How to upgrade an organisation’s tribal culture

Immature tribal cultures create silos and distrust, and sustain undesired behaviours. How can we change a dominant culture and become more effective?

My mother spent years of her childhood in Tjideng, a Japanese internment camp for women and children run by the cruel Captain Kenichi Sone.

She was born in the former Dutch East Indies, now Indonesia. The Dutch occupied and exploited the country for over four hundred years, but in 1942 things changed dramatically as a result of the Invasion by the Japanese imperial army.

The women in the Japanese internment camps are sometimes called the ‘forgotten women’ of the war in the East. These camps, as well as Dutch colonialism, are some of the worst examples of tribalism.

Tribalism comes of course in many shapes and forms including, as we all know, in the medical world.

Tribes & organisations

Most leaders know that tribal cultures are a key factor in the performance of organisations. Some leaders are experts at creating close-knit cultures, but only a few can change a culture that doesn’t perform optimally.

Tribalism is the natural way we organise ourselves into social groups. Our ‘tribes’ are part of who we are. They offer support, security and a sense of belonging an there’s nothing wrong with that.

However, tribalism can also refer to a false sense of superiority, sometimes leading to exclusion, bullying and discrimination.

We can change a dominant tribal culture and upgrade our organisations to more collaborative, healthy stages. History shows that goal-oriented groups and organisations that work well with others are more successful.

5 tribal cultures

In the book ‘Tribal leadership’, Professor David Logan et al describe five stages of tribal culture. As he points out, the medical profession is only half way, at stage three of five.

Five tribal cultures
The five tribal cultures. Source: Tribal leadership. David Logan, John King, Halee Fischer-Wright 2011

Logan’s tribal stage one is the mindset of gangs and war criminals – people who come to work with weapons. There is hostility and violence and no cohesion.

People working in a stage two culture may have coffee mugs with slogans like: “I hate work,” or “I wish it was Friday”.

There is often a high suspicion of management and authority in general, and team-building efforts are not effective in this culture.

Stage three is the dominant culture in almost half of all organisations, including many professional workplaces. Quite often doctors fall into this category. In stage three it is all about personal success and being the smartest. Stages four and five are the collaborative cultures.

Let’s have a closer look at the most common culture, stage three.

I’m great (and you’re not)

The mantra of stage three is ‘I’m great’, often followed by the unspoken words ‘and you’re not’. There’s a long history in medicine of stage three cultures with a strong focus on individual expertise and success.

Anatomy lesson
The Anatomy Lesson of Dr Nicolaes Tulp, by Rembrandt. Source: Rembrandt Huis.

One of the earliest examples I could find is this well known Rembrandt painting titled, ‘The anatomy lesson of Dr Nicolaes Tulp.’

Dr Tulp was a highly respected surgeon in Amsterdam in the seventeenth century; he is clearly the central figure in this painting. He’s the only one wearing a hat. Sadly but not surprisingly there are no women present.

You could argue that this scene demonstrates the dominant culture of the exclusive Amsterdam Guild of Surgeons. These days, almost four hundred years later, the dominant culture in medicine hasn’t changed all that much.

Professionals working in a stage three culture are often very good at what they do as individuals but what they don’t do is bringing people together.

They may think they are. Interestingly people in stage three often think that they are at one of the collaborative stages. They may talk about collaboration and teamwork – hallmarks of stage four and five – but their actions firmly put them in stage three.

The issue with a stage three culture is that it cannot be fixed – it can only be abandoned. The solution is to move your tribe to the next stage, stage four.

How to upgrade

People working in a stage four culture don’t talk about themselves. They first start listening. It’s no longer about being the smartest or about personal success.

There’s a move from ‘expert’ to ‘partner’. The language used is not “I’m great” but “We’re great”. There’s tribal pride.

Eventually, later in stage four, organisational boundaries become less important and cross-pollination between organisations may occur.

So how do we upgrade our culture from stage three to the more collaborative stage four? Logan describes several principles, including:

  • Focus your team on tribal success instead of personal success
  • Point out the superior results of stage four tribal cultures
  • Describe role models in the organisation that show stage four behaviour, for example people who are talking about ‘we’ instead of ‘me’
  • Encourage transparency and sharing of knowledge & information as much as possible.

There’s one main problem with stage four, reflected in the unspoken sentence that often follows “We’re great,” and that is: “… and you’re not,” referring to other groups or organisations. That’s where stage five comes in.

Stage five is the dominant culture in two percent of work places. In this stage there is no ‘they’.

‘Them & us’ thinking has gone out of the window and there is a focus on inspiring purposes. These are often universal values, taking away the need to compete.

People working in stage five cultures can work with any group that has a commitment to universal core values – even if these values are different from their own.

Effective followership

More collaboration in medicine has many benefits, including for direct patient care, mental health of doctors and healthcare reform.

We always talk about leadership but effective followership is just as important.

Effective followers don’t blame their leaders when things don’t go as planned; instead they offer support and gently, but persistently, steer their leaders in the right direction to help them achieve the organisational goals.

What the medical profession needs is people who build bridges.

I’d encourage you to review your own organisation(s) and look for opportunities to collaborate. Don’t accept non-collaborative cultures.

Find role models and like-minded people, people who talk about ‘we’ instead of ‘me’, and together take your dominant culture to the next level.

This is an adaptation of a presentation given at GPDU18.

Is community pharmacy on a road to nowhere?

If the community pharmacy sector wants to work better with other healthcare providers, something has to change.

Health Minister Greg Hunt recently announced that the Federal Government rejected many of the proposals in the King review of the community pharmacy sector.

This means for example that pharmacies will not be required to separate alternative remedies, including homeopathic products, from evidence-based medicines.

Community pharmacy owners want to be taken seriously as healthcare providers yet, at the same time, they continue to behave like a commercial interest group.

Recent actions of the sector, such as the pro-codeine lobby, raised many eyebrows. Political donations and backdoor lobbying are still the norm in this industry.

Chemist shop model

“The Guild looks forward to continuing our close dialogue with the Government on all matters to do with the sector and community pharmacy’s role,” said Pharmacy Guild President George Tambassis in response to the announcement by Minister Hunt.

And the Guild’s David Quilty stated: “When it comes to pharmacy, the Federal Government has taken the very reasonable approach that when something works very well, why tinker unnecessarily with it?”

These responses speak for themselves.

The question is, does the chemist shop model work ‘very well’, or is it relying on lotions and potions, anti-competitive regulation and protection, lobbying and political donations to stay afloat?

In the Financial Review Stephen Duckett commented, “Once again, the power of sectoral interest groups in Australian health policy is exposed.” And, “Once again, the public interest has lost out.”

