Is it possible to have strong general practice (GP) ownership of a primary health care organisation, whilst pursuing a population health agenda? Geoff Meads termed this age-old tension between general practice and public health the attempt to mix oil and water.
In mineral-rich but water-poor Australia recently, I had a strong sense of déjà-vu about the general practice-public health tension.
Australia is setting up a national network of 'Medicare Locals' as part of wider health reforms. These new organisations will be responsible for planning more integrated, local primary and community health services, and in some ways resemble the new clinical commissioning groups (CCGs) being established in England.
GPs in New Zealand, Australia, Canada and the UK have all succeeded, at different points in time, in creating their own organisations to carry out a range of shared functions.
Examples include: independent practitioner associations in New Zealand; divisions of general practice in Australia; divisions of family practice in Canada; and GP multi-funds and total purchasing projects in the UK.
Given the traditionally isolated and small-business model of general practice in these countries, the emergence of organised general practice continues to be radical and important.
The benefits include: a geographical basis for local service planning; the development of new primary and intermediate services and facilities; and more general practice influence within the wider health system.
Why then do governments give in to the temptation to try and take over these GP-led and owned organisations? Is it so difficult to let them flourish in an independent form, using funding contracts or other methods to try and align their activity with the aims of the overall health system?
Governments seem to appropriate GP-led organisations for their own ends, as with primary care groups in the English NHS in 1999, which sounded the end of GP multi-funds and total purchasing schemes.
Likewise, the New Zealand Labour Government did its best to see off independent practitioner associations in the 2000s, requiring GPs to be members of new primary health organisations if practices were to receive Government funding.
The current move to develop Medicare Locals in Australia is arguably an attempt to replace (or bring into the mainstream of the health system) the long-standing divisions of general practice that have been proudly GP-owned.
One reading of this phenomenon is that when GP-led organisations get too powerful and independent, publicly-funded health systems struggle to engage with (and control?) them.
Another is that it represents the 'oil and water' of general practice and public health, with very different cultures of training, perspective, values and service delivery appearing to be irreconcilable.
It is however in organised general practice that these two perspectives are able to be reconciled and surface tension dissolved. New Zealand IPAs show the way here, as do some practice-based organisations in England.
The challenge facing new Medicare Locals in Australia is to honour and preserve the work of divisions of general practice in supporting practices and developing new services, and not squander two decades of gains in the rush to focus on population health and multi-sectoral working.
Engaging GPs and practices in the work and leadership of Medicare Locals has to be a top priority. To be distracted into what might become a bureaucratic mire of collaborative work with equivocal outcomes (and there is an evidence base here) would be little short of a tragedy.
Oil and water do not mix readily, and this appears to be a particular challenge in Australia, where they lack the burning platform of economic challenge that can arguably encourage radical service change.
Mind you, new clinical commissioning groups in England face a similar challenge – how to enthuse and engage the mainstream of general practice in what will be population health-focused statutory organisations.
How far these new organisations will feel 'owned' by GPs will be critical to their success as commissioners.
Dr Judith Smith is head of policy at the Nuffield Trust.