This year marks the twenty-fifth year since the Practice Incentives Program (PIP), and subsequently the practice component of the Workforce Incentive Program (WIP) was linked to general practice accreditation. These programs annually contributed $830 million to practices into the 2020-2021 financial year and do not include other financial benefits that accrue from accreditation, including eligibility to host GP registrars and through them, access MBS service fees. The average financial incentives across all practices for the PIP is around $70,000 but there is wide variability with larger and rural practices commanding higher payments. While current payments equate to between 8 and 10% of Medicare funding for general practice, it is proposed that under structural reforms to general practice that this percentage could rise to 40% of Medicare payments for general practice under a proposed blended payment model.
Prior to 2000, the uptake by practices seeking accreditation was limited, but with the linking of accreditation to financial benefits there was a rapid increase in practices seeking accreditation, creating a three year hump that was to remain a continuing operational challenge for accrediting agencies to manage for many years.
Budget holding and a process of random practice audits were first promoted by the RACGP as early as 1990 as part of the so called reform process in general practice. The pressure to establish general practice as a speciality, led in the 1992 Commonwealth Budget to the establishment of Divisions of General Practice, initiatives to improve distribution and supply of general practitioner workforce, measures to implement vocational registration and ultimately mandatory training and certification for general practice, support for increased uptake of information technology in general practice and the practice enhancement grants, precursors to the PIP payments.
Conceptually accreditation was framed as being complementary to vocational registration and certification of individual practitioners, but practice focused. Initially, accreditation was politically too sensitive to implement, especially with suspicion about the motivations of the RACGP in promoting budget holding and random practice audits. There was, however, reasonable, if not broad, agreement that development of standards for general practice would be a good thing. The RACGP was funded to develop and conduct the Field Test of Standards in 200 (199) practices. Subsequently the author was commissioned to run local demonstration trials of standards and accreditation in 500 practice nationwide.
Accreditation was originally predicated on a number of key principles and aims, described in The Future of General Practice – A strategy for the 90’s and Beyond.
These were, that accreditation should:
- provide a publicly recognisable measure of quality,
- be voluntary but have tangible benefits,
- be an educational and developmental process, and not punitive, with gradual improvement in quality,
- be self funding after initial establishment costs, to ensure its independence,
- be controlled by the profession with details relating to individual practices remaining confidential and protected under legal privilege,
- be available to all practices regardless of size or location.
It is important to understand that accreditation was originally seen as a professional, peer visit activity. Standards were based on then current practice. While there was always an intent that a quality improvement approach be adopted, notions about accreditation providing assurance to the public as to the safety and quality of general practice only really evolved some time later. Indeed the current standards still do not map well against the ACSQHC’s Primary and Community Standards framed around safety and quality.
Accreditation and implementation of reforms in general has not been without challenges. Accrediting agencies and practices now operate in an increasingly regulated environment. But it is doubtful that accreditation has become a publicly, or even professionally, recognisable measure of quality. Successive reviews have identified a need for change.
It is pertinent after twenty-five years, without seeking consolation in either nostalgia or the usual motherhood comments about the quality of the Australian health care system and general practice, to ask some hard questions.
Meeting standards for general practice
Standards for general practice were originally designed as professionally lead, entry level standards. They were intended to reflect the status quo in general practice at that time and deliberately fashioned so that 90% of then current general practices could meet the standards with minimal effort. Now in their fifth edition, while there is significant variability in assessment findings between accrediting agencies, one agency reports that 90% of practices do not meet all the mandatory indicators at the time of an on-site assessment visit.
Practices and health services do not have a choice of standards and the current standards do not necessarily support a quality and safety framework across the geographic diversity and scope of general practice and primary health care. The draft six edition standards separate GPs even further from accreditation and seem more motivated by the politics of payroll tax and a desire to preserve the conflicted independent contractor model of general practice, than supporting a whole of practice approach to meeting modern health care needs.
While part of the lack of conformance identified above could be related to the standards as much as the practice, the general scope of the standards (practice services, medical records, practice management etc) has not significantly changed since the first edition and many standards have been removed or reduced in scope – for example with standards regarding the provision of after hours care by practices or number of patients seen per hour. In addition non-conformities are not weighted more heavily in newer indicators.
The standards are complex with 125 indicators, over 500 must or could statements that describe how the indicators should or might be met, 176 pages of explanatory notes and multiple references to other regulations, legislation and guidelines. But this complexity doesn’t explain the significant difference in non-conformity findings between accrediting agencies, the different indicator non-conformities reported by agencies and different times taken to close these non-conformities across agencies.
