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 ..................................................................................................