Re-imagining general practice

This editorial is about general medical practitioners – GPs – also known as family physicians. It is acknowledged that some physicians, paediatricians and surgeons have general scopes of practice and also work in the community; in the USA, they are key members of the primary care health workforce. A broadening of primary care is inevitable once new values-based financial models are introduced.¹ In the interim, this editorial will focus on GPs per se.

I recommend a re-imagining of general medical practice and will describe a successful example of such a process.¹ It is not my intention to describe a brave new world for GPs. I have never worked in primary care. When I left medical school in November 1977, I had no intention of becoming a GP for two reasons. First, it seemed to me to be the most difficult of all medical specialities and yet ironically was pejoratively viewed from both within and without. Second, during my attachments as a medical student, the role models that I saw were unattractive.

The editorial is written from a New Zealand perspective, but similar arguments exist for any jurisdiction where the medical profession works predominantly in either hospital or community settings.

There have been many attempts at top-down reforms of primary healthcare.² Almost without exception, they have been strongly opposed by the GPs themselves and have been largely unsuccessful – the most recent attempt in 2001 in New Zealand actually had a predictably perverse outcome from a behavioural economic perspective and now (according to Ministry of Health surveys) the single biggest cause of un-met health need in New Zealand is the unavailability of the GPs that patients want to see.^{1, 2}

The most famous of these political and bureaucratic ‘reforms’ was in 1938.² New Zealand's first labour prime minister, Michael Joseph Savage, an Australian import, tried to introduce a universal healthcare system. As is often the case with such plans, he only had half of the formula – that is who was entitled (i.e. all New Zealand citizens and permanent residents). He did not have the rest of the necessary calculus, which is the nature of the entitlement. Although he was successful in regard to publicly funded hospitals, and despite all the political capital he had accrued from the Great Depression, he was successfully opposed by the New Zealand chapter of the British Medical Association (i.e. the GPs) who retained the right to charge a fee for their services. A similar outcome occurred 10 years later during the creation of the National Health Service in the United Kingdom. This is an example of a powerful political economy operating in healthcare. Murray Horn and I have described these previously and attribute significant health inequalities to the efficacy of such economies, along, of course, with the many and various social determinants of health.^{3, 4}

The format of the editorial will be by way of addressing six successive Inquiries.

Inquiry number 1.

How important is primary care to New Zealand's healthcare system?

As a preface, it is worth noting that New Zealand does not have a healthcare system – what it has instead is a disease and injury management system. It is funded annually and with an expectation of certain levels of activity.¹ Inevitably, this directs political attention and funding to hospitals and end-of-life care. Despite decades of arguing that the point of healthcare delivery should be shifted as much as possible out of hospitals and into the community and people's homes and that the locus of responsibility should shift from providers to citizens, this type of funding and planning acts against such outcomes.

From 2008 to 2017, Health Workforce New Zealand (HWNZ) undertook workforce modelling. Short-term modelling was achieved by ‘stock and flow’ approaches. The major limitation, however, of this is that it requires models of care to remain constant; by contrast, the history of medicine shows that models of care change unpredictably and sometimes significantly.¹

For this reason, HWNZ developed a method of forecast planning that explicitly recognised this uncertainty.^{5, 6} For each service area (e.g. mental health), a series of clinical vignettes was created. These were chosen to represent the major clinical presentations seen for each service. A cohort of clinical experts was then tasked with imagining how these clinical vignettes could be managed in the future. They were told not to constrain their ‘options’ because of existing limitations in technology or funding. Consequently, for each service area, a collection of clinical scenarios was generated. Intelligence was derived from these scenarios by first considering how many of these would be possible given the existing workforce, capital and IT investments and developments. As a generalisation, almost none of the scenarios – other than the status quo would be adequately addressed, which illustrates that the healthcare system had placed ‘all its eggs in one basket’. The inevitable conclusion was that the system lacked agility.

The second way in which intelligence was derived was to view all of the scenarios cross-sectionally and to seek common trends or factors. The outstanding finding in this regard was that almost all future scenarios relied upon a strong primary care and community-based healthcare workforce. The answer to this inquiry, then, is that a strong primary care service is essential in almost any forecasted healthcare service ecosystem.

