136 Benford (1997, p. 413) notes the multiplicity of definitions of framing and believe it stems from different understandings of the frame ‘metaphor’. He recognises two understandings of the concept of frame (Benford, 1997). The first is as a ‘grammar’ or ‘descriptor’, which relates all elements contained within the frame (Benford, 1997, p. 413). The second understanding is contextual, in which a frame serves to promote certain views over others (Benford, 1997, p. 413). Rein and Schön (1996) noted four different ways in which a frame can be understood: ‘[a] frame can be seen as a scaffolding (an inner structure), a boundary that sets off phenomena from their contexts (like picture frames), a cognitive/ appreciative schema of interpretation …, or a generic diagnostic/prescriptive story’ (p. 88). Rein and Schön (1993) have utilised this fourth understanding for their work in policy analysis.

Benford and Snow (2000) suggested extending the diagnostic/prescriptive story concept by advocating a method of identifying frames through identification of several core framing tasks. These tasks were identified as ‘diagnostic’, ‘prognostic’ and ‘motivational’ framing (Benford & Snow, 2000). Diagnostic frames are ways in which people construct meaning to answer the question ‘What is going on here?’ Problem definitions are developed through interactions with other stakeholders, lived experience and consideration of personal and communal values. ‘Prognostic’ frames consider the question ‘What should be done?’ These frames tend to develop in response to ‘Diagnostic’ frames. ‘Motivational’ frames are ways in which people are mobilised for action. Motivational frames develop out of group consensus and may or may not be a consequence of ‘diagnostic and prognostic’ frames (Benford & Snow, 2000). Although these are considered core tasks, diagnostic, prognostic and motivational frames develop from sense-making processes, perhaps the dominant of which is storytelling as described by Rein and Schön (1993).

Storytelling is regarded by Rein and Schön (1993) to be an integral part of framing discourse in policy. Most policy situations are complex, and actors use stories to organise and analyse this complexity, and often as persuasion for a course of action (p. 146). In doing so, they engage in sense-making, the development of frames. According to Van Hulst and Yanow (2016, p. 98), ‘What gets produced in the framing process is both a model of the world—reflecting prior sense-making—and a model for subsequent action in that world’. The stories of policy actors contain information about the problem as perceived by the actors, leading to an understanding of what should occur (Rein & Schön, 1993, p. 148). This does not hold that for every policy position one frame exists; multiple frames can champion the same action, or one frame could

137 champion several different courses of action (Rein & Schön, 1993). Although frames can potentially act as a unifying resource for social movements or for policy actors, this may not necessarily result. Understanding framing as an implicit rather than explicit process is important for undertaking policy analysis. Perceptions that policy frames are intentionally constructed to achieve resonance with policy stakeholders often causes confusion in health policy (Van Hulst & Yanow, 2016). The overt construction of a policy position is part of an agenda-setting process and should not be confused with framing (McCombs & Ghanem, 2001). Policy frames are often conceptualised as static entities presented as choices to stakeholders, a type of ‘top down’ perspective of framing (Dekker, 2017; Steensland, 2008). The frames available to stakeholders depends on the outcome of competition between perspectives on a policy issue (Dekker, 2017). Having explicit knowledge of the importance of issue framing has been the focus of framing analysis in media studies (Gamson, 1995). Here, the media is regarded as a vessel for transmission of explicit frames favoured by stakeholders. However, even explicit framing is the result of negotiation between actors with conflicting hidden constructions of meaning (Rein & Schön, 1993, p. 148).

This is demonstrated in the study of social movements by Benford and Snow (2000) and Rein and Schön (1996). A core idea of social movement framing is the Collective Action Frame in which group members engage in frame construction through collectively negotiating meaning (Benford & Snow, 2000). Here framing is not necessarily seen as intentional, but rather as an outcome of collective sense-making. Such collective sense-making is thought to act as a motivating and unifying factor for social movements (Van Hulst & Yanow, 2016). If individuals are given an opportunity to critically reflect on their frames, there may be opportunity to reframe and reach policy agreement (Van Hulst & Yanow, 2016, p. 96). Framing as a possible motivational tool for policy implementation has led to interest in framing in health policy analysis.

The concept of individual and group sense-making in the development of created realities sites framing analysis firmly within a constructivist ontology. The basis for framing analysis is the understanding that multiple interpretations of reality exist for any given situation and that conflict arises when agreements about such interpretations cannot be reached. This reflects the constructivist understanding that reality is created subjectively by individuals and groups through development of shared meaning (Lincoln et al., 2011, p. 103). This ontological grounding has been resisted by some who have sought a more positivist understanding of

138 framing analysis (Benford, 1997; Johnston, 1995). This position is particularly noticeable in policy studies (Dekker, 2017). This possibly reflects an increasing interest in evidence-based policy in which the notion of evidence is understood to be reflected by the quantitative evidence hierarchy and in which qualitative research is largely ignored. The criticisms of framing analysis have focussed on areas that constitute what Mickenautsch (2010) regards as the usual critique of qualitative research: prone to subjectivity, lacking internal validity and a propensity for systematic error.

The lack of unifying theory able to demonstrate how frames achieve prominence or impact on thinking has led to claims of both subjectivity and lack of validity (Entman, 1993). As Johnston (2002) notes, framing analysis is rarely retrospectively reviewed to determine if the identified diagnostic frames led to the expected actions. The assumption that frames do impact on thinking underlies much of the frame analysis research, particularly that which seeks to alter behaviour (Chong & Druckman, 2007, p. 109; Gilliam et al., 2010; Wilensky, 2004, p. 36S). However, this use perhaps overextends the purpose of frame analysis which is largely descriptive rather than proscriptive. Although frame analysis considers the question ‘What must be done?’, it does so within the context of the frame itself, rather than as a response to the frames identified. For example, an analysis of an ‘injustice frame’ (Benford, 1997) may reveal certain expected courses of action. However, in framing analysis, there is no expectation that such actions will occur as action in any arena results from competition between multiple frames. This distinguishes frame analysis as a constructivist approach from other structural- analytic approaches.

Another criticism of framing analysis is a lack of systematicity (Johnston, 1995). Indeed, there is a lack of a standard structure for frame analysis. Several authors have offered suggestions for such a framework in the past. Entman (1993) suggested developing consistent or generic frames that could be commonly understood and, therefore, applied as a research paradigm in multiple disciplines. Benford (1997) supported generic framing for improving utility of research findings. However, he did note that less specific frames could be important for understanding circumstances in particular studies and that such a move could oversimplify matters (Benford, 1997, p. 415). Such oversimplification was a criticism of Goffman’s work which was felt to reflect a structuralist perspective (Denzin & Keller, 1981). The ‘top down’ perspective of policy frames discussed earlier is an example of the potential for this oversimplification and tendency towards structuralist analyses of policy frames.

139 Framing analysis in policy remains an emerging theory of sense-making and criticisms reflect ongoing methodological debate between positivists who seek objective and re-producible frames and constructivists who seek to understand the process of sense-making. To put it another way, positivists hope to answer the question ‘How can I use this to promote certain policy outcomes?’, while constructivists would hope to answer the question ‘What factors should we possibly consider when exploring policy development and implementation?’ It could be argued that a positivist approach would be more useful for policymakers or those wishing to influence policy processes. Yet attempts to discover objective reality in framing analysis are likely to be unsuccessful as the researchers own sense-making and framing of reality is likely to impact on the findings of the research. If framing analysis is therefore an exercise in subjectivity, what benefit can it offer studies in the policy realm? The benefit of framing analysis stems from the uncovering of layers of meaning within discourse. Understanding that deeper layers of meaning exist within policy perspectives can enable reflective processes which can assist with policy compromise (Van Hulst & Yanow, 2016). Such compromise may help where seemingly intractable policy problems exist (Van Hulst & Yanow, 2016).

9.2 How will Framing Analysis be Performed?

Framing analysis will be performed on the three separate caches of data under study. The analysis will consider framing using the descriptive/prescriptive story conceptualisation of framing analysis used by Rein and Schön (1993). It will consider the values underlying the ‘diagnostic’ question ‘What is going on here?’ and the ‘prescriptive’ question ‘What should be done?’ to consider how policymakers and stakeholders understand issues of waste within the Australian health system. It is important to remember that diagnostic and prescriptive framing evolve from narrative representations of reality. Van Hulst and Yannow (2016, p. 101) note that this approach ‘moves beyond “mere” problem definition’. It does this by providing rich contextual information that illuminates the problem definition. By understanding these contextual factors, it is possible to demonstrate the process of sense-making for individual stakeholders and groups of stakeholders.

The process of producing a document for media consumption generally involves some level of understanding of how issues can be framed within public discourse. Gamson (1995, p. 91) notes that leaders of social movements are often ‘media junkies’ who closely observe and attempt to manipulate media coverage of their particular cause. The same could be argued of

140 politicians. Hence, in this analysis, the media release may indicate explicit and implicit attempts to frame the issue. Conversely, in the case of GPs, attempts to frame the issue are likely to be implicit and potentially highly individualised. Finding shared frames of meaning here may be more problematic, but any shared frames may reflect shared experiences and values, the knowledge of which would be useful for policy development and implementation. Findings from all three groups will be compared and analysed for shared and convergent frames.

9.2.1 Policymakers

Framing of the issues in the health system differed between the three health ministers. Mr Dutton framed the situation in health as a future fiscal emergency, Ms Ley framed health as a (failing) business and Mr Hunt framed health as an investment. These ways of framing the issue were met with varying degrees of acceptance from other stakeholders.

9.2.1.1 Mr Dutton

Mr Dutton’s framing of health as a fiscal emergency was probably the least effective for convincing other stakeholders of the need for action. This framing was scaffolded by the claims of increased spending, troubling future economic forecasts and future predictions about healthcare needs detailed in Chapter 5. That a crisis was imminent was reinforced by words and phrases emphasising the urgency of the situation. Mr Dutton spoke of the ‘inescapable reality’ of the current spending excess, a situation that was ‘frankly alarming’ (Department of Health, 2014b, 2014e). Economic waste in healthcare was a ‘cancer within our health system’, while costs associated with rising rates of chronic illness were something that Australians ‘urgently’ needed to confront (Department of Health, 2014b). This alarmist rhetoric reinforced the urgency of the crisis framing and justified government alterations to the status quo. Because of the urgent nature of the ‘crisis’, the government was forced to make difficult choices: ‘However, it won’t be a shock to anyone that the upcoming Budget will be tough – it has to be’ (Department of Health, 2014i).

While the crisis mandated, according to Mr Dutton, difficult government decisions, he was also eager to frame these decisions as ‘sensible’ and ‘reasonable’. The government was the cool head required in an emergency and Mr Dutton framed those opposing such approaches as lacking in common sense:

141 they’ll fox and have all of the public comments, but I think in the end common sense has to prevail on these issues, and that’s the argument that we have to push. (Department of Health, 2014l)

Picking up 100 percent of the cost in the public setting makes no sense for the taxpayer when the patient is prepared to pay for 70 percent of the cost of an appropriate insurance product. (Department of Health, 2013)

Therefore, only supporters of government policy could be said to be reasonable and sensible.

Mr Dutton’s attributional claims about patients provided scaffolding for a further frame supporting his diagnostic narrative. This claim, as noted in Chapter 5, framed patients as profligate users of the health system, responsible for the fiscal emergency. This framing presented patients as separate from taxpayers whose hard work contributed to the funding of the health system: ‘But patients are demanding these treatments for free, or at minimal cost, but all to be subsidised ultimately by the taxpayer. And the taxpayer has continued to subsidise them, no matter the cost’ (Department of Health, 2014e). This is a false dichotomy as most patients are taxpayers and most taxpayers are patients. However, framing patients as ‘the other’ in an emergency created a suitable villain for Mr Dutton’s emergency narrative. Doctors were framed as lesser villains in this scenario, with a line drawn between ‘good’ and ‘bad’ doctors.

Bad doctors, according to Mr Dutton, failed to spend appropriate amounts of time with patients. This resulted in increased expenses for the health system because patients then required more expensive care in secondary or tertiary settings. Bad doctors were also those who bulk billed everyone regardless of their ability to pay. Conversely, a doctor could also be considered bad if they charged a co-payment for a patient unable to pay. Good doctors, according to Mr Dutton, were able to distinguish between patients for whom healthcare was affordable and those for whom it was not and were able to adjust their billing habits accordingly. Good doctors, therefore, were both tax collectors and social workers. Good doctors were, like the government, able to make sensible decisions. The framing of health as a fiscal emergency supported by framing of some patients and doctors as wasteful, provided the diagnostic story required for the prescriptive story desired by Mr Dutton. A fiscal emergency required economically focussed solutions, which Mr Dutton was eager to present. The hard choices required by a fiscal emergency translated into budget cuts that simultaneously punished wasteful patients and doctors and acted as a deterrent for future waste within the system.

142 9.2.1.2 Ms Ley

Ms Ley’s claims about the health system did not differ markedly from Mr Dutton’s claims about the health system. However, her framing of the issues showed subtle differences. It is possible that this was a deliberate attempt at reworking the narrative of health policy, given that Mr Dutton’s framing lacked acceptance. However, with the ongoing focus of the Abbott Government on cuts to government spending, any alterations to the narrative were to prove difficult. It was to take Ms Ley approximately six months before she settled on an idea that conveyed fiscal conservatism while minimising the threat of cuts to healthcare. Possibly attempting to avoid the association of economics and health, Ms Ley initially used a health analogy to explain her perspective: ‘Basically, there’s wide agreement the Medicare system in its current form is sluggish, bloated and at high risk of long-term chronic problems and continuing to patch it up with Band-Aids won’t fix it’ (Department of Health, 2015a [emphasis added]). However, this terminology was short-lived and soon defaulted to financial rhetoric, with Ms Ley framing the situation in health as a failing business desperately in need of sound financial direction.

While words such as ‘consumer’, ‘investment’ and ‘productivity’ imbued Ms Ley’s discourse with a corporate flavour, the term ‘efficiency’ was to prove a useful buzzword that enabled her to pursue conservative fiscal policies without the appearance of cost-cutting, which had hampered Mr Dutton’s initiatives. By speaking of efficiencies, Ms Ley framed the diagnostic narrative as an issue of good stewardship (Department of Health, 2016c). Good stewardship of resources was necessary for good business management. While good stewardship may result in savings for the government, these savings were not the primary focus of government policy. According to Ms Ley, the primary focus of government policy in health was to ‘get the best bang for our dollar when it comes to health’ (Department of Health, 2015l). This framing steered focus away from budget cuts to system reform.

Reform of the health system through a quest for efficiency was a key aim of Ms Ley’s tenure: ‘The Turnbull Government is currently undertaking broad-ranging reforms to build a healthier Medicare’ (Department of Health, 2015j). If reform was necessary, the implication was that the system was broken. According to Ms Ley, government policy initiatives noted the need for ‘rebuilding primary care’ (Department of Health, 2015b). Framing the health system as in need of reform justified the search for efficiencies and proved more difficult for stakeholders to

143 argue against. However, Ms Ley also ensured that arguments against her department’s policies were kept to a minimum by framing the calls for reform as being stakeholder driven.