I couldn’t agree more.

I’m looking forward to the day the community pharmacy sector shakes its retail sales focus – we need more team players and collaboration.

You can’t have your cake and eat it too

The Practice Incentive Program is shrinking but the government expects new quality improvement systems and general practice data.

Most GPs were underwhelmed, to say the least, when they heard about the changes (read: cuts) to the Practice Incentive Program (PIP). Cutting the funding for nursing home visits is a hard sell for the Department of Health and the Federal Health Minister.

This is the wrong message at a time when there are more elderly people with complex chronic health problems in need of appropriate medical care, preferably in the community.

I have heard about various ‘fixes’, including improvements to the Medicare Benefits Schedule (MBS) schedule (good idea) and introducing nurse practitioners (not necessarily a good idea) – but nothing has been confirmed and it all sounds a bit like policy on the run, not a planned and coordinated strategy.

Quality improvement

The scrapped incentives, including the aged care service incentive payment (SIP), will be used to set up a quality incentive payment system (QI–PIP) in GP practices. There are certainly arguments for supporting an enhanced quality improvement system in general practice, but was it the right decision to sacrifice the aged care payments?

We need practice data to review and improve patient care. I agree with the RACGP position that the development of a QI–PIP should assist general practices to undertake quality improvement activities.

However, the RACGP has also indicated that it will not support measuring performance against key performance indicators (KPIs) or so-called ‘quality indicators’ in combination with performance payments. There is just not enough evidence that this will significantly improve care in the long-run, but there is evidence of harm, including detrimental effects on the doctor–patient relationship and practitioner burnout.

Although we have had verbal assurance from the Department of Health that the new QI–PIP – to be introduced in May next year – will not be a pay-for-performance system, the longer-term plans are unclear. This has raised many concerns and it will hinder business planning for general practices.

Data deal

In return for the quality improvement payments, practices will be required to hand over their patient data to Primary Health Networks (PHNs) under the current proposal. From there, the data will flow to other agencies but – just like the My Health Record data – we have not yet heard for what purposes it will be used, and what the implications will be for individual GPs within practices. Many GPs have indicated that they are not prepared to hand over data to their PHN or the Government.

Another big issue is the eHealth Practice Incentive Payment (ePIP), which was originally introduced to strengthen practice IT systems, but is now used to make practices – often practice nurses – upload shared health summaries to the My Health Record. As we are moving to a My Health Record opt-out system later this year, the time may have come to review the ePIP and make it more meaningful for general practice.

Lastly, the practice incentive funding was introduced in the 1990s and has never been indexed. In 2016, $21 million was earmarked for removal and used to partially fund the Health Care Home trials.

It all sounds like another example of the Government wanting more for less. You can’t have your cake and eat it, too.

This article was originally published on newsGP.

Is value based healthcare devaluing care?

There’s a lot to say for high value care. High value care is healthcare that generates a large amount of benefit for patients and the community compared to the resources invested. But there are also concerns.

Value based healthcare links outcomes with costs: ‘Value’ is derived from measuring health outcomes against the cost of delivering these outcomes. Although it makes sense to fund care that gives us the greatest health benefits, some argue that ‘value’ is more than outcomes.

Dr Jan Kremer is a Dutch Professor in patient-centred innovation and has a passion for patient-focused quality and innovation. In a recent blog post he questioned value based healthcare, stating that value has a different meaning to different people – ranging from efficiency to solidarity, equity and quality of life.

The right things

In healthcare, he said, it is not just about doing things right, but also about doing the right things. The former can be measured, the latter is about decision-making which can’t always be quantified. After all, we can achieve the desired outcomes by doing the wrong thing.

Indeed, a focus on outcomes only tells part of the story. Care may have value for people even when the outcomes are not good.

It is impossible to capture the complexity of healthcare through linear mechanical quality systems, like measuring isolated single-disease parameters. As Goodhart’s law says: ‘When a measure becomes a target, it ceases to be a good measure’.

Models that focus on outcomes often result in only modest improvements, usually not long-lasting and sometimes reducing quality of care for health conditions that are not targeted.

These models can negatively affect the patient-doctor relationship and take away the passion and enthusiasm of care providers.

Learning together

Everyone wants value in healthcare. Professor Kremer said we must be careful with anglo-saxon models that measure everything. But there are alternatives.

In the Netherlands, learning together based on shared values, and measuring less, has resulted in important successes. According to Professor Kremer outcome data has been helpful in the development of Dutch high value care models, but it never controlled the process.

Can we deliver high value care with one eye on the clock and the other on the screen?

Given longer consultations are associated with better health outcomes, the Medicare Benefits Schedule should be restructured to incentivise appropriate consultation time in general practice.

It is estimated that doctors are making an incorrect diagnosis in up to 20% of cases, and up to 30% of investigations may be unnecessary. It is often thought that medical knowledge and skills are the culprit, but there is another reason for the majority of medial mistakes.

Doctors need time to listen and think. General practice’s inherent time pressures, interruptions and the need to record information on computers can be distracting and cause cognitive errors. Our thinking process is also influenced by our emotions; for example, as a result of work stress or running late.

This is not rocket science and has been well documented. For example, in his New York Times bestseller, How doctors think, Harvard professor Jerome Groopman described how snap judgments and other cognitive errors by doctors can lead to medical mistakes.

In a television interview, Professor Groopman explained how over the years the consultation time gradually had to drop from 30 minutes to about 12 minutes. A doctor can’t think, he said, with one eye on the clock and the other eye on the computer screen.

Increasing complexity

In Australia and New Zealand, chronic conditions account for 85% of the total burden of disease, and a chronic disease is a contributing factor in nine out of 10 deaths. The increasing multimorbidity and complexity of care requires that doctors spend more time with their patients. Managing several medical and psychosocial problems in a 15-minute consultation is increasingly challenging for doctors and many patients.

It is not surprising that longer consultations seem to be associated with better patient outcomes. The benefits of extended consultations of 20 minutes or more for certain patient groups have also been explored overseas. More time with patients may lead to higher patient satisfaction, fewer errors and a lower volume of prescriptions, investigations, referrals and hospital presentations.

It is time to slow down. At the moment, the Medicare Benefits Schedule (MBS) fails to recognise this growing problem as it encourages throughput. For example, seeing patients in blocks of four 15-minute appointments per hour is valued at $148.20, but two 30-minute consultations per hour is worth a total of $143.40.

Health Care Homes

Is block funding such as proposed in the Federal Government’s Health Care Homes model encouraging more time with patients? Probably not. In fact, one could argue that it incentivises less face-to-face time with the GP and more contact with nursing staff and other team members.