Regrettably, with the demise of HWNZ, the service forecasting approach has been abandoned for more traditional modelling approaches – a figurative return to ‘horses and buggies’ with predictable impacts on both speed and hygiene.

Inquiry number 2.

Is the model of primary care that operates in New Zealand fit for purpose?

As implied above, the funding arrangements for healthcare in New Zealand direct political attention and funding to hospitals and end-of-life care. In this environment, primary refers to first point of contact and constrains GPs to limited contact with people who are injured or ill and tasks them with either management on an ambulatory basis or a triage and referral role to more influential, more highly regarded and better funded secondary, tertiary and quaternary services (Fig. 1).

If the intention is to shift the point of care into the community and people's homes and concurrently to shift the locus of responsibility, then this model of primary care is not fit for purpose and will serve only to maintain the status quo. It needs to be emphasised that this model is also characterised by significant health inequalities and is increasingly difficult to fund because of a relatively ageing community and health workforce and an uncapped demand for health services. Health inflation generally runs above 10%, and publicly funded health facilities struggle to stay within their budgets; national health budgets also progressively crowd out other essential government funding. This is not sustainable.⁷

Given the overall ambitions cited here, Figure 2 represents a preferred model of primary care, but one that will require new funding, business and operating models. In this world, the word primary means most important or principal. This school of thought regards providers in secondary, tertiary and quaternary services as ‘partialists’ rather than ‘specialists’, although it acknowledges the utility and expertise of their narrow scopes of practice. By comparison, primary care providers are considered to have broad and holistic practices and the role of ‘partialists’ is to provide support as required for the primary care community. Adopting this concept of primary care would see a significant shift in funding away from hospitals to community-based services and, eventually, to citizens themselves.

Inquiry number 3.

How important are general medical practitioners in a primary health service?

This vignette illustrates the essential role for GPs in primary care. This sort of example has also led to a call for doctors to be restricted to the ‘top end of their licence’. However, requiring GPs to work for prolonged periods of deductive logical analyses of complex cases (i.e. what behavioural scientists would refer to as high-energy demand ‘slow-thinking’) would be exhausting and unsustainable.⁸

Inquiry number 4.

Does AI represent a meaningful alternative to GP?

This vignette demonstrates the complex higher communication challenge of medical practice, and one that our GP colleagues engage in every day. This is a job for humans. People do not present to healthcare providers as blank sheets but, rather, as people with lived and shared experiences that determine their illness perceptions and sickness beliefs. Effective communication also relies upon an understanding of individuals' coping strategies (i.e. monitors or blunters) and cultural norms and metaphors.^{1, 9}

The second example of why I think it is unlikely that AI will substantively reduce the need for GPs is because complexity in primary care usually arises from the social context of people and their health problems. An example would be a 65-year-old woman who is dementing and is the sole carer of her 40-year-old Downs Syndrome son, who has never been institutionalised. The diagnosis itself is not particularly complex and is reasonably easily established by repeat neuropsychometric testing and MRI evidence of brain wasting; by contrast, the ongoing support of the 40-year-old son and addressing his mother's anxiety about his future is very complex.

Inquiry number 5.

What are the existential risks to primary care and general medical practice in New Zealand?

As mentioned already, a reform of primary care will require a sea change in funding mechanisms and in consequent business models and models of care.¹⁰

The most recent substantive primary care funding reforms of 2001 have had a significant deleterious effect on GP availability.¹ Since that time, and according to the data that the GP themselves report to the Medical Council, the average GP has reduced their weekly clinical workload by 7.5 h (compared with 2.5 h per week for other types of doctor during the same period) and reduced after-hours and on-call work from 10 h per week to 4 h per week. These data are neither explained by ageing nor feminisation effects. To restore the ratio of GP availability hours to the population to the levels that existed prior to 2000 would require an additional 403 GPs.

