Published: 13/12/2001, Volume III, No. 5785 Page 20
Australia and Canada have a lot in common with the UK: developed countries with high living standards, members of the Commonwealth, anglophone (of a sort) - and all believe in public sector values.
In their health services, all three face the same issues: high expectations and demands, well developed hospitals, escalating costs and a growing awareness that a sea change in strategic policy is needed to turbo-charge effectiveness and efficiency.
All this makes it tempting to compare the three systems, and important lessons are to be learned in doing so - but with a caveat.Health services, like other large, society-wide structures, are culturally sensitive, and what can be done in one country may be inappropriate in another.
In the UK, for instance, we have a strong sense of fairness, and the need for queuing is generally accepted. In Canada, and especially in Australia, choice and accessibility take precedence over egalitarianism, and people expect instant service from their chosen provider in a way that is still (but for how long? ) alien to us.
Nowhere are these cultural facets more obvious than in general practice.Users and practitioners have views of their own system that we would find odd, views which can give us acute insights into the way that people think, and how systems work.
Australian and Canadian GPs work as independent practitioners, like their British counterparts. They usually work in their own premises, and these are often shared. But unlike British GPs, they are not shared on the basis of formal business partnerships; they merely share the costs of the building and, indeed, are often in competition with each other. But there are two key differences between the UK and its two ex-colonies: our patients are registered, theirs are not; we work on the basis of capitation fees, they receive a fee for every service rendered.
These two factors are linked but not synonymous. In the UK, over 97 per cent of the population is registered with a GP. The registration becomes the keystone of the bridge linking all parts of the NHS, the coordination that allows our care to be informally managed, our population demography to be mapped, and our resources to be used more efficiently than most other health systems, even today.
It also forms the backbone of the capitation system that accounts for about half of all selfemployed GPs' pay, but this is not an inevitable consequence. The capitation payment system pays GPs for 'being' rather than 'doing', and in that sense is simply an insurance premium: everyone pays, and those who have to claim are subsidised by those who do not.
The intriguing part of this system lies beyond the predictability of its costs, in the fact that the risk of managing within resources has been passed from the NHS to GPs, who have to manage their patients within the constraints of their predictable income.Never mind flu epidemics and rising demand, the capitation system means it is up to providers to manage and 'own' their own risk - entirely different from merely dealing with patients who 'belong' to the NHS.
In Australia and Canada capitation doesn't exist because GPs fear that once set, an increase in workload will not be reflected in income - cheap for the system, but expensive for them. Instead, they would rather walk the treadmill of the fee-for-service system that rewards activity, not outcome.The more they do, the more they get.And if you pay people for doing more, they tend to do more.More consultations, more tests, more referrals. But whether this activity is linked to health improvement... well, there is not much evidence for that.The bureaucracies in both countries are well aware of this, and would dearly love to put their providers onto a capitation model.
Thus GPs' paranoia about capitation may well be justified, for though the population would benefit from a system that rewarded outcome rather than activity, the real reason it is being considered is probably more to do with cost containment than health improvement.
As for patient registration, it is actually the population at large which is resisting that idea.
Choice is a much higher priority in Australia and Canada, and the concept of having a GP with whom you are 'stuck' is not one that gains much sympathy, apart perhaps from those with longterm chronic illnesses.
There is a lot more to be said on this subject, but perhaps we should count our blessings, and be wary ofmoving from a sophisticated (albeit apparently low-choice) blended system that shares its risks between commissioners and providers, towards a more mechanical, activity-based model that requires much stricter monitoring, has misaligned incentives and puts ownership of the problems firmly back in the commissioners' court.
Personal medical services, anyone?
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