Ms Ley was eager to note that the need for reform within the health system had been highlighted during her consultations with stakeholders. Phrases alluding to collaboration pepper her discourse. Ms Ley called for ‘intensive stakeholder engagement’ (Department of Health, 2016a), assured the public that, ‘The Abbott Government will work hand-in-hand with health professionals and patients’ (Department of Health, 2015a) and consistently noted that her ‘approach to the Health portfolio has been one of consultation and collaboration’ (Department of Health, 2015b). By doing so, she created a diagnostic narrative that suggested policy was based on advice from those at the coalface (Department of Health, 2015b). Those at the coalface included a broad mix of stakeholders including doctors, patients and other health professionals. In doing so, Ms Ley was able to gain support for her policy from some stakeholders, although gaining support from doctors was more difficult given her framing of doctors as the villains in the narrative. Ms Ley cleverly pre-empted criticism of her policies by appealing to the sacred cow of evidence-based medicine, making it difficult for doctors to argue against. Ms Ley framed ‘bad’ doctors as allowing their ignorance and greed to result in inefficient practices which placed pressure on the system. ‘Good’ doctors were those that practice evidence-based medicine which, according to Ms Ley, would alone prevent inappropriate testing and increased costs to the system.

Ms Ley’s descriptive narrative of a failing business undermined by inefficiencies caused by lack of adherence to evidence-based medicine provided the necessary basis for her prescriptive framing of the health system in need of reform: ‘This isn’t tinkering at the edges of health policy. This is not a series of mutually exclusive reviews. This is a fundamental reform of the various interdependent components our health system’ (Department of Health, 2016i). Ms Ley framed the prescriptive narrative as a grand undertaking. Initiatives such as the MBS Review and Health Care Homes were framed as markedly progressive policies which, rather like Mr Dutton’s initiatives, required staunch leadership. Ms Ley noted that her policies were ‘bold’ (Department of Health, 2015j, 2016c) and felt that she presented the policies in a ‘frank and fearless’ manner (Department of Health, 2015i). These words were important as several policies were at risk of being interpreted as punitive. Like Mr Dutton, Ms Ley needed to emphasise the tough measures required for change. Ms Ley’s framing was arguably more effective than Mr Dutton’s, with greater acceptance among advocacy stakeholders. However,

144 her tenure was prematurely terminated, and the new health minister again changed the framing of health policy.

9.2.1.3 Mr Hunt

Despite the relative success of Ms Ley’s framing of health policy, Mr Hunt did not continue with it. His framing of the situation differed from his predecessors in that it took a far more positive approach to issues in health. Healthcare, according to Mr Hunt’s diagnostic narrative, was a unique investment opportunity: ‘It’s going to be a strong health budget. I can say that confidently. And we’ve been working with the medical profession to lay the foundations for investment in the future’ (Department of Health, 2017m). This framing could be seen as an attempt to reverse the negative effects of budget cuts and assure the public that the government was not interested in cutting funding for health. However, Mr Hunt noted that as with all investments, care must be taken to ensure that money was invested in the right commodities at the right time: ‘But our vision is that we can take it to be unequivocally, with all of the resources, human, capital and societal that we have in Australia, the best health system in the world’ (Department of Health, 2017b). This framing served two purposes. Firstly, it challenged the public perception that the government was still focussed on cutting costs in health. Secondly, it addressed party concerns about fiscal responsibility. Spending money in health was not wasteful, according to Mr Hunt, if it produced a significant return for investment. This justified Mr Hunt’s generous spending in health, despite previous government warnings about the unsustainability of such spending.

Unlike his predecessors, Mr Hunt framed himself as a champion of healthcare. While his predecessors framed their policy choices as ‘sensible’ and ‘bold’, Mr Hunt framed his policy choices as evidence of the government’s commitment to Medicare and health. Mr Hunt’s discourse contained words intended to convey the level of such commitment:

Well, I absolutely understand this, which is why I fought, and we have fought to get these premiums down as low as possible. (Department of Health, 2017a [emphasis added)

So, across the front you have a health system which we’re investing in and guaranteeing and strengthening. (Department of Health, 2017n [emphasis added])

Mr Hunt’s diagnostic narrative was notable for a lack of villain and his prognostic narrative notable for a lack of detail with regard to the expectations of patients and doctors within the

145 health system. Instead, he framed the solution to health as being driven by the private health industry, a response consistent with the framing of health as an investment. According to Mr Hunt, the more private investment in healthcare, the more successful the Australian health system would become. Despite Mr Hunt’s narrative lacking a villain, he creates a subjective reality by framing the problem of health and health care as rooted in economic mismanagement. In this he engages with the sense-making efforts of the previous health ministers and this will be discussed further below.

9.2.2 Stakeholders

9.2.2.1 AMA

Stakeholder frames compete for traction within the policy arena. Framing which appeals to policymakers provides stakeholders with an advocacy advantage for their agenda. As with policymakers, the way stakeholders frame their message can also reveal underlying ideas about health and healthcare. While policymakers have attempted to frame the current situation in health in a variety of ways, the AMA was relatively consistent in framing the situation. The AMA diagnostic narrative framed the situation as a battle, a fight for fairness over economic rationalisation. Policymakers, according to the AMA, have become fixated on the financial aspect of health, to the detriment of ‘fairness’. This concept of fairness implies the need to ensure care of vulnerable patients for whom access to healthcare is jeopardised by government policy:

It is a health system designed by bean counters for bean counters. It puts saving money ahead of saving lives. It is shifting more and more health costs on to patients, including the most vulnerable – working families, the elderly, and the chronically ill. (AMA, 2014d)

References to vulnerable patients abound in AMA rhetoric. Considered vulnerable are children, the elderly, the chronically ill, the poor and Indigenous patients (AMA, 2014g, 2014h, 2017b). The AMA frames itself, rather paternalistically, as the guardian of the health system and of patients. According to the AMA, fighting for the rights of doctors is the same as fighting for the rights of patients, as doctors have the patients’ best interests at heart. Challenges to the current system would not be an attack on doctors, but an attack on patients:

Scrapping bulk billing incentives would be a direct attack on the most vulnerable people in our communities. It would be a direct attack on children, on the poorest

146 people in our communities, and it would be a direct attack on Indigenous health. (AMA, 2014c)

GPs are those doctors singled out by the AMA as being suitably qualified to provide universal health coverage (AMA, 2014i). General practice and GPs are framed by the AMA as being the lowest-cost option for medical care within the health system. Words such as ‘efficiency’, ‘low cost’ and ‘quality’ pepper the AMA rhetoric on general practice:

Front line primary care services are very efficient and are a low-cost part of the Australian health system. (AMA, 2014a)

General practice, in particular, is cost effective and proven to keep people well and away from more expensive hospital care. (AMA, 2017b)

general practice, pathology and diagnostic imaging are delivering high quality and efficient health services for patients. (AMA, 2014a)

The diagnostic narrative of the AMA frames the situation in health as a fight for patients over policymakers, health over economics, and right over wrong. The prescriptive narrative frames a strengthened general practice as the solution to the concerns of policymakers. General practice is presented as the cheap and efficient peace offering with which to end the battle.

9.2.2.2 RACGP

While the AMA and RACGP made differing claims about the situation, both framed the situation as a battle. Unlike the AMA, which framed the current situation as a fight between fairness and economic rationalism, the RACGP framing of the situation was less nuanced. The RACGP framed the current situation as an attack on general practice. General practice, according to the RACGP, is ‘targeted’, ‘held hostage’ and ‘attacked’. Current government policies and the current structure of the health system are perceived as deliberately opposed to the discipline of general practice: ‘The RACGP is astounded and disappointed that the Government has targeted general practice in its pursuit to “save” the health dollar by proposing a model that will equate to higher out of-pocket costs for everyday Australians’ (RACGP, 2014f).

Attacks on general practice are considered by the RACGP to be profoundly unjust and reflect a government tendency to overlook the importance of general practice within the health system:

147 GPs and their healthcare teams provide over 150 million patient services at a fraction of the cost of the far more expensive, overcrowded hospital system, yet our government continues to look past them and the value they bring to our community. (RACGP, 2017c)

Further, these attacks distract the government from considering other sectors of the health system which the RACGP feels are more deserving of government scrutiny: ‘General practice is the most cost-effective part of our healthcare system but it is being held hostage by ever increasing inefficiencies of other sectors’ (RACGP, 2017c). This framing of the current situation paints general practice as underfunded, undervalued and at risk from government policies. Policymakers are at war with general practice.

According to the RACGP, an attack on general practice is also an attack on patients. GPs back the AMA suggestion that doctors are firmly on the side of patients. Thus, advocating for general practice is also framed as patient advocacy (RACGP, 2015f). Policies affecting funding of general practice are regarded as attacks on patients primarily because of the potential to reduce access to medical care. This reduced access is caused by increases in cost related to poor funding:

As GPs who care about our patients, the last thing we want to do is ask them to pay more for vital healthcare services. But in many cases, if GPs don’t pass on the costs, their practices run the risk of becoming unviable. If a practice becomes unviable and they close down, patient access will be reduced. (RACGP, 2015d)

GPs defend the right of patients to access healthcare from their own perceived position of prominence within the health system. GPs are framed as the centre of the health system by the RACGP, a position the government fails to recognise. Yet, according to the RACGP, GPs are ideally placed to provide policy advice: ‘GPs need to be strongly represented across all of these reviews because frontline GPs know what needs to change to make the system better for patients’ (RACGP, 2015a). The justification for this framing of GPs as the centre of the health system is largely economic. GPs are the centre of the health system because GPs are the most economically efficient medical specialty: ‘GPs see more than 80% of Australia’s population every year and are the most cost-efficient pillar of the healthcare system’ (RACGP, 2015f). The narrative for the RACGP, therefore, focusses on perceived wrongs against general practice. The diagnostic frame suggests that the problem in the health system is that general practice is treated badly by policymakers. The prescriptive frame focusses on better treatment of general practice and GPs.

148 9.2.2.3 CHF

The CHF, too, frames the policy arena as a battlefield. For the CHF the battle is for the principles of Medicare, the most notable of which is affordable healthcare:

We should reflect on how fortunate we are that most Australians – particularly young families, the chronically ill and the elderly – face no financial barrier to see their GP. It took great effort and leadership over many years to develop Australia’s ‘fair go’ health system. (CHF, 2014n)

Within the framing of the battle for health is a patriotic framing of affordable healthcare. Affordable healthcare is framed as ‘Australian’, an important part of national identity. ‘Real’ Australians, according to the CHF, understand this and the need to support Medicare: ‘Medicare is about a fair go for all Australians. When this is properly understood, all members of Parliament, as fair dinkum Australians, have an obligation to protect and enhance our system of universal healthcare’ (CHF, 2016e).

This principle is at risk from unpatriotic government policies that increase costs to patients, and policymakers who promote these policies are likely to have their loyalty to the country questioned:

Australia is a government seeking to undermine basic human rights – the right to health and the equitable right to treatment. (CHF, 2016e)

This is simply un-Australian – Australians fundamentally believe in a level playing field and a fair go for all. (Public Health Association, 2014)

Promoting fairness is about promoting primary healthcare, and general practice is framed as the core of the primary healthcare system: ‘The Consumers Health Forum recognises the GP as the pivotal figure in primary health care’ (CHF, 2017a).

General practice is allotted this role for several reasons. GPs appear well liked by consumers and general practice is regarded as the most cost-effective form of healthcare for patients (CHF, 2014o, 2016k, 2017b). However, general practice is not considered the centre of healthcare. This role belongs firmly to the patient or consumer: ‘Consumers must be the makers and shapers of the health system rather than just the users and choosers’ (CHF, 2016o). The placing of consumers at the centre of healthcare reiterates the importance of health as ultimately being for patients and not for the medical profession. For the CHF, health is a human right.

149 Health, framed as a human right, is considered something that should be available to everyone regardless of their ability to pay. The perceived failure of certain policies to ensure that this occurs is considered a significant issue within the current health system: ‘The trouble is that in Australia universal health care does not guarantee equal opportunity to be healthy. That is most graphically shown in the yawning gap in health status between Indigenous and non-indigenous Australians’ (CHF, 2016f). Such a perspective demands a vision of healthcare without political or economic drivers. The attainment of health should therefore be more important than economic savings. If health is a human right, it is not a commodity and should not be bought or sold or subjected to market forces. The CHF at times is clear about this distinction: ‘The Government suggests the Medicare co-payment is a price signal for consumers. Price signals work for discretionary items. Health care is not discretionary!’ (CHF, 2014h).

Yet the CHF struggles to establish a policy voice without an economically inclined rhetoric. For example, while the CHF frames health as a human right, it paradoxically frames health as good economics, mirroring policymaker rhetoric. Framing health as good economics is seemingly the opposite of framing health as a human right. Here, healthcare is discretionary and deliberately subjected to market forces in the belief that such forces will result in a better deal for consumers. While the CHF decries such a belief, the words and arguments used to emphasise the CHF’s situational claims have an economic flavour. This starts with the ‘Consumers’ in the title, continues with discussions of health as an asset and ends with a need to emphasise an economic benefit of good health outcomes: ‘It’s a matter of recognising that health is a national asset and that investing in it is to invest in our future productivity and prosperity’ (CHF, 2016n). The syntactic dualism here undermines the strength of the framing of health as a human right by surrendering to the need to claim an economic benefit for an initiative:

By empowering consumers to live healthy lives and take an active role in health care decisions, we will have a more responsive and cost-effective health system. … Ineffective management of chronic conditions in primary care leads to worse health outcomes and higher costs. (CHF, 2016l) [emphasis added]

The diagnostic and prescriptive narratives in the CHF’s framing of issues within the health system appear at times paradoxical. While healthcare is framed as a human right, the prescriptive narrative in which cost-effective general practice is a solution and the use of economic references as justification for certain actions echoes policymaker neoliberal rhetoric. The sense-making shared by the health ministers is, therefore, unwillingly adopted by the CHF

150 as it struggles to have its agenda recognized by policy makers. This struggle is not limited to the CHF and will be discussed further below.

9.3 Discussion

As has been noted, the different ways of framing were to have differing levels of success. Mr Dutton’s tenure as health minister was to prove difficult for the Coalition. His framing of issues in health was unpopular with the electorate. This, in turn, affected the voting priorities of minor parties in the Senate and Mr Dutton’s policy initiatives foundered here from a lack of the required support. The Australian public, it appears, viewed Mr Dutton’s framing of arguments with suspicion and his policy initiatives were regarded as antithetical to government claims about supporting Medicare. Indeed, Mr Dutton’s claim about the commercial sector providing benefits for the healthcare system was widely interpreted as a wish to privatise Medicare (Gunn & Mintrom, 2017). Commentators have suggested that this had an impact on the outcome of the 2016 federal election in which the Coalition suffered significant losses even while retaining power (Gunn & Mintrom, 2017). Mr Dutton’s framing of the situation, therefore, was not a success.

The failure of Mr Dutton’s framing to attract public support likely came as a surprise to the health minister and his colleagues. This is because his policies reflected the traditional values of the Liberal Party, that of fiscal conservatism and individual responsibility. Following a successful election in 2013, it is understandable that the Coalition regarded this as a mandate to introduce policies that reflected these values. Further, the strategy of placing the blame for a political issue on one segment of society, in this case, patients with chronic illnesses, had proven fruitful when the Coalition had previously been in power during the 12 years of the Howard Government. Wilson and Turnbull (2001, p. 386) describe this tactic as ‘wedge politics’:

a calculated political tactic aimed at using divisive social issues to gain political support weakens opponents and strengthen control over the political agenda. This tactic is sharpened by awareness of issues and groups that attract resentment or antipathy in the wider electorate.