Our patients deserve our time. The MBS schedule could support our patients with chronic and complex health conditions by better rewarding longer GP consultations.

This article was originally published in newsGP.

Thank God, Australia is now licensed to ‘moisten intestines’ and ‘replenish the gates of vitality’

A while back I spoke with a politician who was very cross about the decision by the Therapeutic Goods Administration (TGA) to make codeine products no longer available without prescription. When I asked why, the answer was, “Codeine is great for jet lag, especially with a Scotch.”

Clearly there was some confusion here about the indication of (the painkiller) codeine, which can cause serious side effects, especially in combination with other drugs and alcohol.

An ‘indication’ is defined in the law as ‘the specific therapeutic use(s) of the goods.’ Confusion about indications of medications is common. For example, people often mistakenly believe that green snot is an indication for antibiotics or that back pain is an indication for diazepam (Valium).

And, just to be clear, codeine is not indicated for jet lag.

Dryness in the triple burner

Unfortunately the Australian Government has just muddled the water by passing two bills in the Senate that allow manufacturers of vitamins, supplements and herbal complementary medicines to use a range of odd claims, such as ‘expel damp-heat in the bladder’, ‘moisten intestines’ and ‘cool blood heat’.

It appears the TGA’s new list of permitted indications is not based on scientific evidence.

RACGP President Bastian Seidel expressed concern about many of the indications. He said: “(…) phrases such as ‘moistens dryness in the triple burner’, ‘replenishes gate of vitality’ and ‘softens hardness’ have no place in any genuine healthcare situation. These types of claims are extremely misleading and could lead to significant harm for patients.”

Profitable industry

The new process has been warmly welcomed by Complementary Medicines Australia (CMA), representing stakeholders in the complementary healthcare industry and the Australian Self Medication Industry (ASMI), the peak body for the non-prescription medicine industry.

The Australian complementary medicines sector has grown rapidly in recent years – and manufacturers have just received a pat on the back from the Senate. Unfortunately, many Australian health consumers will be just as confused as doctors about these claims.

Tribes, tribulation and the elephant in the room

If we want to change bullying and abuse within the profession we have to move our tribal cultures to the next level.

The medical profession has come a long way in the past 25 years, but sadly seems to have difficulties eradicating issues of humiliation and abuse of colleagues and medical students.

One option to fix the problem is to make junior doctors and students more resilient, which seems like a good principle that is currently being applied by other organisations in other areas. Fore example, Beyond Blue has released a practice guide for professionals to help children deal with the adversities they experience early on to prevent mental health conditions later in life.

But teaching resilience alone is not enough.

Another option is to increase awareness and understanding among senior doctors and educate them about bullying, discrimination and sexual harassment. A good example is the mandatory education module, ‘operating with respect’, from the Royal Australian College of Surgeons (RACS).

Elephant in the room

The elephant in the room, however, is our culture – or at least certain aspects of it.

David Logan, a professor at the University of Southern California, said it a few years ago in his New York Times bestseller ‘Tribal leadership’: on the tribal culture scale of 1-5, most professionals around the world score a meagre three. This includes lawyers, doctors and professors.

According to Professor Logan and fellow authors John King and Halee Fischer-Wright, a stage-three culture or tribe is built around knowledge, personal accomplishments and individual expertise. The emphasis is often on winning. Although there may be talk of teamwork, the group interactions usually resemble those of a master-servant relationship.

The mantra of a stage-three culture is, ‘I’m great’. The language used is often along the lines of, “I’m good at my job,” “I try harder than most,” “Most people can’t match my work ethic,” and key pronouns used are ‘I,’ ‘me,’ and ‘my’.

This creates several problems. Professionals operating in this type of culture often feel unsupported, undervalued and frustrated, and those around them feel like a support cast.

Stage-three cultures cannot be fixed, but they can be abandoned. The answer is to upgrade the culture and move away from the ‘I’m great’ mantra to ‘We’re great.’

The next level

Instead of relying on personal achievements and expertise, at stage-four it becomes all about the accomplishments of the group. Partnerships, communication and transparency are recognised as essential ingredients for success. This is a healthier environment, in which people feel more valued and supported.

Professor Logan’s top level is stage-five. Highly functioning teams focus on maximising achievement – not in competition with other groups or tribes but with what’s possible. Stage-five teams can work with anyone.

Australian research has shown that hierarchical and stereotype behaviours largely dissolve when health professionals are working in a more collaborative, multidisciplinary environment.

Resilience training and anti-bullying education are essential, but if we really want to make a difference we have to move our tribal cultures to the next level.

This article was originally published in newsGP.

New skills, fewer scripts and less screen time: 3 resolutions for the new year

Richard Branson said we should put our resolutions in black and white, because that helps us stick to it. Just in case he is right, I wrote down 3 professional & personal resolutions for the new year.

1. Learn a new skill

Rightly or wrongly, one of my fears is deskilling – at a personal level, but also at a macro level as a profession. As Dr Margaret McCartney wrote in the BMJ, the enterprise to streamline medicine by outsourcing certain tasks to protocol-driven non-doctors, runs the risk of deskilling generalist doctors.

There are probably other reasons for losing our skills, such as policy changes and the costs of consumables and maintaining skills. But we can’t always blame others for everything, so I have decided to learn at least one new skill every year.

2. Change prescribing habits

I have made a conscious effort over the years to reduce unnecessary antibiotic prescriptions. I am doing the same with opioid analgesics for chronic non-cancer pain, in line with new RACGP guidelines.

In the case of antibiotic prescribing I had to overcome a few hurdles, such as the fear of not meeting my patients’ expectations or leaving a serious infection untreated.

Talking to colleagues was helpful and I found that – after a careful history, examination and explanation – most patients accept a ‘watch & wait’ approach, with appropriate safety netting.

I feel better for practising less defensive, ‘play it safe’ medicine, which in the end may not be as safe as we’d like to think.

There are parallels when it comes to prescribing opiates. After the GP17 Conference in Sydney I took the RACGP’s 12-point challenge to GPs (see image) and found that I am now spending more time talking with patients about the pros and cons of opioids.

Yes, it is easy to slip up, especially under time pressure and just before lunch or closing time. However, by perseverance the snail reached the ark. I find every small successful dose reduction or non-pharmacological intervention satisfactory. I hope this will be a drive to continue the conversations with patients.

12 point challenge
Image: The 12 Point Challenge to GPs. Source: RACGP

3. Spend less time behind screens

Excessive screen time for children may be linked to several adverse health outcomes, so at home we use an app to limit the recreational time our children spend on their devices – making sure they have opportunities to learn, create and connect in the digital space. This sounds great but in reality it is a never-ending balancing act. It also made me realise that I may not be the best role model here.

