Nearly two years since the ‘Unleashing the potential of our workforce – scope of practice review’ final report recommended the government implement new direct referral pathways from allied health and other primary care providers to allow consumers access to specified non-GP specialist MBS items, the MBS Review Advisory Committee (MRAC) has formally commenced a review.

The news was posted this week in the MRAC’s September meeting minutes.

The communique noted that the MRAC is assessing Recommendation 12 from the final report against the MRAC Guiding Principles, which are outlined in a terms of reference document published in March. The five principles include being ‘outcomes focussed,’ ‘evidence based,’ ‘patient centred,’ ‘sustainable,’ and ‘collaborative, coordinated and integrated.’

What did the scope of practice review recommend?

The report recommends expanding certain direct referral pathways to allied health professionals, midwives, nurse practitioners and remote area nurses as long as the health professional is “within their scope of practice,” and relevant treating team members, including the patient’s GP, receive “appropriate, timely notification,” of the consultation.

It lists several specific examples of recommended allied health referral such as chiropractor, osteopath and physiotherapist referral to orthopaedic surgeon, dietitian referral to gastroenterologist, and psychologist referral to psychiatrists among many others. The recommended instances for midwives and nurse practitioners include referral to psychiatrists, as well as NP referral to urologist, gynaecologist and geriatrician, among others.

But the recommendation leaves the door open for even further expansion, stating that “in the first instance, these are recommended to include,” before launching into the examples – some of which were more controversial than others.

Concerns over inappropriate referrals and loss of continuity of care

At the time the recommendation came out, the RACGP expressed deep reservations, with then president Dr Nicole Higgins saying that allowing MBS rebates for non-GP referral to a specialist would lead to a loss of coordinated care. “Dropping that coordination will lead to a free for all, without a GP’s oversight to ensure care is necessary and in a patient’s interest, and not doctors and other health professionals duplicating each other’s work,” she said, adding that there was also a risk of more inappropriate referrals which would increase out-of-pocket costs.

A Healthed survey of more than 1200 GPs at the time showed most shared these concerns, with 80% believing it would have a negative impact on the number of inappropriate referrals, and 69% anticipating negative impact on continuity of care, while 50% felt it could have a negative impact on costs.

These concerns seem to relate to at least two of the guiding principles that the MRAC will use to assess the recommendation.

“Principle 4: Sustainable

• Value for the health system and patients by ensuring the MBS remains sustainable through funding services with high clinical value and avoiding low value services and unnecessary administrative burden.

Principle 5: Collaborative, Coordinated and Integrated

Through an MBS that:
• promotes and incentivises co-ordinated multidisciplinary teams of providers able to work to their full scope of practice
• recognises the central role of the patient’s general practitioner or primary care nurse practitioner in achieving holistic care for patients
• promotes and incentivises appropriate clinical governance to reduce fragmentation and duplication and delivers better health outcomes.”

Source: Medicare Benefits Schedule Review Advisory Committee – Terms of reference

Room for nuance

However, GPs in Healthed’s November 2024 survey were not blanketly opposed to direct referrals from other health professionals.

While only 10% said they unequivocally support the proposal, another 51% said they would support it if the referral process included meaningful collaboration with the GP. The remaining 39% said they do not support the idea.

Drilling down further, the survey found significant differences in support for some direct referrals compared with others when we asked GPs for their views on some of the specific examples recommended in the report.

For example, eight out of 10 GPs opposed allowing chiropractors or osteopaths to refer to orthopaedic surgeon and nearly three-quarters of GPs did not support allowing dietitians to refer to gastroenterologists.

But on the flip side, around eight out of 10 GPs supported remote area nurses referring to medical specialists, and seven out of 10 agreed that midwives should be able to directly refer to an obstetric physician or anaesthetist.

Numerous GPs in the survey pointed out that optometrists already routinely refer patients directly to ophthalmologists – with most citing this as an example of where it works well, though some said they sometimes feel out of the loop.

“I agree with referrals from optometrists to ophthalmologists as they will often pick up concerns regarding vision. Unfortunately, we do not always receive the information from the ophthalmologist,” one GP commented.

The MRAC has not said when they expect to conclude their review of the recommendation.