Wear (2008, p. 626) claims the Howard Government benefitted from such tactics aimed at issues such as Aboriginal land rights, welfare, multiculturalism, refugees and nationalism. Mr Dutton may have been considering this concept when differentiating between taxpayers and patients. However, Mr Dutton’s failure to gain support for his claim may be reflective of

151 Australian attitudes towards the right to access healthcare, an attitude reflected in the CHF’s patriotic framing of healthcare.

Ms Ley’s decision to blame the medical profession for what she regarded as waste in the system was an example of wedge politics that was to prove more successful. However, targeting doctors also increased the risk of implementation failure as doctors are powerful stakeholders within the Australian health system (Boxall & Gillespie, 2013, p. 65). Boxall and Gillespie (2013, p. 68) claim that the medical community in Australia has significant veto power in health policy, leading to the blocking of legislation deemed not in member’s interests. Ms Ley successfully leveraged this power by framing health policy as a collaborative effort. Ms Ley’s consultative approach gave the impression that doctors were contributing to health policy. An appeal to ‘evidence-based medicine’ as the basis of several of Ms Ley’s reforms pre-empted attempts at opposition by framing objecting doctors as opposed to best practice. She did receive some incidental support in this effort from the popularity of low-value care as a discussion point within the medical community where criticism of the concept was at times considered akin to Freudian neuroses (see, e.g., Scott et al., 2017).

Mr Hunt’s more positive reframing of the situation addressed a need to pacify angry constituents while mollifying party conservatives. Framing health as an investment helped to distance the government from accusations of cost-cutting while still maintaining an appearance of good economic management. Good economic management was an underlying theme of all three health ministers. While each minister framed issues in health differently, the framing was limited to economic rationalist descriptors, indicating that all the health ministers subscribe to the neoliberal ideologies discussed in Chapter 3. Despite the different framing used by the three policymakers, the agenda of the Coalition Government remained the same.

Common to all health minister frames was an implicit agreement that success in health equates with economic success—good economics is good health. This is evident from the economic flavour of all three attempts at framing the issue. A fiscal emergency, a failed business and a solid investment all have at the core an emphasis on financial concerns. This is further evident from the syntactic dualism of rhetoric used by the health ministers in which the success of policies was partnered with economic benefits:

More meaningful engagement with primary care for the general public and those in aged care settings delivers better patient outcomes and an ultimate savings, which

152 is why I make this important point. (Mr Dutton, Department of Health, 2013 [emphasis added])

Medical research not only makes good health sense; it makes good economic sense. It’s a key driver of productivity and innovation in the health care sector, which employs more than one million Australians. (Mr Dutton, Department of Health, 2014d [emphasis added])

We are determined to ensure every dollar lands as close to the patient as possible. Because a healthier patient means a healthier Medicare. (Ms Ley, Department of Health, 2016d [emphasis added])

our health is our greatest and most important asset. (Mr Hunt, Department of Health, 2017t [emphasis added])

Within this framing, health is regarded as a commodity. As a commodity, health is valued according to market desirability, measured not only in how much health is consumed but in the economic benefit it produces (Bambra, Fox & Scott-Samuel, 2005). Economic outcomes are therefore considered a proxy for health outcomes. Further, if health is a commodity, provision of healthcare is best left to the machinations of the market. According to neoliberal ideology, this will result in good outcomes as the market regulates supply and demand. Government intervention in health, in this scenario, would involve only the destruction of bureaucratic red tape to ensure the smooth, unfettered operation of these market forces. A system such as Medicare is problematic within this ideology because of promises of free healthcare. Health and healthcare are not an obligation of a government to its citizens here. The right to health is not regarded by policymakers as concrete and policymaker rhetoric constantly challenges the idea of such a right. Each health minister made it clear that any initiative would be valued as much for its economic benefits as for its health benefits. These values constrain discussions about healthcare as benefits to patients yield in importance to benefits to the economy.

The strength of neoliberal ideology within the political discourse is demonstrated by this economic focus of all three political frames. While reframing was politically expedient, policymakers found themselves constrained by neoliberal discourse to discussion of economic themes in healthcare. Since the introduction of neoliberal ideas under the guise of economic rationalism in the 1980s, such a discourse has become firmly embedded in Australian political life (Mooney, 2012). McKenna (2004) notes that a discourse can be regarded as being dominant when it is largely viewed by participants as common sense. That the need to discuss economics in discussions of healthcare appears rational could therefore indicate the dominance of this

153 discourse. This reflects a global phenomenon noted by Lomazzi, Jenkins and Borisch (2016) who have demonstrated the dominance of neoliberal discourse within discussions of global health issues. However, policymakers are not the only stakeholders constrained by neoliberal discourse.

As noted earlier, the CHF found its message of health as a human right undermined by rhetoric that emphasised the importance of economic benefits to health initiatives. The syntactic dualism noted in the CHF’s discourse is also shared by the AMA and RACGP. Contrary to attempts to frame themselves as opponents of economic rationalist perspectives in health, the AMA finds itself mimicking the language of policymakers:

It maximises the benefits of high quality primary care in general practice, keeping people well, and keeping people out of more expensive hospital care. (AMA, 2014b [emphasis added])

More importantly, the AMA’s recommendations will deliver a healthier and more productive population to drive further savings into the future. (AMA, 2017b [emphasis added])

Preventive health is not only an investment in the health of our nation, it is an investment in Australia’s economic productivity. (AMA, 2016e [emphasis added])

If people with complex and chronic disease cannot access the right services in the community, they often end up in hospital, and this costs the health system a lot more. (AMA, 2015a [emphasis added])

The health benefits or disadvantages are occasionally lost in the need to illustrate the economic advantages or disadvantages of the initiative: ‘These services are critical to early diagnosis and management of health conditions to allow people to remain productive in their jobs for the good of the economy’ (AMA, 2015g).

The RACGP finds itself in the same dilemma:

General practice performs an essential service at the coalface of primary care keeping people well and out of hospital, benefitting both individuals and saving the entire health system billions of dollars. (RACGP, 2016a [emphasis added])

Australia needs a funding model that values and supports quality primary healthcare which will lead to better patient outcomes and reduced expenditure in the more costly tertiary healthcare system. (RACGP, 2014c [emphasis added])

154 While the AMA’s, RACGP’s and CHF’s respective framings present problems in health differently from policymakers, they are constrained by the dominant neoliberal discourse in the policy environment. Although attempting to decry the government focus on economic outcomes in health, these stakeholders are enmeshed in the economic rhetoric of neoliberalism.

I argue that financial or closed-gate gatekeeping is a product of this discourse. The concept imbues general practice with an economic value likely to appeal to policymakers focussed on economic outcomes. GPs are not only good for health; they are good for balancing the budget. Gatekeeping easily reflects the syntactic dualism of neoliberal discourse. Therefore, it is unsurprising that gatekeeping is used by advocates to promote the value of general practice to policymakers. Yet gatekeeping is not necessarily embraced by policymakers. Mr Dutton, as has been noted, feels that GPs should be responsible for determining who can be bulked billed. In his claims about healthcare, GPs appeared to be a convenient scapegoat for policy rather than an important resource. However, his policy initiatives did act as tools to encourage gatekeeping behaviour. Likewise, Mr Hunt largely ignored the potential financial benefit of gatekeeping GPs, passing them over in favour of free market strategies to foster a ‘health investment’. Conversely, Ms Ley railed against the failure of GPs to gatekeep. Her framing of the issue as a poorly run business with a focus on GPs as a cause of waste best illustrated the difficulty of using the gatekeeping argument to prove the worth of general practice. For Ms Ley, if economic outcomes are poor or not to the government’s liking, it is GPs who are responsible. The interchangeability of health outcomes with economic outcomes within this discourse leads to a blurring of distinctions for the GP; that is, if good economic outcomes are not forthcoming, GPs may be viewed as poor clinicians. A further potential negative outcome of promoting general practice as the specialty that can do more for less is that more may indeed be asked of GPs for much less, a process of underfunding primary care while increasing expectations.

This framing analysis provides several insights into policymaker and other stakeholder beliefs about healthcare and the health system. It highlights the dominant nature of neoliberal discourse in discussions about health, the struggle of representative bodies to challenge government framing of issues and the potentially negative effects of promoting general practice by appealing to the function of gatekeeping. While gatekeeping intuitively sits well in discussions where health and economics merge, the unexpected negative outcomes may outweigh the benefits of promoting GPs as gatekeepers. Of course, GPs may have a different

155 perspective and the next chapter considers how they frame concerns about health and healthcare and how this reflects attitudes towards the gatekeeping role.

156 Chapter 10: General Practice Framing

GPs in Australia work in a multitude of different contexts which impact on the way they practice. GPs themselves have a wide variety of backgrounds which is also likely to affect how they practice. Yet it is possible that they do share some underlying values and beliefs and this chapter explores this by identifying shared frames. Shared frames are likely to point to shared sense-making, as described by Benford and Snow (2000), among GPs and provide insight into how they view their place within the health system. Shared frames are also likely to help answer the question posed by Rein and Schön (1993): what is going on here? This chapter identifies several shared frames that indicate that GPs have a strong sense of responsibility to their patients and that patient well-being guides GPs as they navigate the complexities of health and healthcare. In doing so, GPs do act as a type of gatekeeper, albeit not the financial gatekeeper desired by policymakers. These factors impact on the acceptance or otherwise of health policy and provide important information for future policy planning.

10.1 The Heterogeneity of General Practice

As previously noted, general practice is not homogenous, and having previously criticised policymakers and other researchers for treating it as such, it would therefore be remiss of me to fall into the same practice. Fortunately, the colleagues I have interviewed are unlikely to let me forget the heterogeneity of our profession. The GPs interviewed had numerous stories highlighting the diversity of general practice. Some of these stories are detailed in Appendix B. In this study, GP framing of the policy landscape presents as a battle between GP identities. The framing of general practice by the GPs interviewed reflects somewhat the idea of tribalism promoted by Maffesoli (1996), where groups form within a society based on a shared focus. However, where Maffesoli (1996, p. 123) believes modern identities centre on aspects of consumer culture, general practice identities centre on location, billing practices and qualifications. Rural GPs, for example, often point to differences between their practice and the practice of urban GPs:

because we are a bit of a unique situation in that we are very rural. Like we’re almost, I think we’re three in our major cities, and then four everywhere else. And then in the really rural places like Queenstown, it’s five. So there’s nothing, nothing above a three. And so we have all these weird mismatches of services because of that, which I think is a bit different than on the mainland, but like things are like fairly close together. (GP 12)

157 I mean city patients, it’s easy enough to just go to your specialist, you know, down the road or on the other side of the city for a review but when you’ve got to drive 3- 400, 500k round trip or more, it’s not that practical and patients don’t want to have to do it all the time. (GP 17)

I don’t think you need this, which I find really interesting because in Australia I feel like, particularly in Sydney, the patients will just go okay, I’ll just see someone else. That wouldn’t happen in Queensland where I was practising. (GP 19)

Private or mixed-billing doctors often differentiate between themselves and bulk-billing doctors. Bulk-billing doctors are often framed as the GPs responsible for bringing the specialty of general practice into disrepute:

For instance, in Melbourne there’s probably three rings of General Practice; there’s an inner-city ring, which is quite full of high-turnover entrepreneurial businesses and then there’s the established suburbs in Melbourne where you’ve got sort of a fairly high income–earning population who can afford the full fee-paying General Practice business model and the quality practices which exist within that area they are generally quite well staffed with good-quality GPs and again never leave. So, the quality there is usually quite consistent and good. And then you’ve got the outer-ring suburbs where you have a large population of people who are, I guess, white-collar and blue-collar families, usually two incomes or one and a half incomes and large mortgages who tend to typically visit bulk-billing practices, and it is in that ring and in the inner-city ring sometimes where I’m finding that the quality of the referrals that come through indicate to me that GPs are not thinking through the problem-solving aspect of their clinical consults. (GP 14)

GP identity is therefore not uniform. However, while location and billing style provide important fragmentary tribal identities within the specialty of general practice, other qualifications provide a unifying identity for all GPs. GPs all frame general practice as a specialty and a specialty unique in the practice of medicine. This framing of general practice is perhaps a response to non-GP framing of general practice as something other than a specialty. It has been previously noted that GPs feel misunderstood and undervalued by both their colleagues and by policymakers. This feeling appears to promote pride in general practice and in doing things differently from other medical colleagues, which produces a unique identity based on a perception of mistreatment.

10.2 The System Does Not Support General Practice

The framing of general practice as misunderstood in turn supports a framing of general practice as poorly supported by the system. This framing is scaffolded by claims of poor compensation, inappropriate payment models and inappropriate MBS item numbers. Evidence for the

158 perceived lack of respect is the ongoing battle for what GPs regard as sufficient remuneration: ‘How do you reward quality not quantity? I accept all of those issues, but the basic quantity payment still needs to be sufficient to guarantee a standard’ (GP 3).

Other payment models suggested by policymakers are viewed with cynicism as GPs express strong doubts that policymakers are motivated to address the funding gap between general practice and other specialties:

I mean, it’s much easier politically to freeze and remove funding or freeze funding in primary care than it is in secondary care. (GP 2)

And you know that’s the same reason why GPs don’t like sort of the Medicare freeze because at the moment we’re the ones getting targeted, you know, not the other specialities. (GP 15)

That policymakers appear to preference other specialties over general practice is a further claim providing support for the framing of general practice as unsupported. This preference is not only seen in the way general practice is financed, but also in the way non-GP specialists are treated:

It’s really weird, and it’s just because there is a consultant that has a special interest in it, probably because, it’s probably, like if you’re anywhere else in Australia, no one would ever agree to it. But like, I don’t know how he managed to get management to agree to ECMO, because I’m sure it’s tremendously expensive. (GP 12)

General practice is also unsupported within the hospital system, beginning with training of general practice registrars:

You know that restatement of ‘The importance of General Practice as an aspirational speciality’ should also flow through the hospital system so that you know people who have already identified early that they want to go into General Practice aren’t dismissed and ignored. (GP 14)

The framing of general practice as unsupported by policymakers and non-GP specialist colleagues may also contribute to the clinical decision-making of GPs. Loyalty to a system perceived as unsupportive may be difficult to inspire:

The government is not going to reimburse the doctors any higher than what they are at the moment, then the doctor’s reaction, particularly in this area has been to say: ‘We’ll drop off the things that aren’t essential to our income, and that’s [accreditation] one of them’. (GP 3)

159 The lack of support may filter through to patients which can affect the ability of GPs to influence patient decision-making:

So, they sit down, and they go, ‘Right, this is a requirement. I want my referral; I’ve had it for more than six months’. We’re forced into doing it and I feel so guilty claiming that Care Plan Item Number; I really do. And I feel it’s so wrong. And the only reason I’m claiming it is because they’re wanting their rebate. (GP 5)

I guess, a lack of respect for your GP as a specialist I guess, is like, the GP can’t really convince you, you don’t need to go and see the expert in this field. (GP 11)

An unsupported general practice is likely to encourage poor behaviour, while a better supported system may encourage more appropriate behaviour and save costs to the system.