Australian National Audit Office
The current data also reflects prescient concerns expressed in an ANAO Performance Audit Report published in 2010-2011 into the Practice Incentives Program (Audit Report No.5, 2010-11).
Given that accreditation was (and still remains) the entry requirement for practices to access the benefits of the PIP, the ANAO report examined whether the department (then DoHA) was able to gain assurance over the quality of accreditation processes and compliance with the Standards. The report stated:
“without such assurance there is a risk that general practices could be assessed inconsistently, and that general practices do not maintain their compliance with the standards across an accreditation cycle”, and
“a poor compliance regime could allow some practices to continue to receive PIP payments while not adhering to the standards”
both of which would effectively:
“limit the achievement of high quality primary health care that the government expects from accreditation”.
Further the report noted that each of the (then) two accreditation agencies:
“used their own accreditation framework that general practices were required to follow”
The report also described two risks that can affect the quality of accreditation, namely inconsistency in accreditation outcomes and practices dropping adherence to the standards across the accreditation cycle (emphasis by author).
In its summary, the ANAO report stated (Summary para(s) 33 – 36, page(s) 23/4)
The following features for the accreditation of general practices limited DOHA’s assurance on the quality and rigour of the accreditation processes:
- when conducting accreditation assessments, the two accrediting (agencies) AGPAL and QPA – each used their own accreditation framework that general practices were required to follow;
- while both accrediting bodies seek assertions from general practices on adherence to the standards across the accreditation cycle, there are no checks on these claims through risk based interim assessments; and
- there is a lack of clarity as to the auditability of the current standards and their applicability to all general practice settings such as those that operate outside office settings.
Subsequently the Australian Commission on Safety and Quality in Health Care (ACSQHC) assumed administration of the National General Practice Accreditation Scheme and developed an approvals process for accrediting agencies that sought recognition to accredit general practices for the Practice Incentives Program. Some years on, the fundamental concerns expressed in the ANAO Report have not been addressed. There is no consistent assessment framework or processes across agencies, there is no mandated surveillance process and there remains concerns about the auditability of the standards and their applicability across the scope of primary health care.
mpconsulting review into general practice accreditation arrangements
A Review of General Practice Accreditation Arrangements (mpconsulting 27 October 2021) commissioned by the Department of Health, confirmed these concerns. In the executive summary the authors of the report noted:
Critical to the effectiveness of any accreditation scheme is that the accredited entities and end service users (general practices and patients in this case) have confidence in the scheme – including that it is fit-for-purpose, fair and equitable and that assessments are robust, independent and consistent. The accredited bodies also need to see benefits in the process, noting that it necessarily involves some cost. Practices need to view accreditation not as a bureaucratic process that is completed once every three years for the purposes of accessing government funding, but as part of good clinical governance that occurs every day and involves the whole practice team.
While Australia’s current voluntary accreditation arrangements have a number of strengths (explored in this Report), the NGPA Scheme does not have the overall confidence of general practices and health practitioners and is not broadly viewed as a foundation for safe, quality practice. Throughout the Review, many general practitioners (GPs), practice managers and owners and other stakeholders described the accreditation process as a ‘tick a box’ exercise and a ‘pathway to PIP payments’.
Stakeholders also described a range of limitations with the existing standards, a perceived lack of support for practices seeking to become accredited, concerns about the quality and consistency of assessment, apparent inequities in the way accreditation fees are charged and the administrative burden that accreditation can place on practices. Stakeholders made a number of suggestions for change, in many cases drawing on years’ of experience in the general practice environment. mpconsulting worked closely with stakeholders throughout the Review to identify a range of improvements to the NGPA Scheme, which were validated through our analysis of the existing arrangements, review of data and comparison with international models and other health service accreditation schemes in Australia.
The report also noted a lack of engagement among GPs with accreditation, and by implication practice based quality assurance relating to the services delivered by GPs.
While the review reported a “number of strengths” with the Scheme, it is difficult to reconcile this observation with the damning commentary on the lack of confidence reportedly expressed by general practices and practitioners in the Scheme and the failure to view the Scheme as a foundation for safe, quality practice, but rather the view that the process is a tick a box exercise to access government funding.
The concerns expressed in the ANAO Performance Report have not been addressed formally or substantively in the almost fifteen years since they were identified. The recommendations of the mpconsulting review have not been formally or substantively addressed in the over three years since that report was published.
If the integrity and consistency of accreditation are called into question, the short to medium term financial situation for both general practices and accrediting agencies suggests that the business models that accomodate the Scheme must also be considered. There is a significant concern that cost pressures and business models can influence assessment quality and service delivery. Market imperatives are limiting the value of the program to patients and the community in general.
