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