10.3 General Practice Complexity and the Discourse of Difficulty

A perceived lack of support within the health system results from a perceived lack of understanding among policymakers and other specialists about the complexity of general practice. Framing general practice as complex further adds to the framing of general practice as misunderstood and unsupported. Complexity is reflected by the discourse of difficulties present in general practice. Difficulties are caused by the system itself, such as the problems with accessing information, and arise from contextual factors and patient characteristics:

I mean I’m sure my referral and testing rate probably goes up when I’m totally under pressure. (GP 6)

Because it’s really individualised and trying to put a blanket approach to it doesn’t work most of the time, because of, there’s so many different factors between each patient. (GP 1)

You can rely on evidence, but it doesn’t always work because the patient may have a psychological, or a cultural, or a religions barrier to accessing the best practice. There could be something stopping you from doing the best for that patient, whether it’s a language barrier, a cultural barrier. (GP 3)

Difficulties arise from the tension between being responsible for patient well-being and other responsibilities such as running a business, maintaining family and peer relationships, and the GP’s own health.

it’d need to be something where you could see this really going to be economically viable, at least cost no—you would at least be the same, you wouldn’t lose money and it would be more enticing if it was more efficient, so not only might you earn a

160 bit more money, but you’d provide better services you know and you’d have greater job satisfaction and think ‘yeah, job well done’. (GP 3)

You know if have a typical family with two kids and you’re hoping your kids do really well, and you live in a suburb that doesn’t have a great primary school or a high school—you know private schools now where we are it’s [$]26,000 a year. Yeah. So, if you’ve got two kids that’s [$]50 grand; your first [$]100[,000] is gone. Yeah. So, you find yourself, if you’ve bought a house that costs now, on average, one and a half million, you know that’s another, what’s that, [$]150[,000] a year in interest and capital payments. So, now you’re up to [$]300,000 before you’ve even saved a dollar. (GP 14)

Added to these tensions is the conflict between responsibility to patients and responsibility to the healthcare system. While GPs feel a professional responsibility towards waste within the system, these various other factors appear likely to have a greater impact on clinical choices:

And what are we wasting? The patients’ time? The staffs time of the two clinics? How much does all that cost, compared to just repeating the full blood count? (GP 2)

I think it’s up to us to practice good medicine, and yet within the realms of the fact that we’ve got a limited money supply. I totally accept that, but you would hope that if the test was necessary it’s going to either treat something early before it gets more expensive, if you want to look at it that way, or avoid something that you don’t need a hospital admission. (GP 3)

It depends on how sure or unsure I am about something so probably the area I use it is when they particularly want antibiotics, I’ll do a throat swab and bloods instead because I think preserving antibiotics is more important than saving money on blood tests. (GP 17)

According to GPs, decision-making in general practice is difficult. However, complexity is regarded as simply a part of general practice. GPs, it appears, are relatively comfortable with this complexity.

10.4 Good Doctors and Bad Doctors

GPs make their own judgements regarding good and bad doctors. Using Rein and Schön’s (1993) narrative concept of framing, the descriptive narrative here frames general practice as complex and this impacts the framing of ‘good’ and ‘bad’ doctors. Good GPs are those who seek the best outcome for the patient, despite any complexity. This involves the adoption of multiple behaviours considered ‘good’, including spending an appropriate amount of time with a patient, addressing the patient’s concerns, following evidence-based medicine, working

161 within Medicare guidelines and assisting patients with navigating the health system. Note that while these behaviours are considered ‘good’, most GPs consider these as ideals to strive for rather than behaviours reflective of regular practice. This is illustrated in the way GPs discuss their day-to-day choices; GPs hint that while much of their daily practice involves trying to do the right thing, this may not always happen. This is due to the complexity of patient presentations, situational factors such as doctor fatigue and characteristics of the health system that may not facilitate ‘good’ behaviour. GP discourse contains cautious terminology that avoids promoting a monochromatic view of general practice actions:

I think that probably puts a professional burden on you rather than a legal burden, and I think most of us hopefully being good ethical doctors, that professional burden would make us accountable to ourselves. (GP 3 [emphasis added])

If somebody presents with seven problems and you’re totally busy and you can’t get through it all, it is sometimes easier just to reach for the sure go and see a dermatologist for a skin check which I’m quite capable of doing myself. Do X, Y and Z, you’re fine, you need this scan or test or get a blood count before I think about that any further sort of stuff which they’re not inappropriate or bad medicine but they’re not very efficient. (GP 6 [emphasis added])

But I try not to order stuff just because it’s there. Like I try and have clinical need. (GP 12 [emphasis added])

I mean, usually, I would try and get them to come back, yeah, and if they really don’t qualify, like they have … I would sometimes say to them, you know what, actually I’d usually just palm them back to their usual GP. (GP 19 [emphasis added])

Many doctors expressed ambivalence about the ability to say ‘no’ to patients requesting inappropriate investigation and treatment. While this was usually regarded as a ‘good’ doctor behaviour, it again came with many caveats that depended on the foreseeable outcome for the patient:

what they may have come in with, which is a modest test, and you’re going to go against that. That’s the one thing they came in for, and you’re, you know, not going to give it to them. Yeah. And how do you tell that to a patient in a way that they’ll understand and not be offended and understand why? (GP 1)

I think the problem is if you try to be clinically astute it can come back and bite you because some things are very subtle; some things are very, very subtle. There’s always that one case that will come back and bite you. So, often I find sometimes it’s just not worth it; you just get it done. It’s just not worth; it’s not worth taking on that risk sometimes. (GP 15)

162 Therefore, ‘good’ doctors are those that try to do the right thing; however, GPs admit to many grey areas regarding ‘good’ and ‘bad’. The diagnostic narrative of the good doctor is supported by the prescriptive narrative of responsibility for patient well-being which ultimately determines the purpose of general practice.

10.5 General Practice is Responsible for Patients’ Well-being

All the GPs interviewed shared the framing that general practice was responsible for patient well-being. This framing was evident in the way GPs spoke about their patients and the responsibility felt towards them:

you’ve got that whole balance there of patients fears and needs versus your own. (GP 2)

But I like to think that most GPs try to do their best for their patients at all times. (GP 5)

The responsibility felt by GPs towards their patients is multipronged. GPs feel responsible to address the concerns and anxieties of their patients, and reassurance of patients is considered an important part of general practice:

I do a lot of pathology because people need to be reassured on things. They want a CAT scan, or something like this. Their friend has one, or that type of thing. (GP 4)

I mean, of course our job is to reassure. (GP 5)

GPs feel responsible about the costs of medical care to patients. This includes caring about the time people spend seeking medical care:

‘Cause you’re trying to do what’s best for that patient in front of you, and that’s often a hard balance between, you know, they can’t afford it. And so, you’re trying to find the best therapy for them within what they can afford. (GP 1)

I think isn’t quite right because there are patients that are so busy these days, the don’t want to have to come back to the doctor for a result if it’s not necessary or if it’s not the most efficient way to do it. (GP 14)

So, I feel as though usually it was the value-add for the patient, and it it’s not going to be useful for the patient the I guess, yeah, I don’t think it’s worthwhile doing. (GP 19)

163 This was particularly concerning for remote GPs given the long distances patients are often required to travel to seek medical care: ‘but it takes about seven or eight hours to get into [city]. It’s a long time to ask somebody to sit on a bus. It’s a $120 one way on the bus’ (GP 13).

GPs felt a strong responsibility for the education of their patients, considered a way to encourage patients to make decisions and empower them, which GPs felt was important for their healthcare: ‘I think there’s an element of having confidence in your own capacity to communicate with your patient and the old question of doing what the patient needs rather than what the patient wants’ (GP 3).

Responsibility extends to an advocacy role for patients, especially with interactions between the patient and other levels of the health system:

though if somebody really needed something, I would definitely advocate for them. (GP 19)

Yeah, I mean, I think it’s on a few levels, like I think financially it was not a wise decision on the part of the hospital but I am also not convinced that it was in the best interest of the patient’s health. (GP 19)

The responsibility GPs feel towards patients is reflected in their attitudes towards the term ‘gatekeeping’. Some GPs—those who regarded the gatekeeping role as positive for patients— proudly called themselves gatekeepers:

I think GPs are in a, I think it’s [gatekeeping] a very important part of what we do, is explaining to people when tests may not be appropriate, or referrals may not be appropriate, and I think EDs [Emergency Departments] are particularly bad at some of that. I just hate the way people just get CT’d from head to toe. (GP 13)

Now, that’s why we are the gatekeepers, we deal with everything from simple colds and flus, depression to heart attacks and to anything. So, we are trained for all this and that’s why it’s a very natural thing to be the gatekeepers. If you put the gatekeepers or the first point of contact neurologist or neurosurgeon, I think he wouldn’t be able to do anything. So, it’s quite natural that we are the gatekeepers. (GP 8)

Other GPs were less enthusiastic about the term. The ambivalence towards gatekeeping expressed here mirrors the findings of Gross et al. (2001) in their study of attitudes towards gatekeeping among doctors in Israel. GPs who perceived gatekeeping as restricting access to services were reluctant to describe themselves as gatekeepers, instead preferring words such as ‘facilitator’, ‘navigator’ and ‘coordinator’:

164 To me, that’s a gatekeeper. Once you get passed me, you’re okay. And that’s not the case anymore. We’re actually accompanying the patient through the whole journey. I’m trying to remember what they called them in the war, but anyone, we’re a co- traveller. I think that’s how I’d look at it. I’m actually the tour guide. You don’t just walk through the turnstile and then I leave you alone because that doesn’t happen anymore. It used to happen, but people come back to us now. If you look at the social demographic people are coming back to the doctor for legal advice, financial advice. We’re having to help them to seek out some people who probably are not even in our own fields. I think that’s what you are. I don’t think the gatekeeper role, it may be if you’ve got a purely English speaking, very educated, cohort of patients, but not anymore, not out here. (GP 3)

Because I think it diminishes what we do in primary care. I think Barbara Starfield’s stuff about the four pillars being about access, coordination, comprehensiveness and continuity better describe it and particularly the—and if you had to bundle those things up, I really think we really are coordinating care. And being somebody’s care manager, care trusted advisor, whatever it is, I don’t think it’s, I think gatekeeping is part of what we do but it just seems like a fairly simplistic description for what the job is, I don’t know. (GP 6)

Yeah, we’re more navigators than gatekeepers. I think ‘navigator’ is the right word to use. (GP 18)

The responsibility to ensure patient well-being lies at the heart of general practice. This framing affects how clinical decisions are made and how GPs view the system. For example, GPs are not likely to regard any patient-instigated visit as irrelevant or inappropriate as these visits are opportunities to assess patient well-being and provide preventative healthcare:

There can be some patients who come for very minor ailments but it’s not a large number, I would say I would see probably one patient a day who if he doesn’t come will not affect him much. But that is out of 40 patients, one is—so it’s about 2%, that’s not much. But then you end up doing preventative health on them so eventually it leads to better health to those people. (GP 6)

I think that patients that were presenting a lot frequently had underlying mental health issues: anxiety, health anxiety. (GP 16)

A result of this framing is that GPs are more likely to value patient considerations over available evidence when ordering investigations:

No, but if in doubt, I would be more inclined to do the test than not and particularly if the patient is pushing for it, so if I don’t have a strong clinical reason not to do that investigation and they have a good clinical reason themselves or justification to do it. (GP 2)

165 Some of the time with some things, yes, and I probably give in to some things because you can kind of gauge personalities and know that some of them are more likely to cause problems than others and tend to probably given in a little bit more to the ones who you judge to be that kind of personality type as opposed to the ones that just whinge. (GP 17)

This is not to suggest that GPs ignore evidence; rather, their desire to assist the patient can impact decisions to order pathology and radiology investigations. This attitude also applies to the supply of referrals:

I do offer them, but you can’t really force anyone, it’s their choice if they want to see a specialist. It’s just that puts more burden on the specialist that there’s a long wait. (GP 8)

I think we are more likely in Australia to have a conversation with a patient about why they think they might need to go and see a specialist and have a conversation about that this may be something that we could manage in the practice, but if they still felt that they needed to go and see a specialist for a second opinion, it would be very rare that I wouldn’t give them a referral. (GP 18)

This reflects, in part, a customer service orientation with concerns about patients taking their business elsewhere if patient requests are refused:

And the patients sometimes feel more satisfied unless you’re very good at educating them and convincing them that they don’t need the test. You’ve got to be able to convince them otherwise they will leave there unhappy basically (GP 15).

However, to relegate GPs’ responses to patient concerns to a pure customer service outlook ignores the complexity of the GP–patient relationship. GPs regard the doctor–patient interaction not as a service–client interaction, but as relational. GPs consider a good relationship as central to the success of a clinical encounter:

You know, if you can build a relationship with the patient, then down the track, they might see you earlier for something, they might choose not to get it next time, because they trust you, you know? (GP 1)

When it gets down to the individual patient, it’s that one decision, that one-on-one, it has to be trust. (GP 3)

I think if I’ve got a relationship with them I feel more comfortable that they will come back if they’re not improving or if things get worse, whereas for a new patient, and having worked at practices which had lots of new patients, I would be less comfortable about that and probably in those settings I’d order more investigations to reassure myself as much as the patient. (GP 18)

166 For GPs, the relationship between doctor and patient is an alliance. Formation of this alliance may involve making choices between the system and the patient. This is something the GPs interviewed suggested they consider when making such decisions:

I do think that when you come back to patients and their care, sometimes that can clash a little bit with it, ‘cause you’re still looking at the patient in front of you and what’s best for them, while we’re still trying to think of the system and the cost and that kind of thing. (GP 1)

Ultimately, GPs consider their responsibility to the patient more important than any financial responsibility to the health system: ‘because I’d like to think that the investigations that I personally order, are done for a medical reason, and basically the financial thing is probably not that important’ (GP 13).

10.6 Health as Well-being

The framing of health by GPs differs from that of policymakers. Remarkably, the GPs interviewed rarely discussed health. This was unexpected as doctors would seem the most appropriate people to talk about health. Instead, the discourse of GPs refers constantly to the well-being of patients. Health, for GPs, is framed as well-being. Outcomes for patients are not regarded in terms of disease cure or even disease management, but in terms of whether the outcome has improved or restored patient well-being. Outcomes that worsen patient well-being are regarded as failures of the system. How well-being is understood by doctors is difficult to encapsulate, but it appears to involve the patient’s physical and mental health, as well as financial, educational and situational components of the patient’s presentation. Concern for these components is considered a part of general practice responsibility and important for overall positive outcomes for patients. This is congruent with the framing of responsibility for the patient as the heart of general practice and the subsequent advocacy for patients, even seemingly against accepted guidelines. This perspective results in tailored medicine responsive to the individual needs of patients. This involves ordering specific investigations for specific patients and tailoring things such as medication to the patient’s needs:

So a huge one is compliance, because if the patient thinks it’s going to work for them and something hasn’t worked, then even if you explain to them that they’ve both got the same medication—you know, medication and all of it, that either of them work better than the other, they’re still going to go with what they found felt better. (GP 1)

167 Health as well-being differs significantly from policymaker framing of health as a commodity. Health as well-being reflects more accurately the World Health Organization’s definition of health as ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’ (World Health Organization, n.d.). Health as well-being is a more complex framing of health than health as a commodity and has different consequences for the behaviour of doctors.