It turns out most adults spend more time on their digital devices than they think, which was certainly true in my case. Some of the time behind screens, such as in the consulting room, is difficult to cut back but not all screen time is essential.

I took a social media ‘holiday’ during the month of December and it felt good. So this year I will unplug more often from the social media fire hose. I may even read a book.

This article was originally published in newsGP.

Less is more

I was asked to address the Committee for Economic Development of Australia (CEDA) about how to place health consumers at the centre of future healthcare reform and the delivery of health services. ‘Less is more’ is the presentation I gave on 2 November in Brisbane.

I would like to take you with me this morning to my practice in the Sunshine Coast hinterlands and introduce two of my patients. For privacy reasons their names and details have been altered.

To refer or not to refer?

My first patient is Susan, age 24. Susan requests a referral letter to a plastic surgeon. When asked she explains that she thinks her breasts are too small, and that she wants a breast enlargement.

What would you do if you were in my shoes? Can I please see a show of hands: who would refer Susan? Who wouldn’t?

This is of course about shared decision-making. I noticed Susan was slightly uneasy, she clearly felt uncomfortable about something, so I decided to explore her request a bit further. During our conversation Susan broke down in tears and told me that it was actually her boyfriend who thought her breasts weren’t the right size.

Our conversation about relationships and body image went on for over 20 minutes. Susan decided she needed some time to think things over and talk to good friends, and that she would come back if she needed further assistance.

Susan could also have gone online to an automated referral website.

Issues with online referral services

This is a screenshot from a real Australian online referral service. Here, Susan would have had to fill out a brief online questionnaire, pay with her credit card and she would have received a referral instantly via email.

But Susan decided to make an appointment with me instead and left without a referral. She could have ended up with implants she didn’t really want or need – and a large bill.

Never just about a script

My next patient this morning is John. He comes for a repeat prescription for blood pressure pills. When he sits down the first thing he says is: “Doc, I can do my banking online, why can’t I just send an email to request my scripts?”

John has a blood pressure machine but hasn’t been able to use it recently as he has been overseas.

I take his blood pressure which is very high. I notice John has gained weight since his last visit. He tells me he has a new job and works overseas as a plant operator for a mining project– and hasn’t had much physical exercise. He suddenly also remembers that he needs boosters for his travel vaccinations. As I check the records I notice his blood tests are overdue.

Although John came in for a script it looks like there are several health issues he may want some help with. Email contact would have been more convenient for John – but some problems would have gone unnoticed if he hadn’t come in.

In my job it’s never just about a script or a referral. Opportunistic screening and preventive care are key elements that make general practice effective.

At the same time we must ofcourse find ways to increase the uptake of digital health solutions. Telehealth, video consultations and asynchronous consultations with the usual GP practice have many advantages including potentially reducing travel and waiting times for our patients.

Unfortunately, one of the main reasons for the low uptake is that Medicare currently subsidises face-to-face GP care only.

High value care

Good doctors know when not to ask for a test, when not to prescribe antibiotics or opiates, when not to refer and when not to operate.

There are some great initiatives appearing that promote ‘less is more’ healthcare such as ‘Choosing Wisely Australia’. This initiative brings consumers and health providers together to improve the quality of healthcare through reducing tests, treatments and procedures that provide no benefit or, in some cases, lead to harm.

On the other hand we are seeing more disruptive, commercial, mainly profit-driven healthcare: Competitive markets built around growth, turnover and profits, and as we all know corporate medicine can drive resources away from patient care to meet market priorities.

After Hours presentations
Source: Department of Health and Australian Institute of Health and Welfare

This chart shows what happened after the rapid expansion of after hours home visiting services operating outside the more traditional medical deputising approach.

The two bottom lines show the explosion of visits by after hours home visiting doctors, funded by Medicare, with no meaningful reduction of emergency department visits – the top line.

Although the service is convenient for patients, the question has rightly been asked: does it represent high value care?

Health Care Homes

A solution suggested a few years ago by the Royal Australian College of General Practitioners (RACGP) was the patient-centred medical home, which concentrates care and funding for a patient in one preferred general practice.

The model was meant to enhance patient-centered, holistic care. It included for example:

  • Support for coordination of care, to improve the patient-journey through the various parts of the healthcare system;
  • Support for practices providing a comprehensive range of services locally;
  • A complexity loading which would support practices to respond to socioeconomic and Aboriginal and Torres Strait Islander status, rural status and the age profile of their local community, and reduce health inequalities.

This concept was reviewed, adjusted, modified, tweaked and tuned but what the Department of Health eventually came up with was a very different model; a model that simply pays practices a capitated lump sum for patients with chronic health conditions, and removes the fee-for-service system for chronic care – without significant extra investment to keep Australians well and in the community.

The department’s version of the ‘healthcare home model,’ which doesn’t necessarily solve our main problems such as poorly integrated care, is being trialled but the profession is lukewarm at most.

Pay-for-performance

What about performance indicators, targets and pay-for-performance? This seems to be a hot topic in Australia. It is tempting to pay doctors when their patient loses weight, has a lower blood pressure or improves sugar levels.

Pay-for-performance schemes have been tried elsewhere in the world but the results are disappointing.

For example, performance management has gone wrong in the British Quality and Outcome Framework pay-for-performance system and has resulted in:

  • only modest improvements in quality, often not long-lasting
  • decreased quality of care for conditions not prioritised by the pay-for-performance system
  • no reduction of premature mortality
  • loss of the patient-centeredness of care
  • reduced trust in the doctor-patient relationship
  • reduced access to GPs
  • decreased doctor morale, and
  • billions of pounds implementation costs

As Goodhart’s law says: “When a measure becomes a target, it ceases to be a good measure.”

Primary care is a complex system. Quality improvement processes that are traditionally applied to linear mechanical systems like isolated single-disease care, are not very useful for complex systems.

Slow down

We know that countries with a strong primary care system have better health outcomes and more efficient health systems. An important ingredient is continuity of care by the same general practice team.

It involves empowering patients to drive their own care as well as improvements in the healthcare system. We need to listen to our patients. This may also mean that we need to slow down. Less is more.

The RACGP believes that when GPs can spend more time with their patients, this enhances continuity and quality of care and will result in less prescribing, less pathology tests, less referrals and, importantly, less hospital presentations.

Government health spending
Source: AIHW

This chart, based on data from the Australian Institute of Health and Welfare, shows that General Practice services represent less than 9% of total government recurrent expenditure on health. Less than 9%…

In comparison, expenditure for hospitals represent 46%. Are we really doing everything we can to keep people well, in the community and out of hospital?

