The power of general practice: Strong lobby or cogs in a machine?

From the perspective of others…the power of organised general practice is palpable and real

Discussing his submission to the Waitangi Tribunal Health Services and Outcomes Inquiry, GP Rawiri Jansen said, “we need to have an honest conversation about where the power resides” in primary care.

In a similar vein at the tribunal hearings last month, University of Otago researcher Peter Crampton identified GP organisations as powerful lobbyists.

Judging from the comments made in response on nzdoctor.co.nz, these statements hit a raw nerve. A number of correspondents disputed the notion that GPs are powerful in the current system.

Power is an emotive word.

In our popular culture, in our media, naming particular groups and individuals as powerful typically carries with it an implicit or explicit critique and questioning of that power. It is easy to conflate the naming of power with an attempt to shame it.

My training is in the discipline of political science; questions of power are central to what we do. For political scientists, there is nothing inherently shameful about power (although one may well make such judgements in specific contexts).

Rather, power is essential to getting things done. At the core of political science is the task of understanding what power is, where it is situated, who benefits, and under what circumstances power is rightly and legitimately exercised.

Perhaps the most useful way to think about power is in terms of energy, which can take many different forms. Just as electrical power can be generated from many different “raw” materials, so can power over health policy. Power is never absolute. One group’s power always rubs up against the power of others.

In the field of health policy scholarship, it is universally accepted that medical professionals have power in health systems.

True, this power is frequently challenged by governments, insurers, patients and citizens. There are arguments about whether or not medical power is waning, but not over its existence and importance. Medical professional power is based on a number of resources – the capacity to define health need, the (partial) control over the supply of professionals and considerable autonomy over work (when compared with most other occupations and professions).

How does this square with the comments and feelings of frustration – often eloquently articulated in New Zealand Doctor – about how powerless many doctors feel? Perhaps the first thing to note is that whenever we hold power, we tend to take it for granted. If we think about it at all, we see the power we have as inherently legitimate and natural. However, others who are subject to that power usually see it much more clearly than we ourselves. In the same way, we tend to be adept at identifying the power we don’t have, that others have.

So, medical specialists are often bemused to hear their primary care colleagues highlighting the power of secondary and tertiary healthcare services within the overall health system. In the same way, as the responses to Dr Jansen and Professor Crampton’s remarks illustrate, GPs may bristle when hearing that they have power over primary care, when they feel more like small cogs in a large machine.

Nevertheless, from the perspective of others, such as Māori health providers dealing every day with the health needs of whānau who don’t or can’t access mainstream primary care practices, the power of organised general practice, particularly over primary care funding streams, is palpable and real.

In the Waitangi Tribunal hearings, the Ministry of Health has been criticised for not exerting the power it has. Those giving evidence on behalf of the ministry largely accepted this critique. One clear narrative is that the ministry failed to implement the Primary Health Care Strategy effectively because it did not “stand up” to the power of organised general practice. Again, this will appear strange to GPs who interpret the past 15 years in terms of gradual erosion of their autonomy.

Some witnesses, such as US-based researcher and former Ian Axford fellow Amy Downs, have suggested the answer is to hold government agencies clearly accountable for ensuring reductions in inequities.

However, strengthening the Crown’s formal accountability is unlikely to make a difference unless we better understand the power dynamics within health policy.

The undeniable power of medicine (and general practice) could be harnessed to enhance Māori health. That is clearly what many practitioners would like to see. This is because power does not have to be a zero-sum game in which, if one side wins, the other inevitably loses. This requires some creativity, and therefore it is worth watching developments in places such as Northland, where there is a strong will to try something new to reorient the health sector to serve the needs of its population.

But, in order to get there, we need to have an honest conversation about where power resides in primary care, and an openness to listening to the variety of voices that have something to say about it, and be willing to step into others’ shoes and see where they are coming from.

Tim Tenbensel is associate professor, health policy, in the School of Population Health at the University of Auckland