The task, and operational and financial challenges for accrediting agencies in providing high quality, impartial and consistent assessments to over 8,000 practices and primary health care service across Australia should not be underestimated.
The EOFY 2023 and 2024 annual reports for AGPAL and controlled entities (publicly available through the Australian Charities and Not for Profits website) both reported significant operational losses. QPA focuses solely on accreditation of general practices and primary health care services. As a private company it has an obligation not to trade insolvent and meets its obligation. It does, however, have significant additional regulatory and operational costs not borne by “charities” or not for profit accrediting agencies, such as payroll tax for surveyors. Moving to a mandatory full day survey visit, when the 5th edition standards were introduced, necessitated higher surveyor payments. There is also an imperative for agencies to continually invest in their own quality systems, including for surveyor training and performance assessment to ensure assessment integrity and reliability. This investment is not occurring and is restricted by lack of resources.
Price competition does not sit well in a quality assurance scheme ultimately underwritten by the taxpayer. Accrediting agencies are forced to compromise in areas or compensate if the true costs in proving a reliable, consistent assessment are not met. Inadequate resourcing opens the risk that assessments will not have the integrity expected, or that there are conflicts of interest and influence affecting accreditation decisions.
QPA, to avoid conflicts of interest and threats to impartiality, does not undertake consultancy for practices or services it accredits, or seek sponsorship arrangements or have embedded contracts. It also does not tender for assignments and pays all surveyors based on their experience and skills and engages all surveyors as employees and provides all employment benefits as required by law and indeed under the Scheme. It does not engage in discounting as this exposes the cross subsidisation model and actively discriminates against smaller or rural and remote practices. Discounting is also is a threat to impartiality and is a major risk to the integrity of assessments. After all, if an organisation can negotiate a significant discount for a professional service, what else becomes negotiable?
While mpconsulting couched their recommendations on the premise that costs for practices not increase, it did not conduct a cost benefit analysis of the business models that accrediting agencies operate under or the fairness in pricing arrangements. It did not discuss the implicit issues connecting business and funding models with either quality and consistency of assessments and access for smaller and rural and remote practices or the complexity of impartiality and inappropriate influence.
Accreditation pricing and costs and the cross subsidisation model
With the introduction of accreditation there was a clear premise that no practice would be discriminated against, either financially or otherwise, by virtue of size or location. The Department commissioned JAS-ANZ to develop a consistent, internationally based standard to establish rules for accrediting agencies wishing to accredit practices for the purposes of recognition for the PIP. This Procedure 16 – General Requirements for bodies operating assessment and accreditation of general practices for recognition under the Practice Incentives Program (April 2000) was developed in consultation with stakeholder groups, including the RACGP and AGPAL, both of which tried to use the process at the time to maintain a monopoly control over standards and assessment and exclude alternative providers.
Procedure 16, which still has significant advantages over the current standards and approvals process, mandated that an accrediting agency was prohibited from discriminating against any practice. Clause 5 required that:
- The policies and procedures under which the accreditation body operates shall be nondiscriminatory, and they shall be administered in a non-discriminatory manner. Procedures shall not be used to impede or inhibit access by applicants other than as specified in this procedure (clause 5.1.1.1)
- The accreditation body shall make its services accessible to all applicants. There shall not be undue financial or other conditions. Access shall not be conditional upon the size of the general practice or membership of any association or group, nor shall accreditation be conditional upon the number of general practices already accredited (Clause 5.1.1.2).
The guidelines to this clause further specified that:
- Accreditation bodies shall not practice any form of discrimination such as hidden discrimination by speeding up or delaying applications for accreditation. (G.5.1.3)
In effect, Procedure 16 made it mandatory for an agency accredited by JAS-ANZ to maintain a cross subsidisation or community rating fee schedule, which by definition excludes discounting and cherry picking more valuable (larger) practices and those less costly to service. Both these strategies (discounting and cherry picking) are now embedded in some sectors in the general practice accreditation market.
The cross subsidisation model is also mandated in the latest edition of the standards. The RACGP requires (inter alia) that an accrediting agency have :
- A commitment not to refuse an application for accreditation from a practice that meets the RACGP’s definition of a general practice, regardless of location or size
- A commitment not to financially or otherwise discriminate against a practice because of location or size
QPA was required by the Department to be accredited by JAS-ANZ under Procedure 16. However AGPAL declined to become accredited by JAS-ANZ against Procedure 16 and as such was never formally bound by the cross subsidisation model or fee structure.