4 take-home messages

I have four take-home messages for you today:

#1: Take the good, leave the bad

We need to test new models of care in the Australian context, but we must avoid making the mistakes others have made before us, such as the UK performance payment schemes.

#2: Slow down

Let’s slow down. Allow patients & doctors to spend time together when needed. High turnover or profit-driven healthcare is not healthy for patients, doctors and our health budget.

#3: Convenience ≠ high value

We have to find a balance between convenience and value. Convenience is important, but it is never just about getting a referral letter or a script.

#4: Keep people well in the community

If we want to make a difference we must strengthen healthcare in the community, when people are relatively well, not just in hospitals when they’re terribly unwell. Rechanneling funding from hospital to primary care would achieve this.

Take home messages

Spin and misrepresentation: the toxic mix of academia and media

A good example of the toxic interaction between academia and the media is the coverage of a recent study that claimed parents did not trust their GP. The research data clearly showed Australian parents have confidence in the family doctor – but that didn’t seem to matter.

The study and the uncritical, sensationalised media reports about its bizarre conclusions received a dishonourable mention in ABC’s Media Watch. In this blog post Professor Moyez Jiwa and I examine a worrisome trend in the reporting of academic research.

With an ageing and increasingly morbid demography, health care costs are rising exponentially and, therefore, health policy is under constant scrutiny. Each previous reform is considered and, in many cases, reversed by every new government. In this context, reports that suggest any cause for public concern about the performance of health practitioners or hospitals are seized upon by the media to promote stories that will draw an audience.

In the new era of plain speaking, it is now possible to level outrageous claims against the beleaguered health industry. It is open season on doctors and their employers who may be perceived as a weakened, divided and defensive target. With each claim and counter claim the media chant “fight” and the protagonists oblige.

At the same time, the tertiary education sector is under similar pressure, having long participated in the competition for “most cited research”. The key performance indicators for academics are to grow academic outputs in peer reviewed journals. More than ever, it is a case of publish or perish, and sometimes this comes at the expense of quality.

Sensational stories

The temptation to frame the performance of health practitioners in less than flattering terms may be hard for the media to resist, and poorly designed academic research provides opportunities for them to harvest dubious results. Data to draft sensational stories are ever more readily available, as algorithms capture everything that can be measured and very little of what really matters.

As Lohr and Singer (The New York Times) state:

“… data science is a technology advance with trade-offs. It can see things as never before, but also can be a blunt instrument, missing context and nuance.

Editors of the burgeoning academic journals now vying for higher citations are also tempted to publish articles that can create a media storm and draw attention to their offering among the plethora of me-too rags, many of which derive income from advertisements targeting health practitioners.

Misrepresentation & spin

Exaggerations, simplifications and misrepresentations of research findings are often fuelled by the wording of abstracts and the use of spin in press releases from universities. This self-sustaining race to the bottom can damage health systems as well as grassroots health practitioners working in it and, worse, it may affect health outcomes.

It is time to pause for reflection. There are several elements in the eye of this perfect storm:

  • a sensitised and dissatisfied public;
  • electronic data that are ever more readily available;
  • a government with an eye on its dwindling coffers;
  • a squeezed and competitive tertiary education sector competing for ‘best’ university status based on research outputs rather than teaching excellence;
  • an academic culture encouraging quantity instead of quality of research;
  • media hungry for market share and advertising income;
  • a tolerance for sensational statements because of the trend to behave as if we all live on the set of a soap opera.

Doctors sometimes get things wrong. However, it is also very hard to draw conclusions from “data” without a great deal of the context in which the information was gathered. Data can be manipulated; it can be misleading, if not aberrant. Scientific methods can be flawed and the peer review process can be, and often is, faulty.

Journals publish what sells and the media report bad news because that’s what the public seems to buy. Finally, sound bites and 140-character sentences are now accepted as the way to communicate about complex issues. That includes issues that defy simple explanation.

Stop the rot

What is at stake, however, is our health. Every outrageous comment from an academic with a barrow to push and job to protect heaps more pressure on the very professionals who must prevent, diagnose and manage our illnesses. The results of poor research — badly designed, widely publicised, seemingly endorsed by peer review and poorly understood by a manipulated public — reduce trust.

Many academic institutions, researchers, journals and journalists work to high and ethical standards. However, our hope against the tsunami of chronic and complex conditions is the men and women who commit to the care of people, and we need to stop the rot before it sets in. The responsibility for reversing this state of affairs rests on many, but especially on the shoulders of the tertiary care sector, which needs to call out bad behaviour.

Professor Moyez Jiwa is Associate Dean of the Melbourne Clinical School at the University of Notre Dame. Dr Edwin Kruys is vice-president of the Royal Australian College of General Practitioners. This article originally appeared in MJA Insight.

About addictive painkillers and dirty backdoor deals

It is concerning that those who have been given responsibility to look after the health of Australians take decisions influenced by commercial interests instead of sound evidence and common sense.

As I have said before we have an opiate problem in Australia and it is the responsibility of doctors, pharmacists, consumers and governments to solve it.

One of the opiates that are harmful is codeine. Codeine is closely related to morphine and can cause dependence, addiction, poisoning and, in high doses or in combination with other drugs, death. That’s why in many countries this painkiller, like other opiates, is only available via a doctor’s prescription.

The independent Therapeutic Goods Administration (TGA) has decided to do the same in Australia after extensive consultations with stakeholders including doctors, pharmacy groups and state health departments.

From 1 February 2018, medicines containing codeine will no longer be available without prescription in pharmacies. There will still be safe and equally effective alternatives available through the pharmacy without a script.

Unfortunately some of the stakeholders are undermining this process, putting patients at risk.

Wheeling and dealing

Publicly the Pharmacy Guild of Australia states that it is not seeking to overturn the decision by the TGA. It has, in fact cashed in a large sum of money from the federal government to develop and deliver education, information and communications for community pharmacies and patients to enable a smooth transition to the upscheduling of codeine.

However, behind the scenes it seems other things are happening.

Pharmacy Guild lobby
Shortly after Pharmacy Guild representatives spoke to NSW Deputy Premier John Barilaro he called for a reversal of the TGA decision. Image: Pharmacy Guild

For example, shortly after Pharmacy Guild representatives spoke to NSW Deputy Premier John Barilaro, he made the following statement: “(…) the Nationals are calling on the Federal Government to reverse their decision in relation to the way customers can access codeine products over the counter.”

The Guild’s approach was clever: They picked a pharmacy in a town with no doctor, invited Barilaro, took a picture with him and issued a press release thanking the Deputy Premier for his support of the Guild’s ‘common sense’ proposal to allow pharmacists to continue to supply codeine, stating: “What are patients with headache, toothache or period pain meant to do in Harden when there is no doctor within a hundred kilometres for a week at a time? The AMA has no answer.”