If GPs are seeking the well-being of their patients, it is again likely that costs to the government will have less impact on clinical decision-making than other considerations. This is illustrated by GPs when discussing how they make decisions:

So, I do think, a little bit, but probably, it might have been a quarter—25 percent, I’ll think about it from that point of view, cost, and probably the three-quarters from the patient and what’s appropriate for them. (GP 1)

Having standards is wonderful but the art on how you apply them is a very personal thing. I think that’s where the skill is, in how you apply this, how do you communicate the standard in a way that the patient and yourself end up on the same page, basically. (GP 3)

So, in some ways you know I’m seeing her each week. Yes, in some ways, yes, I’m probably over-servicing her, but she needs to come in once a week for that. (GP 15)

I think it’s easier to manage someone’s expectations when you understand them better and so you probably have more ability to have some shared decision-making with a patient after you’ve seen them at least a couple of times and you can both potentially decide together if you think some investigation or referral is necessary. (GP 18)

Framing health as well-being and having an individual orientation to the practice of medicine both alter decision-making processes for GPs.

10.7 Responsibilities and Gatekeeping

While GPs are ambivalent about the term “gatekeeping”, their framing of patients as the centre of general practice and the priority given to well-being indicate that a type of gatekeeping is occurring. This reflects the second type of gatekeeping noted in the literature by Tabenkin and Gross (2000): a facilitator who guides patients through the health system. While GPs try to consider the overall costs to Medicare when making decisions, patient needs will be prioritised. GPs recognise that this is aided by systemic factors such as vague Medicare guidelines that allow doctors to facilitate patient preferences. The focus on the needs of individual patients is

168 consistent with the framing of health as patient well-being. This differs markedly from the ideology of policymakers which equates good health with good economics. It also differs subtly from the idea put forward by the AMA and RACGP that doctors are guardians of the health system. GPs operate within a considerably different ideological space to that of policymakers and even perhaps advocacy groups.

Of course, definitively saying that all GPs consistently prioritise the needs of their patients over the needs of the system is not possible. As previously noted, the heterogeneity of beliefs and values among GPs is another factor complicating attempts to adequately describe general practice for policymakers. Tribalism, as expressed by various dichotomies within general practice, could make agreement between stakeholders, GPs and policymakers difficult. The different ideas held by different tribal identities, leads to different requirements of policy and applying a generic approach to policy formation is likely to be unsuccessful. Conversely, attempting to satisfy the needs of each distinct group within general practice is likely to make policy unwieldy. However, the value of putting the patient first is sufficiently shared between otherwise quite different GPs that it is worthy of further research and discussion. If GPs prioritise patients over the health system, this will place them at continuous odds with policymakers who have an expectation that doctors should prioritise the health system over patients.

GPs also view their practice as complicated. Framing medicine as complex is again at odds with the linear understanding of medicine held by policymakers. The comfortable complexity of general practice and GPs defies policy that promotes inflexible rules for clinical behaviour. This is problematic for policymakers who expect doctors to behave in strictly regulated ways with the expectation that this will limit expenses within the health system. These factors, rather than simply a lack of responsiveness to education and funding, may explain why general practice reforms never quite achieve the desired endpoint. GPs, unlike other stakeholders, seem immune to the imposition of neoliberal values on their practice. This is unusual, given the pervasiveness of neoliberal thinking in wider society. It may be that the cycle of reform and reinvention has encouraged an identity of general practice as the patient advocate and this necessarily cannot give way to neoliberal thinking which places the importance of cost over that of patient care. It may be, too, that the needs of patients in such a system create a role for patient advocacy which GPs, as the primary carers of patients, naturally fulfil. As such, the

169 success of policy based on neoliberal values will likely be limited as GPs fail to recognise, or dispute, the expectations of policymakers.

170 Chapter 11: Considering the Diagnosis and Treatment

11.1 Introduction

Gatekeeping in the Australian health system is problematic for GPs. This study has shown that GPs have good insight into the health system and try to make clinical decisions while considering the potential costs to the health system. This makes GPs good candidates for a gatekeeper role. However, multiple factors act as barriers to GPs acting in ways they would regard as ideal for the health system. These factors include systemic issues such as poor technology, Medicare arrangements and health literacy, and contextual issues such as doctor and patient characteristics. A further potential barrier is the importance in general practice of ensuring patient well-being, which may at times be at odds with the financial model of gatekeeping. Ensuring patient well-being does, however, lead to GPs acting as facilitators and guides through the health system, reflecting a model of gatekeeping which may or may not have economic benefits. That policymakers have expectations of doctors acting as financial or closed-gate gatekeepers is seen in the claims they make about the health system and in the way arguments about health are framed. Advocacy groups have sought to capitalise on this expectation by promoting the idea of GPs as gatekeepers. However, the ideological opposition of policymakers and GPs makes advocates’ claims of general practice gatekeeping potentially harmful for general practice. Failure to meet policymaker expectations of economic management due to a commitment to patient-centred care and patient well-being, risks GPs being regarded as bad doctors and general practice being used as a convenient scapegoat for problems within the health system. This is a relatively easy cognitive association as concepts inherent in medical hierarchies and research about general practice have influenced understandings of GPs as less able than their non-GP specialist colleagues. The following sections provide a summary of the research findings and consideration of the problem (diagnosis) and solution (treatment).

11.2 Summarising the Consultation

From this research, it is apparent that a certain type of gatekeeping does occur within the Australian health system. GPs attempt to shield patients from expensive and unnecessary treatment while helping them navigate the complexities of the system. GPs also tailor medical care to individual needs. Yet this is not done primarily with a view to reduce costs and waste

171 within the health system; rather, it is done with a concern for the patient’s well-being, the concept at the core of general practice and reflective of patient-centred care. GPs have a professional concern regarding waste within the health system, but this is not their primary concern and multiple factors act as barriers to their good intentions. Factors such as time pressures, fatigue, patient demands, bureaucratic red tape and technological shortcomings all impact the efforts of doctors to limit waste. Further adding to this is the complexity of many patient presentations, the inappropriateness of many guidelines for general practice and a lack of or insufficient communication between GPs and non-GP specialists. This confluence of factors paints a picture of uneven gatekeeping within the health system. Gatekeeping does occur, but not in a standard way across the profession, and not in the financial way expected by policymakers. An assumption that GPs will consider costs to the system results in disappointment with GP practices and perpetuates assumptions of GP ignorance. These assumptions act as barriers to successful development of policy for primary care.

The linear conceptualisation of medicine is also problematic. The temptation to regard medicine as a linear process appears strong for policymakers without medical experience. A linear understanding of medicine causes variation in practice to be regarded with suspicion, and policies aimed at reducing variation may add to the bureaucratic burden of general practice. A linear view of medicine may result in unrealistic expectations of general practice by ignoring the complexity of consultations. Policies based on a linear view of medicine may punish GPs for straying outside guidelines or reward the ability to perform within guidelines. Both are problematic, according to the GPs interviewed, as they could prevent patients from receiving necessary care and could also force patients and GPs to participate in programs with little health benefit. This is seen in the ambivalence many GPs have towards health checks and care plans. The idea of financial gatekeeping inadvertently reinforces these expectations by promoting expectations that GPs will act in rigidly uniform ways when thinking about waste.

11.3 Diagnosis

What, then, is the diagnosis concerning gatekeeping? The aim of this research was to consider the concept of gatekeeping in the Australian health system through exploration of stakeholder understandings of problems of waste within the system. The objectives focussed on deconstructing the concept of gatekeeping by exploring stakeholder expectations of waste management, considering barriers and enablers of gatekeeping and reaching a consensus on ways to move forward. Policy makers have some expectations that GPs will practice in ways

172 that are mindful of the cost to the system. Likewise, advocacy groups are quick to promote GPs as gatekeepers despite abrogating responsibility for waste. GPs themselves do claim some interest in reducing costs to the system. If I was not using a general practice approach to problem solving, it would be easy to conclude that GPs act as gatekeepers in some circumstances and are willing to act as gatekeepers in others; however, various barriers prevent them from doing so, and addressing these barriers will help GPs fulfil the role of gatekeeping within the Australian health system. A positivist approach would seek further quantifiable evidence for the barriers detailed and for potential solutions to develop a plan to improve gatekeeping within the system. In general practice, this would be the equivalent of prescribing a statin drug for a patient based only on clinical guidelines, without understanding how a patient feels about long-term medication, what they have heard about statin side effects and what their financial situation is. This is a common non-GP specialist error. Without knowledge of these things, doing the ‘correct’ thing may be ineffective as the patient quietly ignores the script because their concerns have not been addressed. The general practice approach digs deeper and probes further. It attempts to understand the factors that influence the clinical scenario. By using framing analysis as a tool for this approach, it becomes apparent that not only are there complexities surrounding the gatekeeping concept, there are also significant concerns regarding the concept itself. The use of the term ‘gatekeeper’, whether gatekeeping occurs or not, is detrimental for general practice because it reflects neoliberal ideas which mistake good economic outcomes for good health outcomes and exposes GPs to unfair judgements.

How do we reach this diagnosis? Some policymakers, when considering general practice, have an expectation that GPs will act in ways that reduce waste within the health system. For example, Mr Dutton expects doctors to police Medicare payments while Ms Ley equates the practice of evidence-based medicine with cost-saving. These expectations create a false dichotomy that regards good doctors as those who act in ways that reduce waste, while bad doctors are those that cause or do not make an active effort to curtail waste. Although this is reflected in the media releases of policymakers, it should be noted that the three policymakers examined in this study have paid varying amounts of attention to the role of general practice within the health system and appear unlikely to regard general practice as the specialty to consider when effecting change within the system. This does not prevent policymakers from developing policy that punishes GPs for failing to fulfil expectations. Advocates for general practice struggle to argue against these policies because of the dominance of neoliberal discourse in policy discussions.

173 As long as neoliberal ideology dominates discourse within the political sphere in Australia, the concept of general practice gatekeeping is more likely to harm than improve the standing of general practice in policy circles. This is because neoliberal ideology frames health as a commodity, leading to the valuing of tangible economic indicators. For example, a coronary angiogram could readily be viewed as a product that produces tangible outcomes (stenting or advice for surgery), but measuring how many people have avoided the need for coronary angiograms through good advice and management of risk factors is less easily performed. Claims that general practice reduces waste in the system by reducing unnecessary secondary and tertiary care are difficult to measure and, ironically, makes general practice a convenient target if policymakers view health budgets as excessive. While non-GP specialists are producing ‘bang for your buck’ by performing surgeries and other procedures, GPs’ claims of preventing a need for procedures are difficult to assess. Further, if GPs feel a referral or investigation is necessary despite being outside the guidelines, claims of poor gatekeeping are likely to follow. If GPs act in ways that improve patient well-being and this leads to an increased uptake of secondary or tertiary care, policymakers may only see an increased use of resources.

The central tenet of general practice, best illustrated in the framing of patients at the centre of care, is at odds with policymaker ideology. Patient-centred care and the framing of health as well-being is fundamentally opposed to the framing of health as a commodity. Attempting to align the expectations of policymakers and GPs is unlikely to be successful when such disparate views on health exist. If health equals well-being, then concerns about expense to the system have a low priority in clinical decision-making. Conversely, policymakers insist that affordability to the system takes precedence over concerns for the patient. This is tempered somewhat in the Australian political sphere by the attachment of the Australian public to the Medicare system and the notion of accessible healthcare, as noted by the CHF. Regardless, the general practice version of gatekeeping remains opposed to that of policymakers. The objective to consider areas of agreement about gatekeeping on which to capitalise (see Section 2.3) now appears unlikely to be met, prevented by ideological polarity.

This is not to suggest that policymakers produce policies that negatively impact general practice only because of ideological differences, a superficial understanding of general practice or disappointed expectations. Policy does not exist in a vacuum and the contextual factors affecting perceptions of general practice over time likely have an important impact. The

174 ongoing cycle of reform and reinvention discussed in Chapter 3 indicates a specialty that struggles with its own identity and acceptance from peers. This is exacerbated by the acceptance in research of a hierarchical view of medicine that privileges non-GP specialists over GPs and promotes a non-GP specialist-centric worldview. Research that judges GPs by non-GP specialist criteria, which is often irrelevant to general practice, promotes an environment in which expectations of general practice are consistently low. Acceptance of these expectations without critique has resulted in years of research discussing the ‘problem’ of general practice, adding to the perception that general practice is the medical speciality most in need of rehabilitation. This has resulted in policy solutions that fit this narrative, such as education initiatives for GPs and punishment for GP recalcitrance. This in turn has resulted in ongoing perceptions of general practice as incorrigible and given policymakers insufficient and often erroneous data with which to make decisions about general practice. Unfortunately, appeals to the gatekeeping function of general practice in an environment of increasing health costs have merely confirmed researcher and policymaker bias, rather than promoting new ways of working or increasing respect for the profession.

This understanding of general practice is, perhaps inadvertently, encouraged by representative groups such as the AMA and RACGP through advocacy for better remuneration for their members. Such advocacy provides an impression that increased revenue is likely to change GP behaviour. However, as previously discussed, this impression is inappropriately reductionist and fails to recognise the factors influencing GP behaviour. While GPs should receive better remuneration, it is uncertain if such remuneration will produce the changes in behaviour promised by advocacy groups. By focussing on remuneration as the motivator of GP behaviour, advocacy groups inadvertently do general practice a disservice by implying that money is the primary motivator of GP actions. This also fails to recognise that the argument for better remuneration for GPs is as old as the RACGP itself. The idea that GP behaviour needs to change, and that money will change behaviour, has been the ongoing argument for general practice since the beginning of GP advocacy. That advocacy for general practice appears unchanged over the past 50 years should be of concern to GPs. A lack of change indicates no success with that advocacy approach and a lack of advocacy for other factors that GPs regard as important.

A focus on remuneration causes other issues for GPs. Calls for increased remuneration are accompanied by attempts to prove economic worth within the health system. The argument for

175 GPs as gatekeepers for the health system could be viewed by policymakers as an admission that general practice has a role in constraining costs within the health system. Therefore, for increased remuneration, GPs will reduce costs to the health system. While the research of Starfield et al. (2005) indicates that GPs likely do reduce costs to health systems, as previously noted this may not be in the measurable way that policymakers would like to see. Attempting to negotiate improved remuneration by appealing to the pecuniary value of GPs is unlikely to be successful and could potentially result in punitive actions by policymakers if GPs fail to produce the promised economic outcomes.

Does gatekeeping, therefore, promote the value of general practice? It does not. The idea of GPs as gatekeepers undermines the value of general practice. Even extending the definition beyond that of financial or closed-gate gatekeeping to coordination of patient care does not fully encapsulate what GPs do. As this study has demonstrated, GPs make complex decisions about diagnosis and management, all within short periods of time. This skill is underrated and often not fully acknowledged by policymakers, advocacy groups and non-GP specialists. This is because the patients considered by these groups are those shared by GPs and non-GP specialists. While GPs manage an average of 90% of patients who present to them, gatekeeping is invariably assessed by the 10% of patients referred for non-GP specialist treatment. As noted in Chapter 4, these referrals may not be purely for traditional medical reasons (i.e., the GP cannot identify the health issue or is unable to treat the health issue), but instead represent a decision that considers the cultural, contextual and individual characteristics of the patient. The idea that GPs merely coordinate care is incorrect and stems from a lack of GP involvement in discussions about the health system. This lack of involvement is exacerbated by the idea that GPs do not know as much as their non-GP specialist peers, which in turn diminishes the value of involving GPs in policy discussions. This creates a cycle of misinformation informing policy affecting GP behaviour, leading to further misinformation, leading to further misinformed policy.

