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Abstract

• As with all healthcare services, public or private, what matters most to consumers is that they get a quality service that meets their needs.
  
• Consumers will gain if corporatisation means doctors are freed from administrative tasks and can spend more time with their patients, but pressure to increase profits may compromise the GP-patient relationship.
  
• A broad range of services "under the one roof" offers convenience and ease of access for consumers, particularly families and older people.
  
• All types of practices should listen to consumer concerns, and strive to meet their expectations of quality, accessible healthcare and good doctor-patient communication.

Do most people know who "owns" their local medical clinic? More importantly, do most people care? The answer to the first question is likely to be "no", but the answer to the second question is not as obvious or clear-cut. As with all healthcare services, public or private, what matters most to consumers is that they get a quality service that meets their needs and contributes to their recovery or their ongoing health.

Consumers have a wide range of criteria for choosing a doctor or medical centre, or deciding whether their needs will be met by using one practice or a range of practices. In the absence of financial or physical barriers, their choice of a particular healthcare provider is based on a complex set of criteria, including proximity, availability, sex of the doctor, special skills or interests of the doctor, and perceptions of the doctor's personality and ability.¹ With the rise of corporatisation, consumers may now want to include in these criteria who owns the service, and what effect ownership may have on the services they receive.

The potential for conflict of interest is very high in any private health service, but it would be surprising if many consumers took this into account in their healthcare decisions. In a corporatised practice, owners and shareholders may exert pressure, albeit subtle, for referral and use of certain services in which they have financial interests. Currently, consumers have no way of knowing whether they are being overserviced or whether the doctor is getting a "kick-back". Transparency about ownership of "downstream" services, both for corporatised practices and owner-operator practices, would assist consumers to make informed choices.

People with chronic health conditions or with multiple healthcare needs are often restricted in their choices by their income and their reliance on public hospitals and bulk-billing GPs.

Leaving these issues aside, what might be the arguments for taking ownership into account when choosing a general practice?

Consumers' expectations of corporatisation

• Corporatised general practice might allow doctors to spend more time with their patients

Corporations owning general practices maintain that, with modern administrative and management systems, they can run the practices more efficiently, leaving doctors to concentrate on patients and medical issues. This is certainly an attractive argument. As consumers, we like doctors to give us their undivided attention, to focus on our needs, to provide us with the most up-to-date and relevant treatments, and to supply all necessary information.

If corporatised general practice enables doctors to spend more time with consumers and thus better meet their needs, then that would be an advantage.

However, the doctor may be under pressure to produce the income to support the corporation (and its inevitable middle management infrastructure) by seeing more patients more quickly. Anything that reduces time spent with consumers would be a negative effect of corporatisation. There have been frequent references in the media over the past 10 years to the "high-turnover, three-minute medicine, no appointments necessary, 24-hour, corporate-style clinics" with lots of doctors, all "bulk-billing" their fees. Is this the future with corporatised medicine?

• Corporatised general practice might offer a broader range of services

Corporate groups with associated allied health, pathology and radiology services offer convenience and ease of access for consumers, including extended hours of opening. The "one-stop shop", with all the services under one roof, has great appeal, and may save people time and trouble. This may be a boon, especially for those with multiple medical conditions, older people, and families with young children. There is some debate about whether this model is demand driven (consumers asked for it), or supply driven (the corporation simply provides these services).

Private medical services are profit-making concerns, and it is common knowledge that downstream services such as pathology and radiology generate large profits.² Large multifaceted medical corporations might provide subtle incentives to encourage doctors to order tests. Consumers are in no position to challenge these referrals.

• Corporatised general practice might raise the quality of services offered

The Standards for General Practice of the Royal Australian College of General Practitioners (RACGP)³ place great emphasis on the structures and environment of general practices. A corporation with a commitment to quality management systems may be able to improve general practice performance against these reference standards. Consumers would then benefit from their clinic being part of a large professionally run organisation.

But most of the practices that so far have met the RACGP standards and received accreditation have been GP-owned (Mr David Wright, General Manager, Australian General Practice Accreditation Ltd, personal communication). They have been able to meet the standards without help from corporatisation. They have established sound systems of record keeping, they appropriately sterilise their equipment, and they maintain privacy of patient information. They can effectively establish recall systems and have accessible and properly equipped facilities.

• Corporatised practice might affect the doctor-patient relationship

A good relationship with their doctor is an important issue for most consumers. They want to trust their doctor and anything that causes them to doubt their doctor's integrity would be a serious issue. Doctors in corporatised practices may be under subtle pressures to put corporate and profit issues before the best interests of their patients.

Consumers' concerns and ideals

On balance, corporatisation of general practice may offer some advantages, but equally there could be some serious drawbacks.

The general practice issues that most concern consumers include:

• Short, rushed consultations with no time to deal with complex issues;

• Poor communication of information generally;

• Limited integration with allied health services; and

• Lack of acknowledgement and acceptance of alternative therapies.

Consumers need to be reassured that the rise of corporatised general practice in Australia does not perpetuate problems of poor-quality healthcare (or, indeed, lower standards further), and especially that it does not compromise the doctor-patient relationship. Some advocates of corporatisation claim that all stakeholders will benefit. At the same time, there are concerns about the profit motive and the demands of investors, not consumers, being given priority. A set of standards for the business management of general practices should be drawn up.

Consumers have high, but not unrealistic, ideals for their interaction with GPs. Consumers think that GPs should:

• Improve their communication with patients;

• Provide appropriate, timely and quality healthcare;

• Make general practice services more accessible;

• Provide, or facilitate access to, a wider range of services to meet consumers' needs;

• Take a more active role in linking consumers to health and support services;

• Communicate with consumer organisations; and

• Make better use of information technology to meet consumers' needs.⁴

All types of general practices, whether corporatised or not, should strive to meet these expectations.

References

1. Consumers' Health Forum of Australia and the Commonwealth Department of Human Services and Health. Integrating consumer views about quality in general practice. Canberra: AGPS, 1996.
2. Moynihan R. Too much medicine? Sydney: ABC Books, 1999: 80-102.
3. Royal Australian College of General Practitioners. Standards for general practices. 2nd edition. Melbourne: RACGP, 2000.
4. Consumers' Health Forum of Australia. Consumer expectations of general practice in Australia, 1999. <http://www.chf.org.au/issues/gp_expectations.html> (accessed June 2001).

Authors' details

Reprints: Ms Kathy Mott, Consumer Perspectives, 329 Brighton Road, North Brighton, SA 5048.
kmottATbigpond.com

©MJA 2001
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