The AMA reiterated the concerns around codeine, including that 75 per cent of recent painkiller or opioid misusers reported misusing an over the counter codeine product in the previous 12 months and that these products were even more likely to be misused by teenagers.

The AMA also expressed concern about the Guild’s lobbying of State and Territory Governments to undermine the independent TGA ruling.

The Guild immediately responded on social media saying this was ‘overblown self-serving nonsense from the AMA’.

President of the Royal Australian College of General Practitioners (RACGP) Dr Bastian Seidel reminded Guild representatives that opiate painkillers including codeine are not normally recommended for tension-type headaches.

A good explanation of some of the problems with codeine can be found in this article written by a pain specialist from Deakan University: Over the counter codeine gives as many headaches as it fixes.

Substandard rural solutions 

Sales of codeine-containing medications without script represent a revenue of $150 million per year for pharmacies.

The Guild has been busy lobbying State Health Ministers – successfully, it seems.

This weekend the Australian newspaper reported that all State Health Ministers, except for South Australia, have written to Federal Health Minister Greg Hunt “relaying unnamed stakeholder concerns about the unintended consequences of requiring a script” for codeine. NSW Health Minister Brad Hazzard was one of the signatories on the letter according to the Australian.

Here’s a screenshot of (part of) the letter to Minister Hunt in which the State Health Ministers explain why they are worried about the upscheduling of codeine:

Letter from state health ministers

If it is true that people in regional areas are indeed “managing chronic conditions with codeine medications” bought from a pharmacy than that is of course a concern as codeine should not be used for this purpose.

Pharmacy Guild lobby
Pharmacy Guild lobbies NSW Health Minister Brad Hazard about codeine. Image: Pharmacy Daily

The State Health Ministers seem to implicate in the letter that it is preferable to treat chronic conditions by self medicating with over the counter codeine purchased from pharmacies instead of going to a doctor to get appropriate treatment.

This would indicate a lower standard of care for people in rural and regional areas. The upscheduling decision by the TGA could actually help regional patients receive more appropriate treatment via a doctor and cut out-of-pocket medicine costs.

Cash for access unethical

The Australian also revealed that Queensland Health Minister Cameron Dick, who also signed the letter, failed to disclose seven cash-for-access meetings with Labor donors. One of the donors was the Pharmacy Guild of Australia.

Queensland’s Premier Ms Annastacia Palaszczuk had earlier announced she had a moral responsibility to ban certain donations.

The Guild gets high level access to politicians in all states via significant donations. Their political donations are on the rise (see graph). Concerns have been raised for a while now that the Pharmacy Guild is able to influence healthcare decisions based on commercial principles instead of sound evidence.

The Guild regularly negotiates a massive agreement with the Australian Government to the value of $19 billion for dispensing PBS medicines. This begs the question how ethical it is that the Guild, at the same time, transfers money into the bank accounts of the political parties it is negotiating with.

Pharmacy Guild donations
Political donations (Australian dollars) by the Pharmacy Guild Australia 2012-2016. Source: AEC.

The Guild’s solution is weak

The Pharmacy Guild said on their website: “When we put our solution to the politicians they think it makes sense, particularly when we explain how up-scheduling alone will mean a loss of convenience and higher costs for patients, as well as the clogging up of GP practices.”

Although the medical profession and health consumer organisations can see through this rhetoric, it appears some politicians have more difficulties and I don’t blame them – at first glance the arguments by the Guild sound convincing.

The recent Health of the Nation report showed that most Australians can see their GP when they need to and are able to get an appointment for urgent medical care within four hours. The argument of ‘clogging up GP practices’ as a reason for over the counter opiates is deceptive and it is probably not the Guild’s place to comment on this.

So let’s look at the Pharmacy Guild’s preferred solution. They believe that pharmacists should continue to sell codeine without a script for acute pain and state pharmacies would monitor misuse via their real-time monitoring software called ‘MedsASSIST’. The Guild continues to remind everyone that they are the only one with this pharmacy software package.

The problem here is first of all that medications issued without a script in a pharmacy must be substantially safe and without risk of misuse.

Clearly codeine is not safe and there is unambiguous international evidence of harm and misuse. So it makes no sense for codeine to be freely available in the pharmacy on the one hand but on the other be subject to real-time monitoring.

There are also serious problems with MedsASSIST. It is not an independent tool but owned by the Guild. Not all pharmacies use it so it is easy to get around for those who use codeine for the wrong purposes.

The Therapeutic Goods Administration has considered the evidence around MedsASSIST and found that it did not lead to a significant number of people being denied codeine medications in the pharmacy.

The TGA mentioned an example where an individual was able to receive 660 codeine tablets in one month despite their purchasing behaviour being tracked by the software. This raises questions about the efficacy and safety of the Guild’s preferred solution. Is it just smoke and mirrors?

The Guild continues to accuse others that they have done nothing to monitor the use of  drugs of dependence. This is also incorrect as many groups, including the AMA, RACGP and coroners have repeatedly asked for an effective national real-time prescription monitoring system, accessible by doctors and pharmacists.

What do consumers say?

The Consumers Health Forum has raised concerns about the Guild’s solution and said in their press release: “We do not support the proposal from the Pharmacy Guild of Australia and the Pharmaceutical Society of Australia to allow pharmacists to dispense codeine products without a prescription for people with one-off acute pain under certain conditions.”

“CHF supports the role of TGA as the regulator; we believe overall it does an excellent job of ensuring Australians have access to safety and high-quality medicines. We also note that this decision brings Australia into line with most other developed countries. As recently as July 2017 France has moved to make codeine products prescription only. The evidence for harm from codeine and other opioids is growing and their efficacy in assisting with pain management is coming under more and more scrutiny.”

Other groups also expressed concerns about the Guild’s undermining of the TGA. Pain Australia, the RACGP and the RACP have issued a joint press release. Painaustralia CEO Carol Bennett said:

“Chronic pain is a major health issue in Australia – we need to do much better than offering medications that are often both ineffective and potentially harmful in responding to chronic pain. Providing appropriate pain management should be a much higher priority, particularly in rural locations where reliance on opioids is a significant issue.”

“Painaustralia supports a co-ordinated, whole of sector strategy to address the issue of access to optimal pain management, including public and clinical education programs, linkages between rural health care clinicians via Telehealth with specialist city based services.”

And addiction specialists?

Last month, addiction specialists from the Royal Australasian College of Physicians (RACP) reaffirmed their support to make codeine-based medications available only with a prescription because of the many reports about misuse, addiction, and secondary harm.