11.4 Treatment

If gatekeeping were desirable, addressing barriers and enablers to gatekeeping, an objective of this study, would involve systemic change. A concerted effort to develop clinical guidelines relevant to the general practice context in Australia would be required, and these would need to be communicated not only to GPs, but also the wider public in order to moderate patient expectations regarding referrals, investigations and treatments. This would require efforts to

176 improve health literacy. It would also require a focus on research in general practice to avoid the temptation to apply non-GP specialist-centric research to general practice scenarios. Recognition of the variety of general practice scenarios and the specific issues relevant to these is also imperative.

GPs and policymakers do share some areas of agreement about situations and solutions. All agree that the nature of medical presentations is changing and that this creates challenges for the current Medicare system. All agree that inefficiencies within the system are increasing costs, although what these inefficiencies are is debated. Some action claims have also met with widespread agreement. The Health Care Homes initiative is particularly notable for general stakeholder agreement, and a unified electronic health record received similar approval. However, addressing these barriers and developing areas of shared agreement, while no doubt necessary to improve the health system, may still not reduce costs to the health system and should not be promoted as a way to do this. Rather than developing ideas to improve gatekeeping within the system, we need to develop ideas to improve health.

This requires education. However, the findings of this thesis do not agree with the research reviewed in Chapter 4 that suggests education of GPs is the answer. Instead, education of policymakers, non-GP specialists and other stakeholders is recommended. GPs understand their job and do it well. They also have a good understanding of patient presentations and needs. This is not to suggest that improvement is not needed, however, constantly focussing on improving general practice is not a complete answer to problems within the system. Providing professional development for non-GP specialists should be a priority. Helping non-GP specialists understand how patients present in the community, what conditions are frequently missed by specialists, how patients interpret non-GP specialist advice and improving communication skills are just some of the ways in which GPs can educate their non-GP specialist colleagues. No doubt my colleagues could suggest myriad topics to plug gaps in non- GP specialist knowledge. GPs also have a good grasp of issues within the health system, as illustrated in Chapter 8 by the veracity of most of the claims they make about the system. Thus, educating policymakers about issues facing primary care should be a priority for general practice. GPs need to ensure that they are well represented on committees that make suggestions about primary care. Representation matters, and policymakers are likely to learn most from those working at the coalface.

177 This can be illustrated using the experience of the implementation of the electronic My Health Record, with slow uptake among GPs because the ability of the record to meet the needs of general practice is lacking. As noted in Chapter 7, GPs needed easy access to investigation results to avoid duplication. Consultation with GPs regarding what aspects of the electronic health record would be most helpful would have resulted in greater enthusiasm regarding this initiative. While GPs accept the value of technology, it must make their lives easier rather than more complicated. Poorly designed technology does not help GPs or patients and is likely to be ignored. As noted in Chapter 4, technology has the potential to significantly improve communication between GPs and non-GP specialists; however, understanding the needs of general practice is imperative when developing such technology. I should note here that I appreciate the irony that these ideas reflect the historical suggestions of the reform and reinvention cycle noted in Chapter 3. The GPs interviewed had multiple suggestions for ways to improve the system that did not reflect the historical educate/remunerate suggestions noted in Chapter 3. An in-depth discussion of these ideas is beyond the scope of this study. That GPs have multiple, disruptive ideas for general practice underlines the importance of consulting with GPs about problems in, and solutions for, the health system.

Representation and education are not the only requirements needed for change in general practice. GPs do need remuneration parity with their colleagues. Paying a non-GP specialist more for the same consultation or procedure is nonsensical and fails to benefit the patient. An increase in referrals may occur if procedures that general GPs can perform are not remunerated at a rate that makes performing them in primary care financially worthwhile. Similarly, beggaring GPs by taking advantage of their professionalism and concern for patients will not build a strong primary care base. At the time of writing, the government had withdrawn an MBS number for electrocardiograms interpreted by GPs. This will not prevent GPs from performing electrocardiograms which are a very necessary part of general practice. However, expecting GPs to bear the expense is yet another insult to general practice.

That general practice has become the punching bag of the health system over time is a problem that needs to be addressed. The idea of gatekeeping has only managed to exacerbate this problem. Multiple factors affecting general practice, such as tribalism and poor representation in research, have prevented a strong opposition to claims of incompetence and inefficiency within general practice. Negative opinions of the practices of colleagues outside one’s general practice tribe create cracks in solidarity which are easily exploited. Working towards a strong

178 sense of identity as GPs is necessary to challenge the existing policy discourse. Such a challenge is imperative if health is to be rescued from neoliberal economic discourse. GPs, as the largest cohort of specialists in Australia, are best placed to challenge the neoliberal discourse which confuses good health with good economic outcomes.

Challenging this discourse is vital for GPs. GPs are good for health because our expertise allows us to effectively manage the endless variety and uncertainty of undifferentiated patient presentations in the community. This ability improves health outcomes for Australian communities, which the evidence suggests would struggle if healthcare were based on non-GP specialist care (Starfield et al., 2005). While this probably saves health systems money, the important message should be the improvement of health. GPs need to avoid the temptation to refer to themselves as gatekeepers to prove their economic worth. Indeed, avoiding any suggestion that the value of general practice lies in ‘cheapness’ or the ability to save money should be an aim of general practice advocacy. A focus on patient well-being is a strength of general practice and should be used as a building block for discussions on health and well- being. Likewise, advocacy groups need to be aware of the strength of the neoliberal policymaker discourse and take necessary steps to ensure they do not become entangled in policymaker discourse that devalues general practice and health. Researchers also need to be challenged when GP research begins with a premise that GPs do something badly.

GPs face the daily challenge of managing undifferentiated clinical presentations. Some clinical presentations will never be fully explained; however, may need further investigation to rule out potentially harmful causes. In some clinical presentations, the diagnosis may be obvious, but the management plan may be less so, due to patient characteristics, location, or GP confidence with management of this condition. Some treatment plans may be suggested by guidelines, but patient resistance to such plans may make another pathway more suitable for achieving good patient outcomes. These daily challenges faced by GPs may resonate with policymakers faced with the task of formulating policy for primary care. The potential for unintended consequences of policy is high with so many variables at play. However, ridding policy of several assumptions about general practice is the first step to developing good policy for general practice. These assumptions falsely promote a version of general practice in which expectations of GPs are unrealistic. The idea of gatekeeping, so swiftly produced by advocates of general practice, reinforces these assumptions about general practice and is therefore unhelpful. Only by seizing the discourse, insisting on discussions of health over economics and centring general

179 practice as good for health will GPs and general practice receive appropriate recognition. Using gatekeeping as an attempt to prove worth merely entraps general practice in the sticky web of neoliberal discourse.

180 Chapter 12: The Follow-up

12.1 The Situation Review

Discussions of gatekeeping are invariably discussions of the economics of health. Achieving a healthy population is desired because of the perceived economic benefits. The cost of achieving a healthy population must not exceed the perceived benefit, and gatekeeping becomes a tool to ensure this outcome. In environments where commoditised health and free market regulation are ideals, socialised healthcare is problematic, and gatekeepers serve the purpose of ensuring access to more costly services is limited. Yet the role of gatekeeper in such an environment is likely to be a thankless task; opening the gate too wide will incur the wrath of the purse keepers, while keeping the gate too tightly closed will incur the wrath of healthcare recipients. Policymakers also face this dilemma; good fiscal management suggests a narrow gate, while popular support demands a wide gate. Hence, for policymakers, acting as gatekeepers to healthcare is inexpedient and finding others willing to take on this role is imperative. GPs have, according to advocacy groups, been willing to take on this role; however, it is a role which ultimately denigrates general practice and distracts from the aim of achieving patient well- being.

This study began with a review of gatekeeping which questioned whether gatekeeping does occur in the Australian health system, whether Australian GPs perform this role and what factors exist to enable or prevent GPs from performing this role. As noted in Chapter 4, much general practice research has been based on errant assumptions about general practice and this has resulted in researchers asking the wrong questions and reaching incorrect conclusions. In much the same way, the questions that developed from the literature review of gatekeeping in Chapter 1 considered questions based on a primary assumption, that it benefits GPs to prove their economic value to the system. Regardless of whether this is done through gatekeeping or other means, proving an economic advantage of general practice seemed important. However, throughout this research it became increasingly clear that the research questions reflected neoliberal discourse. Several new questions arose. How is it possible to change the discourse on health to better ensure the well-being of patients? How can GPs challenge pervasive views of general practice and provide a better understanding of what is needed for health and healthcare? How can primary care policy be more supportive of GPs and patients?

181 Of course, the answers to the original questions have helped in the development of new questions. As has been noted, a form of gatekeeping likely occurs within the Australian health system, but not the form expected by policymakers and not to a uniform standard that could be readily regulated by policy. Where policymakers expect loyalty to the system, GPs express loyalty to patients and feel an obligation to protect them from some of the more difficult issues within the system. By reviewing the claims stakeholders make about the health system in Chapters 5–7, the contended reality within the health policy arena is laid bare. Rather than a reality based on objective and non-debatable facts, reality is constructed differently for different stakeholders. This is demonstrated by the different interpretations of evidence noted in Chapter 8, although my medical background insists that certain realities are probably more correct than others. This demonstrates the constant struggle GPs face with interpreting evidence for general practice. Some things appear undeniable, but much evidence does depend on the prism through which the data has been interpreted, a prism often irrelevant to general practice. This is the ongoing GP conundrum with regard to evidence. However, as noted in Chapter 10, GPs appear comfortable with the complexity demonstrated here and manage simultaneous positivist and constructivist worldviews with little distress.

Factors adding to the complexity of medical care cause stress for GPs. As noted in Chapter 7, communication issues, patient health literacy, billing concerns, time pressures and nonsensical Medicare manoeuvres are all factors that cause frustration for GPs. These could be called barriers to gatekeeping, but from a general practice perspective they act as barriers to good patient care. While addressing these issues is important to assist GPs in producing better outcomes for patients, the advantage for costs to the system are unknown. However, the outcome of this study suggests that trying to quantify an economic outcome for these improvements feeds an ideological desire. Improving health can be an aim without constant reference to the costs involved. This appears as a strange claim within a discourse dominated by economic rationalism. How can discussions of health not include discussions of economics? As previously noted, where a discourse is dominant it appears as common sense, hence the importance of challenging the current discourse. Governments can prioritise spending in health over spending in areas that may not be as important to the Australian people. More research needs to be undertaken with patients (taxpayers) concerning their priorities.

By using framing analysis to understand the sense-making of stakeholders, this study has demonstrated that underlying perceptions of health and healthcare have a significant impact on

182 the actions of policymakers and GPs. These underlying perceptions are incompatible and make the subject of gatekeeping problematic for GPs. Advocacy groups, so entrenched in policy debate that they are unable to break free of neoliberal discourse, complicate the primary care space when they use gatekeeping to promote the worth of general practice. The AMA claims that doctors are guardians of the system, while the RACGP offers up GPs as gatekeepers. Loyalty to patients, however, conflicts with responsibilities towards the system. GPs, because of their underlying belief that health is about patient well-being, will constantly fall short of policymaker expectations, further cementing the idea that GPs are incompetent and in need of education.

The aims of this thesis were to consider the concept of gatekeeping within the Australian health system and demonstrate a general practice approach to problem solving. Meeting the second aim has revealed the errancy of aspects of the first aim. While attempting to find common ground regarding waste in the health system initially appeared desirable to promote the value of general practice, this research has highlighted the problem of ceding to the dominant discourse in health. Understanding the value of general practice as an economic benefit to the health system tacitly acknowledges the validity of neoliberal arguments concerning health. However, the validity of neoliberal arguments about health can and should be challenged. Therefore, the promotion of GPs as financial gatekeepers is inappropriate. Finding common ground here makes little sense as incompatible versions of general practice make negotiating common ground a waste of time. As GPs are generally time-poor, a more expedient way forward would be to take control of the discourse of health and promote patient well-being as the desired outcome of general practice, rather than financial benefits to the health system. Gatekeeping, therefore, should not be used to promote the value of general practice, and efforts should be made to avoid surrendering to the neoliberal discourse that dominates current discussions about health.

The implications of these findings are that although this study has identified multiple barriers that prevent GPs from performing the gatekeeping role to the satisfaction of policymakers, attempts to address these barriers to improve gatekeeping are not recommended. Instead, this study recommends that gatekeeping no longer be used or discussed when promoting general practice. Avoiding the trap of discussing economic benefits when discussing the importance of general practice will lead to less dissatisfaction among policymakers if expectations can be redefined. Some may argue that the efficiency and relative ‘cheapness’ of general practice is

183 its primary benefit. However, this significantly undervalues the benefits of general practice to the health system. Expressing worth through diagnostic and management abilities should be a priority, and demonstration of what GPs can do is imperative given the years of misrepresentation.

By reflecting a general practice approach to problem solving, the second aim of this thesis, I have reached a different conclusion to that originally expected. This is quite common in general practice when a treatment plan needs to be reworked as patient circumstances and beliefs are revealed. Expectations that a consultation will follow a textbook presentation are rarely met. The variety of human existence and experience that presents in day-to-day general practice means that a textbook presentation is the exception rather than the rule. This thesis also provokes more questions, a common issue at the end of general practice consultations. The bad news is that policy for primary care is proverbially like herding cats, with multiple viewpoints and circumstances complicating primary care. The good news is that GPs are good at negotiating complexity and willing and able to participate in discussions about policy and the issues they face in everyday practice. Policymakers will need to reorient their understanding of general practice and medicine to develop appropriate policy to improve the health system, and advocacy groups need to consider their framing of arguments and the position in which this places general practice. The Australian health system, already producing good outcomes, can benefit greatly from the ideas of GPs if policymakers are willing to listen.

12.2 Reflection

GPs have many informal ways to debrief with colleagues. Debriefing usually involves reflecting on a particularly difficult or unusual consultation, considering what went well and what was potentially problematic. The effect our own prejudices may have on the interpretation of a patient’s symptoms are well known. The same applies to research, although the tradition in medical research is strongly in favour of the claims to objectivity found in positivist research. Yet, as discussed in Chapter 2, claims to pure objectivity are idealistic and each researcher brings their own ideas to the table. Failure to be reflexive can lead to the unquestioning acceptance of certain ‘truths’ which provide dubious bases for research hypotheses. Such is the case with much general practice research which accepts the hierarchical notion of non-GP specialist practice.

184 For this research, I hoped to avoid unconscious bias by considering conscious bias. As a GP working within an activist praxis, it is perhaps unsurprising that this research would present as pro-general practice. I say perhaps because this research originally intended to find areas of agreement between policymakers, advocacy groups and GPs to facilitate better primary care policy. Instead, the conclusion reached is that while areas of agreement do exist, a more profound change is needed within the policy space, with GPs taking the lead and deconstructing neoliberal discourse. This is a result of the research process of learning about general practice history, interacting at a deeper level with my colleagues, perceiving the poor treatment of general practice in both policy and research and contemplating the effect of discourse on health. Research has made me more of an advocate for general practice than I was at the beginning of this process. Research has been a radicalising experience.

The subject of gatekeeping arose from my perception that my colleagues and I did not act in ways that could truly be regarded as gatekeeping and wondering how this could impact on a system where policy was potentially written with the idea that we did act as financial or closed- gate gatekeepers. In retrospect, I see that I had internalised two of the commonly held perceptions of general practice. The first was that GPs were failing to fulfil their role within the health system, an internalised self-loathing. The second was that GPs should be focussed on the financial aspects of the health system. The irony of this research is that the initial aims were to promote the value of general practice through our value to the economics of health. This reflected the neoliberal discourse which I am now at pains to critique.

