I wonder what’s going on at the Department of Health

Australia’s health system is based on a hospital-centric model. I doubt this will change anytime soon, as Government expenditure on hospitals continues to grow – at the expense of primary care.

The recent outrage about changes to the Medicare Benefits Schedule (MBS) is symptomatic: it looks like GPs will no longer be able to charge for electrocardiogram (ECG) item numbers that include reporting. The Department of Health (DoH) seems to believe this is a job for hospital specialists only.

Earlier this year, all hell broke loose after a departmental campaign targeted GPs who deliver mental health care to their patients alongside physical care. And then there was the DoH’s intimidating ‘opioid crackdown letter’ to GPs, affecting the effective delivery of palliative care.

The DoH continues to disrupt healthcare provision in Australia with a ‘penny wise, pound foolish’, management-by-spreadsheet approach. General practice remains largely undervalued.

Yet, the long-term benefits of primary care are well known. Adequate support for general practice is associated with slower growth in health expenditure and better system quality, equity and efficiency, as well as savings to the health system.

State hospitals are facing unsustainable cost blowouts and ever-increasing waiting lists in the face of significant population growth.

Increasingly, there is talk about supporting general practice to deliver more care in the community through collaborative models of care.

Yet the DoH believes GP should not be providing care that includes skills such as interpreting ECGs to ‘reduce low-value care’ and because it is ‘safe and best practice’. I wonder how safe the DoH’s new ruling is for patients presenting with cardiac symptoms to their GP.

It appears the recommendations by the 12-Lead Electrocardiogram Working Group, originally made four years ago, were reworked by DoH. The end result did not go down well at the time.

The RACGP responded in a submission in early 2018, stating that it ‘does not support the proposed recommendation … as it fails to recognise or acknowledge that GPs perform ECG interpretation, report results in the patient record and determine actions without referral’.

The feedback clearly fell on deaf ears. Stakeholder engagement by the DoH appears to be little more than a tick-the-box exercise.

The fact this ECG news came out of the blue and amidst a second wave of COVID-19 is awkward.

Effective care provided in general practice reduces the need for more expensive hospital specialist care. Health systems with a greater focus on primary care are more equitable, have lower costs and better health outcomes.

The poor departmental decision-making of late sadly encourages health inefficiencies and deskilling of the general practice workforce. It goes against efforts to deliver patient care closer to home. It is highly demotivating for general practice teams, especially amidst the COVID-19 pandemic, and demonstrates a concerning absence of a long-term vision.

This article was originally published in NewsGP.

7 thoughts on “I wonder what’s going on at the Department of Health

  • Jim Dickinson was a lecturer at Newcastle U, then a Professor at UWA. Prior to that he spent 5 years working in the Federal Ministry of Health and his insights on “Why politicians always penalise General Practice, and not reward it? (Medicus, February 2020) are important. They are a tactical guide for those organisations that are trying to improve the lot of General Practitioners.

    I cannot copy his document because the AMAWA has fixed it. So, I am précising it in italics. The rest is my commentary.

    His thesis is that health policy is devised by young, healthy, non-medical advisers who do not have a need for a personal GP and instead use impersonal walk-in practices. They often regard these experiences as being substandard medical practice. As a result, they do not understand the multiple tasks required for good quality general practice and do not perceive its relevance. They regard the ‘I’m your adviser in life’ advertising campaign as comical, are mystified about how a generalist can be a specialist and regard any mention of higher Medicare rebates as self-serving.

    The current Minister that they are vying to please is the Hon Greg Hunt who, in 2017, declared that he wanted to be the minister “for GPs” and was committed to ensuring all Australians are able to see a doctor when they need to and can receive medicine when they are unwell. He has not said that he wants to be the Minister for Quality GP. It is obvious that quality GP takes time and the fee structure rewards rapid fire GP and penalises more comprehensive and patient friendly GPs. My youngest is a clinical geneticist. Last week he saw a 78-year old man with recurrent kidney stones. Over the previous 10 years he had seen 9 GPs. None had ever had a stone analysed. Benjamin phoned the referring GP to find out more about the family and what the GP wanted to know that would help him manage his patient. The GP said the patient told him that a cousin also had recurrent kidney stones so that was why he was referring to a geneticist. He added that it was really an ‘economic referral’ since he worked to a strict 10 minutes per patient. It was my son’s second ‘economic referral’ in the fortnight.
    