The RACP said in a press release: “Addiction is a serious medical condition which should be avoided at all costs. (…) Addiction alters life choices, life chances and life trajectory. Addiction specialists have seen the number of patients with addiction to over the counter codeine grow at an alarming rate.”

“People with persistent pain should talk to their doctor to develop an appropriate treatment plan. This may include a referral to see a pain specialist or pain management clinic to manage their condition on an ongoing basis.”

The response from the Pharmacy Guild: “doctors are missing the point on codeine.”

Conclusion

Protection of the Pharmacy Guild’s significant commercial interests seems to drive behaviour that is not always in the interest of the health of Australians. Sadly, feedback or criticism is met with aggressive counter punches. Working with the community pharmacy sector is becoming difficult for other health groups.

It is sad to see because the Guild represents a respectable profession. It appears that the Australian healthcare system, which makes pharmacies dependent on commercial activities, is partly to blame for this situation. I am not accusing anyone of backdoor deals but this whole codeine saga is not a good look. Political donations and cash-for-access programs also seem highly inappropriate, especially in the healthcare sector. We desperately need more collaboration.

Mandatory reporting of health professionals: 4 options

If you are an Australian health professional and you have a health problem, there is a risk that your job is on the line if you seek medical assistance. But help is on its way…

As a result of mandatory reporting obligations under the National Law doctors and other health professionals may avoid seeking help or treatment for fear of being reported to the Australian Health Practitioners Regulation Agency (AHPRA) by their treating practitioner.

The reporting requirements were originally developed to protect the public against practitioners who have e.g. a health problem, an impairment or engage in serious misconduct.

Concerns have been raised repeatedly that health professionals are not seeking help and this has been flagged as a risk to the public in itself. Practitioners have also argued that their treatment should be kept confidential, just like every other Australian who seeks care.

Western Australia is the only state where these mandatory reporting guidelines are not applicable. Sadly, there is anecdotal evidence that this has created interstate traffic by practitioners in need of medical assistance.

Four options

The good news is that health ministers have reviewed this issue last month. The discussion paper ‘Mandatory reporting under the Health Practitioner Regulation National Law’ by the Australian Health Ministers’ Advisory Council (COAG) provides 4 options – of which 3 are new ones.

Option #1

This is the least favourable option as it would mean no change. This option would treat impairment matters and other notifiable conduct identically, requiring treating practitioners to report any notifiable conduct as is currently the case.

Option #2

This is likely the most favourable option from the perspective of health practitioners as it provides a complete exemption for treating practitioners from the requirement to report notifiable conduct in respect of their practitioner patients – similar to the Western Australian model.

Practitioners would have the same rights as any other Australian to seek care, without fear of being reported by their treating practitioner and recognising the importance of confidentiality.

This option would entrust the treating practitioner to make a voluntary notification in accordance with their professional and ethical obligations to protect the health and safety of the public.

When a patient poses a serious risk to the public, professional and ethical obligations require treating practitioners to report (even in the absence of a requirement to do so) and to encourage the practitioner that they are treating to self-report.

Other practitioners including colleagues and employers remain under a mandatory obligation to report impairment and other forms of notifiable conduct.

Option #3

This option would only exempt treating practitioners from the requirement to report an impairment matter if it will not place the public at substantial risk of harm.

All other types of notifiable conduct, current or past, must be reported by a treating practitioner. This means that practitioners with for example a mental health or addiction problem may not disclose issues to their treating practitioner, or may avoid seeking help.

Option #4

This option would exempt treating practitioners from reporting impairment matters and to only require reporting of other forms of notifiable conduct where there is a current or future assessment that the notifiable conduct is likely to occur.

This option creates problems with regards to for example risk assessment which is often based on past conduct. Health practitioners may not fully disclose health matters and avoid seeking help under this option.

The WA model

I expect that most practitioners will prefer option 2. This option allows full disclosure of health issues, facilitating diagnosis and treatment. It respects the confidentiality of the patient-doctor relationship which is the basis of a successful road to recovery.

The COAG discussion paper reports that an independent review found no evidence that the WA model impacted on notification rates, further supporting option 2 as the preferred nationwide solution.

RECOMMENDED FURTHER READING: Mandatory reporting of health professionals: has COAG delivered on its promise?

Health of the Nation: good and bad news according to Australia’s GPs 

Australia’s GPs believe that mental health is the number one emerging health concern, often related to co-existing chronic health conditions – but more is needed to keep Australians well.

This is one of the conclusions presented in the benchmark report General Practice: Health of the Nation 2017 which gives a unique overview of the general practice sector.

The report is based on various sources, including research commissioned by the Royal Australian College of General Practitioners (RACGP) and the MABEL (Medicine in Australia: Balancing Employment and Life) Survey.

Some of the key messages from the report:

  1. Mental health is today’s biggest health problem and will continue to be an issue in the future
  2. The GP is the most accessible health professional and should be utilised to keep Australia well
  3. Patient out-of-pocket expenses in general practice are increasing and present a barrier to patients accessing the required care

The bad news

GPs report that psychological issues such as depression, mood disorders and anxiety are the most common health issues they manage. Mental health was flagged by RACGP members as the health issue causing most concern for the future, followed by the often related problems of obesity and diabetes.

GPs believe that mental health and obesity are two key health policy issues the Federal Government should prioritise for action.

From the benchmark report: “This is a clear warning of both the current frequency and future potential impact of psychological ailments on individuals, the community and the broader health sector. It is also a stark reminder that the personal and financial health costs associated with obesity and diabetes are expected to escalate.”

However, the number one health policy issue flagged by GPs is the problem of the low patient Medicare rebates. GPs have indicated this requires immediate Federal Government action to make sure that access to high quality healthcare is maintained.

As the cost of providing high-quality health services and running general practices continues to rise, GPs are finding it more difficult to bulk bill patients. Between 2013-14 and 2016-17 the growth of the bilk billing rate has slowed down.

Patient out-of-pocket contributions continue to increase each year as Medicare rebates fall further behind the real cost of providing general practice services.

The good news

Most Australians can see their GP when they need to. Nearly all patients (99.3%) report that they are able to see a GP when they need to and most people are able to get an appointment for urgent medical care within four hours.

Australians access GPs more than any other part of the health system. They report that they visit their GP more than they receive prescriptions, have pathology or imaging tests, and see non-GP specialists.

Eighty-three per cent of patients report that they visit their GP multiple times a year, including 11% who report seeing their GP 12 times or more. The availability of GP services has further increased with extended opening hours.

GPs coordinate care within multidisciplinary teams and Australians report positive experiences with their GP.