The important question here is whether such acknowledged bias threatens the validity of this research. I argue that it does not. As stated in Chapter 2, validity is a problematic concept for qualitative research. Instead, the concept of trustworthiness is important. I hope to have established trustworthiness by using both deductive discourse analysis and the descriptive/proscriptive narrative approach to framing promoted by Rein and Schön (1993). I have also attempted to present multiple viewpoints through interviews with GPs from different Australian states, working in multiple scenarios from remote, rural, and urban practice. Further, I have attempted to use an approach that mirrors a general practice approach to problem solving and which I believe is recognisable to my colleagues. That this produced unexpected and deeper findings is, I believe, a justification for this approach. By acknowledging my own bias, I hope to have demonstrated reflexivity within the research and the trustworthiness of the findings.

185 12.3 Limitations

As with any research, there are limitations to this study. The most notable limitation for a GP is the lack of a patient voice throughout this process. For someone suggesting that patient- centred care is a hallmark of general practice, this is a large oversight, however, limitations of resources prevented inclusion of patient thoughts. While patient views are represented by the CHF, individual patient perceptions of the health system and thoughts about general practice gatekeeping would help to provide further context. Patient views concerning general practice and GPs are equally necessary for the successful implementation of policy and further studies regarding patient views are necessary.

While this study attempted to include the viewpoints of GPs from diverse backgrounds, it is possible that individuals willing to participate in interviews may be more inclined to express concern for waste within the health system and more likely to consider patient well-being as the aim of general practice care. It is possible that these interviews comprise altruistic GPs purely on a self-selective basis. Further research is needed to determine if these findings truly mirror GPs’ attitudes towards their profession and patients. The findings from this research can act as a springboard for further research into GP attitudes.

An original consideration of this research was the potential use of quantitative methods to provide further evidence of if and how GPs acted as gatekeepers. This could provide quantitative evidence to complement the qualitative evidence here. However, given the findings that the idea of gatekeeping is problematic for general practice and likely to produce only negative consequences, such a study would have, at best, limited value. As this research suggests moving on from using gatekeeping as an indicator of value, a recommendation for further quantitative research would be paradoxical. The likely risk is that the output from such research would be interpreted as “GPs fail to act as gatekeepers”. It is time for GPs to take ownership of research to highlight the multiple benefits of a strong, supported general practice.

186 Appendices

Appendix A: Participant Details

Designation Qualification Type of Practice Location

GP 1 Registrar Mixed billing, urban Greater Sydney Area

GP 2 FRACGP Private billing, urban Inner Sydney

GP 3 FRACGP Bulk billing, urban Western Sydney

GP 4 FRACGP Bulk billing, urban Western Sydney

GP 5 FRACGP Bulk billing, urban Eastern Sydney

GP 6 FRACGP Mixed billing, rural Rural NSW

GP 7 FRACGP Mixed billing, rural Rural NSW

GP 8 FRACGP Bulk billing, urban Western Sydney

GP 9 Registrar Bulk billing, Aboriginal Northern Territory Medical Service GP 10 FRACGP Mixed Billing, rural Western Australia

GP 11 FRACGP Mixed billing, urban Eastern Sydney

GP 12 Registrar Mixed billing, urban Tasmania

GP 13 FRACGP Bulk billing, Aboriginal Northern Territory Medical Service GP 14 FRACGP Private billing, urban Melbourne, VIC

GP 15 FRACGP Mixed billing, rural metro Central Queensland

GP 16 FRACGP Mixed billing, urban Gold Coast, QLD

GP 17 FRACGP Mixed billing, rural and Northern Territory, Rural remote locum work NSW, Rural WA GP 18 FRACGP Mixed billing, urban Eastern Sydney

GP 19 FRACGP Mixed billing, urban and Inner Sydney and Far North rural Qld

187 Appendix B: Doctors’ Stories

GP 1

I know that the chiropractors and naturopaths requesting things. I’ve had a couple of those come in. Yeah, that was hard. That was really hard. And it was for the MHTFR gene, and then basically explained this was the realm of specialists, and I didn’t know anything about it. So, myself ordering that test means I can’t interpret it. And I was like but that’s—if, I order, I need to be able to interpret it. And she was fairly good about it, but I still ordered it. And I explained to her that I might not be able to interpret it. And so, those results might not be very helpful to her. (GP 1)

I’ve had a couple of those ones recently, and one of—like, one of them was a patient, and one was just our rheumatologist. And when we went through everything, we went through history and everything, and realised they didn’t need to see the rheumatologist for osteoarthritis … We had a big discussion and that was fine. So, and they didn’t end up—they were like, ‘No, I’m happy not to go and see them’. So I think it’s hard, because sometimes, maybe people don’t understand, for example, that we can do something like a pap smear. So like people do think that, for example, from the [United] States or whatever, that their gynaecologists do pap smears. So I think in some parts of Europe, and so they’re quite—they didn’t really know that GPs can do it. So a little bit about, ‘we can do it. You know, if there’s any problems, we can refer you on then’. Usually I do that first, at least explain it, give them the option. And then if they’re really pushing, to go on and see it, then. (GP 1)

GP 2

Because as I say it’s difficult to treat symptoms contentious diseases like limes like illness, blastocysts you know, and other parasitic infection, so often people will come because they want a second opinion, we get a lot of oncology with people wanting some medical advice and evidence-based medical advice about what they can and can’t safely do alongside their standard oncology treatment, a lot of people aren’t satisfied, we’ve just been told to stop everything because they’re not actually confident in the specialists and in their knowledge about things like you know, complementary medicine, natural therapies, diet, exercise. (GP 2)

So I think about the clinical indications what Medicare recommends or not and areas for example where I’ve changed how I spend vitamin D testing. So I was one of the first doctors

188 in Australia to start routinely screening for vitamin D and that was based on all the epidemiology studies because I have a strong epidemiology background, so I was aware of all the epidemiology studies showing that a lot of Australians were vitamin D deficient and it was also because of my nutritional training, very aware of the diseases that salbutamol and deficient vitamin D statuses associated with and it’s not just osteoporosis, its stuck to a wide range of disease, cancers, immune, mental health. So anybody who I thought was vaguely at risk or had one of those diseases which is associated with low vitamin D, I would routinely screen and initially I was definitely screening more frequently you know, I’d often do it like every three months, now I do it every 12 months. (GP 2)

[S]o one of the reasons why sometimes I’ll have people coming in for a second opinion is because they’ve asked for these tests from their regular doctor, like chaotic another example, so they’re convinced that they’ve got suboptimal functioning thyroid, they accept that their TSH is normal, but because it’s 2.5 or 3, they want to still know what their free thyroxin levels are at T3 and T4. Now their doctor will not do it, so they will come here just so that they can get that tested, even though—and they accept that they’re going to pay for it privately, those two tests, but their doctor still won’t do it. So that makes it—if you are looking at it just from a pure Medicare point of view, they’ve paid to see their doctor, they’ve had one TSH done so that’s two Medicare item numbers. Now they’ve come to see me and so there’s another Medicare consultation item number, there’s another TSH and there’s also but not billed to Medicare, a 323 and a 324, because by the time they come, could be two months later, so well hey they were billed high and they still symptomatically getting worse so maybe their TSH level is now double. So of course it is justified to do that TSH again and bill that under Medicare, even though I’ll say to them unless you make the Medicare criteria for the thyroid levels, you’ll have to pay that out of pocket, but I’m happy to do that and order that test for you, if you’re happy to absorb that cost. (GP 2)

GP 3

I can’t give you the patient’s name but he’s a person on Warfarin who was given five days of Nurofen when they came home to treat their fever and their unwellness by a public hospital. So, see the patient, calm them down. The patient had enough common sense not to take the Nurofen because they had already told them before, ‘You’re not allowed to take A, B, C and D’. Contacted the hospital, spoke to the Senior Registrar whose comment was, ‘The patient survived despite our treatment’. I said, ‘Okay, thank you’. (GP 3)

189 They’ve sent them home with instructions. The patient doesn’t want to disobey the hospital and yet I’m saying, ‘I don’t think that’s the best way to manage this’. In two cases, one was the introduction of a NOAC, one of the new anticoagulants. They gave the wrong dose to the wrong age group. The second one was the interaction of a NOAC again, actually the same member of the same family, was given a new NOAC for his AF but actually interfered with his Tegretol which he was on for epilepsy. If he had a seizure while he was driving, you can just imagine the liability that comes out of that, plus he can’t drive for two years.

I had to go back and talk to the hospital pharmacy about the policy. I’m actually in the process of writing a letter to the Medical Administration, not to complain but to raise the issue that these are things that … I’m having to sort in manual general practice with my knowledge, and yet they’ve got a full team up there with specialists, registrars, and everybody else. The pharmacist, actually, was quite supportive. He said because they don’t review the medication charts, they just dispense the prescription. The pharmacist doesn’t see the medication charts. (GP 3)

So, I think how we deal with people coming from overseas. How we deal with that huge upheaval of moving house, moving life, and losing someone along the way, more than likely. I don’t know that there’s a lot of evidence. We may go into the depression, the post-trauma sort of evidence, but really, each person is an individual and your capacity to deal with them I don’t think you can trust evidence. A lot of it’s innate, it’s nature, it’s how you feel they’re responding to you in the room, your skill as a communicator, probably. There are some great examples I could give you but I don’t think that we’ve got evidence for everything. What we need in some cases where we don’t have evidence is good support systems where we can rely on an allied health expert or someone who’s an expert in the field to help us and say, ‘How do I get this lady through? She’s presenting with all the symptoms of fibromyalgia, but I know it’s coming from the psychological stress of her forced eviction from her family home and watching half the relatives shot dead in front of them’. And I’ve got three cases like that just for fun. (GP 3)

Secondly, is the terrible side of it which I’ve seen where I nursed a … we’ve all got anecdotes, but I nursed the father of one of my daughter’s best friends at school through his terminal illness, a 38-year-old who had Gastric Carcinoma. A non-smoker, non-drinker died weighing 36 kilos and he got one year’s prescriptions of one of the PPIs without ever seeing a GP. Picked it up at the desk. It wasn’t until his wife said, ‘Don’t you think you’ve lost too much weight? Don’t you think you need to see the doctor?’ She thought he’d seen the doctor, which was

190 picking up the scripts. I think you know, and we all know about stroke patients who end up with uncontrolled blood pressure and of course the opportunity to check for AF, as we all get older. You’re too young yet. (GP 3)

I don’t know if you know this story. They statistically outlined one of the labs on the basis they didn’t report enough in your abnormalities per 100 cases, because there’s a minimum standard, and if you don’t report so many then it means you’re missing them, that’s the assumption of the program. Of course, they went in and sued them. Medicare bad mouthed them and did everything, put them in the paper, and when you listen to their side of the argument, that lab serviced a large group of GPs who were in the monogamous Greek community. What’s the chance of picking up pap smear abnormalities? So, they didn’t allow for the population variation for that particular lab and they still argued to this day. Their kids were actually getting ridiculed at school. Your dad is killing my mum, and all of this. The newspaper articles all supported, ‘this is a bad lab’. (GP 3)

GP 4

I had a man who recently I had been to the Medical Board over an issue where this man fell in the hostel and he hit his head, but I never knew anything about it. The daughter was suing the hostel, but she complained to the Health Care Complaints Commission and they reported that I was the doctor. I knew nothing about it, I said well they never told me anything. I had to go to the Medical Board and now everybody that has a fall in the nursing home or hostels has a CAT scan of the brain wants to send to the hospital. He never lost consciousness, he was always unsteady and then it just happened to go to a neurologist which was organised by me, but not because of that and the neurologist sort of questioned something and then he said he sent in for a CAT scan and found the subdural hematoma. They said to me, ‘What’s the procedure?’ Before that there was no procedure. Everybody instructed the nurse that any of my patients who has a fall and has a head injury, then because they’re more prone to traumatise blood vessel … many of them are on Warfarin and some of them are on Aspirin and they go to the hospital and they just go and have the CAT scan and come back home if everything is all right which mostly it is, but that’s a big expense and a cost, but that’s Medicare legal. They said, ‘That’s a good idea’. That’s the policy we have now, but previously we used to look at a level of consciousness and there was nothing wrong, you did have some headaches and he was taking a couple of Panadol, or something. That’s the one thing that I’d say was just costing a lot of money because they’re not prepared to rely on … it was too late if you wait until he goes

191 unconscious I suppose. It taught me a lesson because they had nothing to do with me. I still look after the man in a different nursing home. That does concern you if you think. You’ve got to go on what’s serious, but for the majority of things it’s not really medicolegal for that type of thing. (GP 4)

GP 5

I used to, in my other practice, have a 40-year-old, no, a late 30-year-old gentleman come in and go ‘I’ve got kids now. I’m looking after my health. I would like my yearly blood test’. And I’d say, ‘No. Look, here are the guidelines. I’m happy you’re here for the first year. Okay, yeah, I’m happy you’re here but actually you don’t really need to follow it up if you’re fit and healthy’. And then the next year, ‘I’m here for my annual blood test’. I go, ‘No, this is what the guide--’. ‘No, no, no, no, I insist on having this’. And then the year after, ‘I’m here for my annual…’. It’s like, ‘Oh, my gosh!’ (GP 5)

GP 6

So I was thinking of something like, if you had a Twitter handle something like GP Superhero, hashtag GP Superhero or something like that or GP Action Hero or something. Saw a 55-year- old man, started blood pressure medication, boom, another life saved or whack, shazam, just gave an immunisation to a 12-month-old, shabam. They’re not going to die of infant mortality ever. That’s kind of awesome, that would make a really good comic. Yeah. Because it just is not out there in the public consciousness. Somebody goes into casualty and gets their chest cracked because they’ve been an MVA, I mean, yes, that is extraordinarily important for that person at that moment but as a proportion to the population, is that going to make a difference to mortality? No. As opposed to all the other stuff that—dementia is probably stabilising because we treat livers and blood pressure, you know, everyday stuff. (GP 6)

GP 7

And I mean, you know, seven or eight, maybe 10 years ago when Tony Abbott was Health Minister, I remember having a chat with Tony over a cup of coffee in the middle of his polies ride, and he just said, ‘Look, we’ll never get that through so we’re not going to waste our time doing it’. I said, ‘Yeah, but you know we need to do that’. ‘Oh, of course we need to do it’. But he was so pragmatic as a politician he said, you know, ‘We’ll never do that’. It was like fixing the, you know, State Federal Funding … he said, ‘Too hard. I’m not going to spend a minute

192 on it because I just recognise it cannot be fixed’. And you know, so I’m sort of cynical when GPs … it’s a bit like politicians; everybody says their own GP is marvellous but people out there say, ‘Doctors are greedy’, or you know the perception is doctors do very well. You know, I work probably a 60- to 70-hour week. I make reasonable money, but I’m not rich compared to my colleagues in other professions. But yeah, so it makes an old man like me cynical. (GP 7)

But we know, from our patients that—you know as a practice we’ve always worked hard on— you know we now have patients come in and say, ‘Oh, doc, I think I’ve probably got a virus but I just want you to check me out. I’ve had it for five days: I’m not getting any better. I know you’re probably going to tell me I don’t need antibiotics. But your heart just glows when you get a patient like that. (GP 7)