During the planning phase of accreditation, the Department commissioned a consultancy from one of the big four groups to report on both an appropriate fee and pricing structure. The consultancy determined that, to ensure equal access, a cross subsidisation or community rating model should apply so that larger practices and those in more easily to service areas would provide the funding for the (fewer) more remote practices. This was consistent with the structure of the PIP payments which were based on standardised whole patient equivalents (SWPEs), which formed a proxy for practice size. The fee recommended by the consultancy in 2000 was $1,200 per full time equivalent GP (FTEGP). This fee per FTEGP, on average has not significantly increased since the introduction of accreditation and in real terms has declined around 70% against CPI.
The cross subsidisation model has clearly broken down since the introduction of the 5th edition standards and administration of the Scheme by the ACSQHC. Repeated requests for clarity on the cross subsidisation model from either the ACSQHC or RACGP have not had a productive response. Smaller and more remote practices are discriminated against by cherry picking and denial of service. Larger practices are provided discounts by some agencies that provide considerable financial benefits for big corporate groups. Coupled with a lack of consistency in assessment frameworks and lack of assurance that a practice meets the standards across the length of the cycle, discounting and cherry picking opens the door to a lack of integrity, impartiality and influence over accreditation decisions, inappropriate assessment and even fraud.
The link between the future viability of general practice and quality
QPA has identified over 60 areas where the integrity, impartiality and viability of the NGPA Scheme is at risk.
It is hard to not come to the conclusion that the current system of accreditation lacks a threshold level of stakeholder confidence, integrity, consistency, reliability and viability that is required to form the basis for practices accessing hundreds or millions dollars of taxpayer funds; and
Accreditation does not necessarily by itself drive any appreciable practice based strategic or tactical activities that provide assurance as to patient safety or quality or necessary change to meet modern health care system imperatives, with many general practices reporting an existential crisis.
The concerns expressed in this paper are not simply those of a market player. They are problems clearly articulated by the ANAO, an independent review commissioned by the Department and reports from practices, practice managers and GPs. The concerns have their public expression – How is it that a practice outed on the front pages for having a five year history of inadequate cold chain and vaccine storage processes can get to that point when it was accredited, and would have had at least one or possibly two accreditation visits over that five years? Accreditation failed this practice and its patients.
There is a link between quality in general practice and its future viability. General practice is not helped by a system that lacks consistency or integrity or pretending that accreditation is simple.
Summary and the Nous Factor
The Department, in 2024 commissioned Nous Consultancy to conduct a review of barriers in general practice accreditation (https://www.tenders.gov.au/Cn/Show/a1ea59b9-1efa-4009-b426-3d8656c61e3f) and to investigate the current market operation of accreditation services under the National General Practice Accreditation Scheme. The stated objectives of the consultancy were to better understand:
- demand for accreditation, including from different geographic locations and types of practices,
- issues around sustainability for accreditation agencies in delivering services,
- cost drivers in meeting standards and providing accreditation services.
The review report has not yet been released at the time of writing, but there is a clear departmental policy commitment and imperative with the current reform proposals for general practice, to ensure that significant proposed changes to general practice are supported by a strong quality assurance framework. Accreditation could have a greater and more important role in supporting changes to reforms and funding in general practice. The RACGP itself has proposed significant change to the accreditation process with proposals for an ongoing compliance program (MAP-GP).
No general practice is perfect. If general practice is to maintain its centrality in the health system and receive greater financial investment, it will need to provide greater assurance that the services it provides meet patient and community demands for scope of services, access, clinical excellence and quality.
Accrediting agencies are not perfect. They need to better meet the challenge of going beyond a point of time accreditation to support practices to better understand and implement a systems based quality assurance approach to patient care and business management. Accrediting agencies will themselves need to meet higher standards for service quality, integrity and consistency if they are to continue to be effective gatekeepers for a significant amount of taxpayer funds.
More funding, either for general practice or accrediting agencies to fulfil their roles should not preempt, but instead be a consequence of providing value. There is no value in kidding ourselves that accreditation is simple. Quality assurance requires dedication and planning. Tick a box systems and templates do not make accreditation simple, they make it simplistic. They need to be replaced by a mutual commitment to establishing a culture of quality that engages all team members in every general practice.
After twenty-five years it is time for policy makers, professional bodies, practices and agencies to reflect on and build an accreditation system, that gives practices a choice in standards relevant to their circumstances, is not only accessible and supportive for all practices across Australia, but one that puts patients and not politics or vested interests first.
Dr Paul Mara AM MB BS FACRRM FRACGP
Founder and Managing Director, Quality Practice Accreditation