Chris Ham on general practice in Australia

If familiarity breeds contempt, then distance lends perspective. This much I learned – or remembered – on a recent visit to Australia.

Invited to give the keynote address at the Australian General Practice Network National Forum 2010 in Perth, I was reminded of the strengths of general practice in the NHS. Registration with a practice, a blended payment system based on capitation and rewards for quality, team working, and the absence of co-payments mean that general practice in the NHS is rightly admired throughout the world. Contrast this with patients shopping around for doctors in Australia, fee for service reimbursement that rewards GPs for contacts with patients rather than continuity, and the lack of incentives for quality and teamwork, and the advantages of the UK model are plain to see.

This was brought home in a fascinating presentation by a GP who had left England to practise in Australia two years ago. His story of working as part of a team in England, relying heavily on nurses, allied health professionals, and others, was a salutary reminder of things we often take for granted. Unlike in Australia, the NHS payment system offers no incentive to maximise patient contacts with the aim of increasing income, and encourages GPs to use other members of the primary care team as much as possible.

How different from this GP’s current experience where the income of doctors is based on the work they perform directly, thereby encouraging over investigation and discouraging the use of other clinicians. The result is that doctors undertake work that could be better done by others because financial incentives may trump professional judgement about the best way of providing care. Resistance by some GPs to moves by the government to provide public funding for nurse practitioners in primary care illustrates the strength of medical protectionism in Australia.

The other insight from this presentation was the impact of differences in employment arrangements in the two countries. GPs in England who are the owner managers of their practices are able to see the financial and other benefits of delivering high quality care and have a direct stake in so doing. Salaried employment for many family doctors in Australia creates a different mentality with GPs facing weaker incentives to continuously improve performance. There is a clear warning here as more salaried GPs are employed in the NHS.

I was invited to speak at the conference about the experience of primary care trusts at a time when Australia is introducing organisations known as “Medicare locals” to support the further development of general practice at a population level. The minority Labour Government elected in Australia in August has invited expressions of interest from general practices to become Medicare locals with the aim of establishing around 15 from July 2011. Health Minister, Nicola Roxon, emphasised that it was up to GPs to come forward with proposals for moving in this direction, on the basis that GP ownership and commitment would be fundamental to success.

The principal purpose of Medicare locals is to achieve closer integration between GPs and between GPs and other staff working in the community as well as improved access to care. The aim is to move away from the corner shop model of general practice towards a more organised and population based approach to health care provision. There is no suggestion that Medicare locals should become the principal commissioners of care, underlining the extent of English exceptionalism in expecting GPs to take on this role in the future.

The benefit of distance is that it reminds us what a precious asset we have in primary care, notwithstanding the need to tackle unwarranted variations in quality. At its best, NHS general practice sets the bar for others to follow. If we could heed Nye Bevan’s injunction to universalise the best, then we could be confident in having a health service fit for the future.

Chris Ham is the chief executive of the King’s Fund.

This blog also appears on the King’s Fund website at http://www.kingsfund.org.uk/blog/

  • Tiago Villanueva

    I attended last year the first ever Exchange program for European GP trainees and GP's organized bu the Junior International Committee of the RCGP, and my experience of UK General Practice has just been published on Innovait:

    http://rcgp-innovait.oxfordjournals.org/content/3/11/697.full.pdf+html

  • Carmelmarymartin

    How superficial are the comments of Chris Ham!
    As a Australian internationally based Professor of General Practice who researches international primary health service reform, I am equally or even more an experienced key informant than the GP who left the UK to practice in Australia.
    I would say that working in UK General Practice in the past 2-3 years, having trained there in the 1980s, was a most disappointing and frustrating experience. General Practice and team work by numbers, was my experience of UK General Practice. Person-centred medicine it was not! Teamwork is more a myth that reality, with fragmentation of care and shunting people around. (Australians have choice!) The greatest 'relationship-based' care of patients in the UK, was with the low paid staff on the reception desk, who cared about their local community. Many and increasingly more practices are owned by large companies. They have GPs who were salaried and not engaged with practice populations. Nurses were being managed by a nurse manager elsewhere. Coucellors and Physios were limited in what they did being managed by some other authority. In contrast, in Ireland, which is very much seen as backwards by the UK, despite the need for greater structure, the patient-centred approach is still alive and well. Australia is in between the two systems, and the best of both worlds, I experienced this while working back home, two yeards ago. No health system is without the need of improvement, and all can be improved.
    However, Chris Ham who is not a GP, who sees that the boxes for Primary Care/General Practice are all ticked in the UK, compared to everywhere else in the world, is highly and dangerously misguided.

    Patient-centred care is the central facet to primary care/general practice. It has been lost to a tick box payment system. Disease management is improtant but has been highly over-rated in comparison to person-centred care.

    Why, oh why does Australia keep listening to 'experts' from overseas, and fail to look to its own strengths? Do we still have a colonial mentality? The motherland knows best!!

    Wake up and stop trying to emulate another very different country with its patchy successes in Primary Care reform and look inwards at what you are achieving Australia!!!
    Carmel Martin MBBS, PhD etc
    Visiting Professor Trinity College Dublin.