GP 9

That was probably the biggest thing that I realised that I was doing wrong as a first-year intern, like straight out, was sort of—oh, it’s so embarrassing—I was ordering bloods on patients sometimes every day or every second day of their stay, and also like there’s tonnes of reasons to do that but it was for stupid little things like—I don’t know, like a slightly out magnesium level or something. I’m sure that mattered and was different for cardiac patients if they were on anything else or like a surgical patient with an obstruction or a risk of virus or something like that, but I was doing it even on the ones where it was like—I don’t know, orthopaedic patients, so someone with a broken leg and then no reasoning with that. And it was like, ‘Really?’ When he said, I simply didn’t need to be chasing the magnesium every day. So, I think probably there’s a fair bit of money wasted on a lot of sort of like what is perceived as smaller, less expensive tests being done but just too many of them being done so it started to add up. (GP 9)

Because like so much of it is about resourcing as well actually in the GP setting—and not being able to necessarily access—like sometimes, and having worked in more remote clinics in Central Australia a little bit, sometimes you don’t even have an ECG machine. And you’re just like, ‘This person is high risk and they’re showing me they’ve got chest pain. I have to send them in because I want an urgent Trop; I don’t want a Trop tomorrow sort of thing. And I need an ECG and I don’t have one’, and they’ve got an ECG machine. So, you have to send them even though it’s true that sometimes it’s not like quite an atypical chest pain or you might be like, ‘Oh, that’s something and I’ve come across these chest pain multiple times before’. Then,

193 yeah, when you look at their whole overall list it’s still enough to go, ‘No, I do need to try a Trop again and I do have to send you off for an ECG again’. And the ED is just rolling their eyeballs sort of thing and like, ‘Ugh!’ (GP 9)

GP 10

I had a patient in our little local hospital with a pneumonia sepsis—pneumonia sepsis, something like that. Anyway and we were managing him. I had a medical student with me and we were talking. We did his bloods and then she was like, ‘Oh, so are you going to do his bloods again today?’ And I was like, ‘I did them yesterday’. She was like, ‘You’re not going to check his CRP today?’ I said, ‘There’s no point doing a CRP every day because it might go up a little bit, and then what? Like I’m not going to change his antibiotics’. I said, ‘I’m looking at his clinical picture. I’m looking at how he’s feeling, what his respiratory rate is doing, what his stats are doing, what his temperature’s doing and that’s going to guide my management’. And then I said, ‘You know, CRP, more than really, maybe three times a week isn’t actually that useful and the labs will tell you that’. And then I found here the stuff on ‘Choosing Wisely’ and all that stuff, and she was shocked because she said, ‘Like in hospital they do a CRP every day’. (GP 10)

Look, okay, so I had a patient who the presenting complaint was headaches and it was translated through her daughter; she was an Afghani refugee and she didn’t want the telephone interpreter. I’ve known her for a few years and she’s never wanted one so we’re dodgily translating through the daughter because what else can you do? And it took me ages. And so, her presenting complaint was fatigue and these headaches. And I could have easily just sent her off for a barrage of bloods. But without asking lots and lots of questions I wouldn’t have got to the point that this woman was having seizures—prior to headache and feeling tired. And her daughter didn’t have the words for that and neither did she. And it was only when I asked, ‘So, what happens when the headache comes on, like how does it …’, because they were saying, ‘It suddenly comes on’. And she’s like, ‘After she falls down’. And I was like, ‘What do you mean, she falls down?’ And then eventually ended up demonstrating shaking and, ‘Oh, yeah, she does that’. And I was like, ‘Okay, this is a different story’. And then so, she ended up having an MRI and an urgent referral to neurology and then an EEG and being put on anti- epileptics. (GP 10)

194 And a patient that I thought had a stress headache but had this weird vomiting, and I was like, ‘Look, your neuro-exam is normal but I don’t like the vomiting you’ve had the last couple of days. Let’s just send you for an MRI even though I don’t normally do this’. And then he had a bloody bleed in his head, didn’t he? (GP 10)

I mean I had one not too long ago, a woman; she’s about nine months post-partum, I think, who was tired and stressed. And so, we were going through all the things and talking and we were talking about how she missed work and she felt a bit bored being with the baby all day. And we talked about doing day-care half a day a week and stuff. And again this is all sounding like all about the day-care. It’s like, ‘He’ll be in the same room as my baby’. And then I saw her two weeks later for her results because we decided to do some bloods, and she told me she’d put him in day-care, she’d started doing some extra stuff for herself and exercising and was feeling a thousand times better. And she’s actually got Graves’ disease; her thyroid function was way off. But she actually felt better already with just the stuff that we were doing, which was really interesting. But was still losing weight. So, I would have done … because that was her other thing; that was why we did the bloods because she was losing weight more than she expected just through like breastfeeding. (GP 10)

But there are still tests that are done that I don’t think need to be done and that are repeated. I mean I had a patient who has chronic back pain, bad back pain, and he’d had some neurology weakness or loss of sensation down the leg, can’t remember which. Anyway, he had a CT Lumbar Spine and then was waiting for the specialist. And then about three weeks after that he was drunk, and he fell over and hit his head and was in ED [Emergency Department] and they scanned his head. And he must have mentioned his back pain. And they’ve done a CT of his Lumbar Spine. So, like my patient might have been too drunk to tell them he’d just had one. I don’t know. But on the radiology system at some point someone could have easily checked to see that he’d just had one. Like there’s only one radiology place in [city]. (GP 10)

GP 12

We’ve actually got two GPs at work in our department as G-, like I work as a registrar, in a registrar capacity, that’s how I’m paid, but they’re paid as VMOs, and they’re both like highly experienced, of being in their mid-50s, being working for at least 30 years I reckon. And they know what they just like—let’s say, on average 20 patients a shift. Whereas I’d see about 14 if

195 I’m on a good day, like if I’m going really quickly. They just can do stuff so much quicker than they, because of that experience they’ve got. (GP 12)

GP 13

Because we’ve only got two nurses, so to ask them to take on —doing pal care, it’s just not fair, because we’ve got that situation that I mean, you would have two that—a nurse can’t go out by themselves, but they’re both on call 24 hours a day, seven days a week. To ask them to do anything extra, I just couldn’t. And I mean, I’ve got a guy who’s dying of HCC at the moment, and he’s just going to have to go into the pal care unit, because I can’t ask them to look after him there. (GP 13)

GP 15

I always read the stuff from the Indemnity Insurance—you know how they send out a booklet or a pamphlet or a newsletter every three to six months? And they talk about patients. And there was a case where you know clinically it didn’t sound so much like a DVT, but the doctor didn’t do an ultrasound. A doctor ultrasound it and it ended up being a DVT and he ended up getting sued and lost because he didn’t do a Doppler. And you’re like, well, clinically when he saw the leg, calves were soft, yes, they a bit tender but she’d been exercising the day before. So, you’re like, ‘Well, it’s probably just a muscle strain’, you know. But because in these current circumstances because you can get a Doppler, right, because the Doppler is down the road, if you don’t get it and you get into trouble then … so, if you were in the middle of, say, like Tennant Creek or whatever and there’s no ultrasound available, the patient has to travel 300Ks for an ultrasound, right, then you’ve got to base it on your clinical judgement. And then you know you can tell the Coroner, ‘Hey, look, I thought about DVT but I didn’t think it was worth him travelling. Clinically there wasn’t enough there for him to travel 300Ks for an ultrasound’. (GP 15)

GP 15: Like, for example, I had a lady who had a—what’s that big vessel that runs in the middle of your head?

Interviewer: Yeah, like a venous sinus thrombosis?

GP 15: Yeah, exactly. She just had a headache. No red flags, just a simple headache. And you’re like, ‘Oh, shit!’ And so you’re like, ‘Okay’. Do you know what I mean?

196 GP 19

It’s actually amazing. So a guy who had metastatic bowel cancer with a large lytic lesion in his femur, head of the femur with no fracture and no pain and they gave him a hip replacement with a one-month life expectancy. I couldn’t believe it. It a $50,000 intervention with some side effects with rehab. I was just amazed. So it’s just stuff like that all the time, all the time. (GP 19)

I had a few kids where in the preschool they had a speech pathologist come and screen all the children and then if any issues were identified then they were told to see their GP and get a GPMP so then they rock up with their 15-minute appointment and say, ‘I need this’. (GP 19)

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Department of Health. (2014e). Australian Medical Association National Conference—Global practice, Australian perspective [Press release]. Retrieved from http://pandora.nla.gov.au/pan/143032/20140729- 1249/www.health.gov.au/internet/ministers/publishing.nsf/Content/the-hon-peter- dutton-mp-latest-news.html

215 Department of Health. (2014f). E&OE transcript ABC News breakfast [Press release]. Retrieved from https://www.google.com.au/search?source=hp&ei=ONMFXPGaPJuv9QPNg7- gCQ&q=TRANSCRIPT+E%26OE+Transcript++ABC+News+Breakfast+26+May+2 014&btnK=Google+Search&oq=TRANSCRIPT+E%26OE+Transcript++ABC+News +Breakfast+26+May+2014&gs_l=psy-ab.3...1410.1410..2209...0.0..0.302.550.2- 1j1...... 0....1j2..gws-wiz.....0.n_4B7vaZFCo

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Department of Health. (2014h). Interview on Sky News with Peter van Onselen [Press release]. Retrieved from http://www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel- yr2014-dutton140326.htm

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216 Department of Health. (2014l). Radio interview on 2GB with Ray Hadley [Press release]. Retrieved from http://www.health.gov.au/Internet/ministers/publishing.nsf/650f3eec0dfb990fca25692 100069854/421672fdfd0115c5ca257ceb001d86c3?OpenDocument

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Department of Health. (2014n). Speech—The Australian Medical Association National Conference [Press release]. Retrieved from http://pandora.nla.gov.au/pan/143032/20140729- 1249/www.health.gov.au/internet/ministers/publishing.nsf/Content/Profile-PD-1.html

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Department of Health. (2015a, 22 April). Abbott Government to deliver a healthier Medicare [Press release]. Retrieved from http://pandora.nla.gov.au/pan/143032/20150430- 0229/www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel- yr2015-ley045.htm

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217 Department of Health. (2015d). Four corners a sobering insight into why Medicare review necessary [Press release]. Retrieved from https://www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel- yr2015-ley116.htm?OpenDocument&yr=2015&mth=09

Department of Health. (2015e). Government to consult on Medicare reform [Press release]. Retrieved from http://www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel- yr2015-ley002.htm

Department of Health. (2015f). Interview on 2ue Afternoons with Justin Smith [Press release]. Retrieved from http://www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel- yr2015-ley150903b

Department of Health. (2015g). Interview on 5AA Adelaide with Leon Byner [Press release]. Retrieved from http://www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel- yr2015-ley150903.htm

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218 Department of Health. (2015k). Misuse of Medicare chronic disease items [Press release]. Retrieved from http://www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel- yr2015-ley128.htm

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Department of Health. (2015n). Speech—National Press Club [Press release]. Retrieved from http://www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel- yr2015-ley151028.htm

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219 Department of Health. (2016c). Budget puts patient outcomes at centre of health reform [Press release]. Retrieved from http://www.health.gov.au/internet/ministers/publishing.nsf/Content/budget2016- mediarel-ley001.htm

Department of Health. (2016d). Chronic care finds new home in Medicare [Press release]. Retrieved from http://pandora.nla.gov.au/tep/154992

Department of Health. (2016e). Growing at one every 38 seconds the My Health Record hits 4 million! [Press release]. Retrieved from http://www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel- yr2016-ley043.htm

Department of Health. (2016f). Health care homes to keep chronically-ill out-of-hospital [Press release]. Retrieved from http://www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel- yr2016-ley024.htm

Department of Health. (2016g). Medicare items review backed by health professionals, patients [Press release]. Retrieved from https://www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel- yr2016-ley053.htm

Department of Health. (2016h). New Medicare payment model for chronically-ill patients [Press release]. Retrieved from https://www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel- yr2016-ley025.htm

Department of Health. (2016i). Speech—The Committee for Economic Development of Australia (CEDA) [Press release]. Retrieved from https://www.health.gov.au/internet/ministers/publishing.nsf/Content/.../SL160331.pdf

Department of Health. (2017a). 2GB interview with Mark Levy [Press release]. Retrieved from www.health.gov.au/internet/ministers/publishing.nsf/Content/.../GH170210a.pdf

220 Department of Health. (2017b). Australian Medical Association National Conference Melbourne [Press release]. Retrieved from http://www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel- yr2017-hunt170526.htm?OpenDocument&yr=2017&mth=05

Department of Health. (2017c). Chronic conditions. Retrieved from http://www.health.gov.au/internet/main/publishing.nsf/content/chronic- disease#footnote

Department of Health. (2017d). Doorstop Northbridge Medical Practice, Sydney [Press release]. Retrieved from http://www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel- yr2017-hunt170413.htm

Department of Health. (2017e). Doorstop, Melbourne [Press release]. Retrieved from www.health.gov.au/internet/ministers/publishing.nsf/Content/.../GH170427.pdf

Department of Health. (2017f). Encouraging women to make health a priority during Women’s Health Week [Press release]. Retrieved from http://www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel- yr2017-hunt092.htm

Department of Health. (2017g). Frankston Doorstop—Lowest health insurance premium increases in a decade [Press release]. Retrieved from http://www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel- yr2017-hunt170210.htm?OpenDocument&yr=2017&mth=02

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Department of Health. (2017i). Interview with Barrie Cassidy ABC Insiders [Press release]. Retrieved from http://www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel- yr2017-hunt170528.htm?OpenDocument&yr=2017&mth=05

221 Department of Health. (2017j). Interview with Ben Fordham 2GB drive [Press release]. Retrieved from https://www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel- yr2017-hunt170921a.htm

Department of Health. (2017k). Interview with David Speers—Sky News [Press release]. Retrieved from http://www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel- yr2017-hunt170207.htm?OpenDocument&yr=2017&mth=02

Department of Health. (2017l). Interview with Leigh Sales ABC 7.30 [Press release]. Retrieved from http://www.health.gov.au/internet/ministers/publishing.nsf/Content/health- mediarel-yr2017-hunt170206.htm?OpenDocument&yr=2017&mth=02

Department of Health. (2017m). Interview with Leon Byner FiveAA [Press release]. Retrieved from http://www.health.gov.au/internet/ministers/publishing.nsf/Content/health- mediarel-yr2017-hunt170404.htm?OpenDocument&yr=2017&mth=04

Department of Health. (2017n). Interview with Matt Wordsworth ABC AM [Press release]. Retrieved from https://beta.health.gov.au/ministers/the-hon-greg-hunt- mp/media/transcript-of-interview-with-matt-wordsworth-on-abc-am

Department of Health. (2017o). Interview with Peter van Onselen and Paul Kelly [Press release]. Retrieved from https://health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel- yr2017-hunt170319.htm

Department of Health. (2017p). Record number of Australians receiving Medicare benefits [Press release]. Retrieved from http://www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel- yr2017-hunt080.htm

Department of Health. (2017q). Record results for bulk-billing shows Medicare is stronger than ever [Press release]. Retrieved from http://www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel- yr2017-hunt015.htm

222 Department of Health. (2017r). RN Drive—Interview with Patricia Karvelas [Press release]. Retrieved from http://www.health.gov.au/internet/ministers/publishing.nsf/Content/the-hon-greg- hunt-mp-media?OpenDocument&MTH=3&YR=2017

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