Projecting forward, the ageing of the community and of the medical workforce is such that more than 300 GPs would need to join the workforce every year for the next decade to simply achieve a standstill in this ratio. Given the low interest in GP careers among medical graduates of the Universities of Auckland and Otago,¹¹ more than 200 of these doctors will need to be recruited each year from offshore.

The threat to the workforce is greater still if the 2022 Commonwealth Fund review of GPs is considered.¹² This review indicated that almost 40% of all New Zealand GPs were actively considering leaving the workforce. Clearly, measures such as a new medical programme that is focussed on graduates likely to become GPs and recruitment of international medical graduates are essential. However, both have significant lag phases. As such, the existential threat to the GP workforce must be addressed by way of strategies to retain those GPs already in the workforce and extend their roles, functions and availability.

To summarise, addressing the first five inquiries demonstrates the critical need for GPs in primary care; in addition, the workforce crisis that exists and is getting worse requires a re-imagining of primary care to both retain and extend the existing workforce.

Inquiry number 6.

A re-imagining of primary care and general medical practice in New Zealand.

At the beginning of this editorial, I argued that top-down impositions of primary care reform have been resisted and usually unsuccessful.² My intention now is to describe some philosophies to guide this re-imagining, to identify a facilitative role for central government and to describe one successful reform that Murray Horn and I have seen as an exemplar.

Michael Porter is the foremost advocate of value in healthcare.¹³ The value proposition of any new models of care will need to be understood and the value realised. At its most demanding, this definition of value is based on achieving the best possible outcome at the lowest possible cost. It is agnostic as to the way in which providers are employed and also to the care process itself. Instead, it concentrates on defining the desirable outcomes for those receiving the care and on the cost, how these will be measured – and how failure to achieve these outcomes will be addressed.¹⁰

Voltaire popularised the concept that perfect should not be allowed to be the enemy of the good. As such, the re-imagining should take the form of ‘a pursuit of better’. Local solutions will be needed to address local needs. There will not be a single unifying approach to primary care. Models of care being introduced will need to be anchored by accountability matrices that enable fast failure and, hence, agility.¹⁴

Jean-Paul Sartre was an existentialist philosopher who argued humans are the product of the decisions they make and that it is not possible not to choose, for to do so is to choose the status quo.

Daniel Kahneman and Amos Tversky were Israeli psychologists who helped develop behavioural economics. A fundamental principle within this science is the concept of loss aversion, which means that humans will work much harder to retain something of a certain value than they will to earn something of the same value.¹⁵ This helps explain why so many healthcare reforms fail. Consequently, in any reform or re-imagining, attention to and, as much as possible, mitigation of potential or real losses from those involved is essential.

A Minister of Health-led GP working party. The current minister of health In New Zealand is ideally placed in this regard. He is a University of Auckland medical graduate, a Harkness Fellow to Harvard University and a long-term GP. The purpose of his working party is not to produce a primary care blueprint for New Zealand for all the reasons described already, but instead to facilitate local solutions being developed to meet local needs. In any service industry, and health is a service industry, reforms must be focussed on identifying users and their requirements, and decision-making should be as close as possible to where services are delivered.

An example of a successful primary care re-imagining. This example is not intended to be a generic solution for primary care in New Zealand. It is described here to illustrate the utility of the process rather than the outcome per se. In a metropolitan suburb, the local hospital emergency department was overrun by admissions from the community. The hospital authority asked the local GPs to describe what sort of environment would be necessary to encourage them to undertake more after-hours work, house calls and critical care in the community. In addition to being paid for their services and time appropriately, the GPs developed a model of practice where in return for undertaking these extra duties, and given that they were prepared to subject themselves to audit, they could describe themselves as a ‘special’ practice and attract certain gifts and privileges – namely, they could order CT scans, PET-CT scans and MRI scans (which are not within the usual gift of GPs); also, for some conditions they could place their patients directly on hospital operating lists without the need to refer the patients to a hospital anaesthesia or surgical outpatient clinic. When asked what it was that enabled the model of care to be so successful, the GPs made it clear it was not the additional revenue, but rather that it was their idea and that what they valued the most was the status that they accrued from the privileges and so on.