‘Members of parliament pass a steady stream of complaints from their constituents about healthcare issues to the Minister’s office. Complaints about access or quality of hospital or specialty care can mostly be dismissed as belonging to the States. So, complaints that reach the minister’s office are predominantly about General Practice. Some are justified, some not, but the minister and staff only hear one side of the story. The steady diet of stories and personal experiences about poor quality General Practice dampens any enthusiasm to pay for more of it’.

    Professor Dickinson asks: How to change these perceptions?

    Two of my insights in talking with ‘Guberment’.

    Brian Howe, MOH, Deputy PM 1991: Rural medicine activists asked for a meeting. After 3 minutes The Minister interrupted Bruce Chater, our spokesman: “ How much money do you want?”. Bruce replied: “We are not after money, we want better medical care for rural people”. The minister sat up and took notice and we got a lot of DOH support and money. Several middle ranking public servants became devoted to our cause.

    In 1990, the Federal Labor Government announced that General Practice looks after the medical needs of most of the people, most of the time and it was committed to a stronger system of general practice as the foundation for primary health care in this country. It appointed Jenny Macklin, then a 37-year old social worker as Director of National Health Strategy.
    She produced a series of issue papers one of which was the future of General Practice. She came to Perth and visited the UWA Department of General Practice. Despite a training as a social work she appeared to know little about the tasks of General Practice. Her only experience of it was with her own GP.
    I invited her to spend a day at the University practice in Lockridge, then regarded as the most problematical suburb in Perth. She accepted. I organised for her to sit in with 4 high class GPs over the space of a whole day. She later commented that she previously had no idea of what GPs did and this was one of the most educational days in her life.

    Speak to the DOH. They have regular meetings. Get sensible GPs (ie those who are not tainted by media department speak) like you to participate with them on a 4-6 monthly basis. I did this when I was in Bourke. It is mutually educational.

    Jim Dickinson’s insights are valuable.

    Also, government is scared of specialists. They have, can and will strike if their interests are affected (eg NSW under AMA president Bruce Shepherd). GPs would never be able to organise to do that. I applauded the start of Medibank (now) Medicare, mainly because it opened up access of Aboriginal and poor patients to GP. But it has, in many ways, destroyed us.

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    • “…health policy is devised by young, healthy, non-medical advisers who do not have a need for a personal GP and instead use impersonal walk-in practices. They often regard these experiences as being substandard medical practice. As a result, they do not understand the multiple tasks required for good quality general practice and do not perceive its relevance.”
      Very interesting thesis indeed Max. Worth investigating/researching further! Good to hear your historic perspectives as always.

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  • Dear Edwin,

    Glad to see you are out there still positive and trying to find solutions. I, along with my family spent Christmas with my best friend in the Nederland who is also an associate prof of Paediatrics ( our friendship goes back 30 years when she came to Nigeria as a medical student- she knows the nook and cranny of my family and has visited me in all the countries where I have worked or studied).

    We frequently compare notes over the years.

    But this time around I had an immersion education for several days and got to meet most of the team, asked questions, took notes and made videos.

    How collaboration at various levels and appreciation of the skills and contributions of everyone in the health team was crucial to good health and quality health care from craddle to Grave!

    What Struck me immediately when comparing here and there- Holland, is not anything medical or high falluting

    I was immediately struck by 3 things.

    Here we have

    1. Dumb down education – with many ignorant, poorly educated and narrowminded people crafting policies and running affairs leading to 2. Ignorance which in turn leads to a distorted version of things as you highlighted and ultimately 3. Lies in defence of their ignorance and narrow mindedness.

    Ignorant liars often look for scapegoats and unfortunately GPs are the perfect fall guys- don’t ask me why, because that is another topic altogether.

    All our running around, campaigns and all that rubbish wot get us anywhere ( mark my words) until we do a bit- no, a lot of “in house” cleaning- removing the moles and the “me, myself and I syndrome” etc. We will always remain the whipping boys/girls of the health system ( not just amongst Drs).

    Glad to see the Drs bag still going- I hope there is enough in that bag to meet the many challenges we constantly face. Sorry about Harry May his soul RIP

    Cheers

    ________________________________

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    • Thanks for your message Deb & an inspiring lesson from the Netherlands (“How collaboration at various levels and appreciation of the skills and contributions of everyone in the health team was crucial to good health and quality health care from craddle to Grave”). How to embed this in Australia?

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  • Great article Edwin.
    I wonder what the trigger is to turn this creeping death around. I’m sure it feeds into the lack of interest in GP training.

    Regards

    Andrew

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