What is good for general practice not necessarily good for health

Underpinning this divergence of interest between government and primary care is the private business model under which the vast majority of general practices operate

“What is good for General Motors is good for the country”, is a quote attributed to Charles E Wilson; the country is good for General Motors, and vice versa. So even if the General Motors’ CEO didn’t use those famous words, he still meant them. In this month’s column, I ask whether what is good for general practice is good for New Zealand

The ongoing negotiations over the new PHO Services Agreement Amendment Protocol (PSAAP) agreement puts the spotlight on this question, as negotiators from primary care land and the Ministry of Health wrestle with how to absorb the expanded eligibility for the Community Services Card and the extension of zero fees for under-14s into the primary care funding system.

Negotiators representing primary care interests have been seeking to get the best deal they can. After all, if these representatives were not there vigorously arguing the case on behalf of primary care practices, then who would?

Let’s imagine a very simple Venn diagram with two overlapping circles. The first circle represents the interests of primary care practitioners and their businesses. The second represents the multifaceted policy priorities of government (and citizens) in improving the health of the New Zealand population through an accessible, efficient and equitable health system.

There is a significant area of intersection between these circles. A healthy, well-supported primary care sector is essential to a well-functioning health system, something that the late US primary care researcher Barbara Starfield and her colleagues demonstrated convincingly. Any system of health funding that strengthened the role of primary care within the health system, and countered the forces of gravity that lead to ever-increasing proportions of health spending ending up in secondary and tertiary services, would sit within this Venn intersection.

But there are parts of the diagram that are not included in this overlap. Clearly, there are many arrangements that advance the material interests of GPs, but constitute major barriers to more equitable primary care access and outcomes.

The most significant of these historically has been the “right” to charge copayments. This was the result of a pivotal moment in New Zealand health policy in the early 1940s, when the New Zealand branch of the British Medical Association refused to agree to a system in which the state would guarantee universal, free access to primary care.

Ever since feisty James Jamieson won this battle on behalf of the NZ branch of the BMA, retaining some control over the charging of copayments has been central to the interests of general practices as private businesses.

Over recent years, under various incremental adjustments around zero fees for children and Very Low Cost Access arrangements, practices have “negotiated away” parts of this right. Nevertheless, the very existence of copayments works against an accessible health system.

On the other side of the Venn diagram, outside the overlap, there are policies that could lead to a more accessible, equitable and efficient health system which would not be in the interests of general practice. One example would be introducing more control over where GPs can practise in order to address the mismatch between health need and service utilisation.

Many of the stillborn components of the 2001 Primary Health Care Strategy seem to fit in this part of the Venn diagram. These include efforts to develop a more interdisciplinary approach to primary care practice, and the failed attempt to institutionalise community representation at the governance level of PHOs.

Underpinning this divergence of interest between government and primary care is the private business model under which the vast majority of general practices operate. If one were to take a blank piece of paper to design a publicly funded primary care system with the aims of supporting an accessible, equitable and efficient health system, it is highly unlikely we would end up with a private ownership, for-profit model.

But health systems are rarely the result of conscious design, instead they are the product of contingent history made up of many “frozen accidents” such as the battle over the right to charge copayments.

In New Zealand, we know from experience that the combination of private business models and copayments can compromise efforts to shift the balance of health system funding towards primary care. Governments are unwilling to shift new costs on to patients. Secondary and tertiary medical professionals (particularly those working solely in the public system) are able to argue that pro-primary care policy shifts amount to an erosion of the goals of a public system.

Of course, there is the burning question of whether alternatives to the private business model of primary care would actually deliver better health system results. There are very complex dynamics at play. For instance, if GPs were subject to greater control by government or non-profit private organisations, would this diminish the status of the GPs in relation to specialists? There may be significant unintended and unanticipated consequences.

However, this should not distract us from the fundamental point that what is good for general practice is not always good for the health system or the country. I am not singling out GPs here. The same goes for any professional group, including my own. Individual GPs vary significantly in how they balance these competing priorities personally. Regardless, the policy dilemmas that arise from general practice organising to protect its collective interests will be with us for some time yet.

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