More time with patients

The RACGP is arguing for Medicare changes that will incentivise doctors to spend more time with patients – by increasing the patient rebate for longer consultations.

RACGP President Dr Bastian Seidel said: “We believe when GPs are spending more time with their patients, that leads to less prescribing, less pathology, less referrals, enhanced continuity of care, and that would, of course, mean less hospital presentations as well.”

General practice accounts for less than 9% of total government recurrent expenditure. The RACGP, AMA and other groups believe this is inappropriate as more health benefits for Australians can be gained by investing in primary care.

 

Download the report here.

 

Bizarre research article about parental confidence in GPs gets a mention in ABC’s Media Watch

In an earlier post I mentioned the bizarre article published by a paediatrician from the University of Melbourne.

The article concluded incorrectly that “confidence with GPs is an issue for parents of many walks of life”. The paper was rejected by the Royal Australian College of General Practitioners (RACGP) and the Australian Medical Association (AMA).

The odd conclusions from the authors were reported by prime time media which in turn drew the attention of the ABC TV show Media Watch.

The article and subsequent reporting by some journalists attracted harsh criticism from presenter Paul Barry. And rightly so…

Bizarre research article about parental confidence in GPs gets a mention in ABC’s Media Watch
Media Watch sets the record straight: Most parents have confidence in their family GP. Source: Media Watch

The background

The authors reported the results of a survey about the confidence parents have in the paediatric care by Australian GPs. The survey was published in the Journal of Paediatrics and Child Health.

The findings showed that most parents are confident in their GP (only 2% of respondents was not very confident), yet the authors stated that “fewer than half of parents are completely confident in their GP to provide general care to their child (…).”

The authors conveniently omitted the ‘mostly confident’ category (45%) and only reported the ‘completely confident’ category (44%) as their main result. They then went on to conclude that this could potentially lead to “greater numbers of ED presentations for children with lower urgency conditions” and also suggested that GPs needed more paediatric training.

#trustaGP

Record set straight

The poor research quality coming from the University of Melbourne has raised eyebrows. GPs voiced concerns that, as a result of the paper and the incorrectly informed media coverage, some parents may take their sick children to the emergency department (ED) instead of the GP.

But ABC’s Media Watch has now set the record straight.

In a reply on this blog lead author Professor Gary Freed previously said: “If you do not like how we presented the results of this parent survey, for whatever reason, I respect that. However, I sincerely hope that does not result in you and others ignoring the underlying issue of worrisome changes in paediatric care and education among GPs.”

We now know that these ‘worrisome changes’ are not confirmed by the results of Professor Freed’s survey which clearly shows that most parents have no problem with the care provided by GPs.

View ABC’s Media Watch here.

Why your GP doesn’t have a Facebook sharing attitude

The success of Facebook is based on sharing content with friends and family. I’m a fan of social media but in healthcare sharing of information is often a no-go zone.

Doctors don’t like sharing patient information with third parties for various reasons: they have sworn an oath, must adhere to a code of conduct and have an ethical and legal obligation to safeguard the privacy of their patients.

The patient-doctor relationship is built on trust: patients need to feel safe to share their concerns with a doctor. Unfortunately in Australia there are a few worrying cracks in the system, such as the access of insurance companies to health records.

Life insurance industry

Last week I had the opportunity to present the concerns of the Royal Australian College of General Practitioners (RACGP) at the Inquiry into the Life Insurance Industry of the Joint Parliamentary Committee on Corporations and Financial Services in Canberra.

The issue is well summarised in this ABC News article ‘Doctors resisting health records being sent to insurance companies’. Based on feedback from GPs, the RACGP recommends in its submission into the inquiry that insurers should not be allowed to ask for full patient health records.

This is an example of inappropriate sharing of information with a third party (which differs from sharing between health professionals) and can have serious ramifications.

Inquiry in Life Insurance Industry
Last week I had the opportunity to present the RACGP submission at the Parliamentary Inquiry into the Life Insurance Industry.

5 reasons not to share

There are five reasons why third parties such as insurance companies should never have access to health records:

# One

People often don’t understand that ticking a box on the life insurance application form means that insurers can have access to their health records, including confidential information that has been shared with doctors, often over many years, and may not be relevant to the insurance company.

In the experience of GPs many people withdraw their consent once they are aware of the possible repercussions, and in some cases discuss with their GP to submit a targeted, more relevant medical report instead.

# Two

The therapeutic trust relationship between a GP and a patient could be affected.

Patient knowledge of the issues they may face after disclosing symptoms or seeking treatment, particularly for mental health issues, is likely to discourage disclosure and help-seeking, which adversely affects patient wellbeing.

# Three

Understanding that medical records can be requested by an insurer may lead GPs to under-document or under-identify patients at risk in efforts to make sure the patient’s access to insurance is not affected.

GPs have advised that they feel they are placed in a difficult situation where they need to ensure adequate documentation of their consultation with patients while also considering the broader impact this may have on their patient. This in turn may have medicolegal ramifications for doctors.

# Four

Insurers not only have access to but also store thousands and thousands of health records. This raises all sorts of questions with regards to data usage and standards around security, privacy and confidentiality.

# Five

Many GPs are concerned about the risks of misinterpretation by insurers when reviewing a patient’s consultation notes.

Medical consultation notes are a comprehensive written record of concerns, symptoms, examinations, investigations, treatments and planned reviews. They function as an aide memoir and are not made for the assessment of risk for insurance purposes.

Suggested solutions

There should be a tightening of the requirements around requests for full medical records by insurers. With patient consent, doctors should only be asked to provide a targeted and relevant report to the insurer.

There is also a clear need for greater patient education on consent and the release of health information to insurance companies.

New study shows high parental confidence in GPs, but researchers draw bizarre conclusions

High confidence in GPs

A new national study published in the Journal of Paediatrics and Child Health shows that around ninety percent of parents are mostly or completely confident in GPs to provide general care to their children.

This is of course good news.

The findings also show that 93% of the parents participating in the study reported that they would take their child to see a GP in the event of a minor illness, instead of visiting the emergency department – which is exactly what everyone wants.

Therefore I was surprised to read the conclusion from the authors, a group of mainly academic paediatric researchers, that “confidence with GPs is an issue for parents of many walks of life” which could potentially lead to “greater numbers of ED presentations for children with lower urgency conditions.”

Sorry? The results of the study clearly show that only 2% of parents were not very confident in their GP (see table). I wonder what is going on here.

Most parents are confident in their GP. Only 2% of respondents was not very confident. Source: Journal of Paediatrics and Child Health.

 

The authors conveniently omitted the ‘mostly confident’ category (45%) and only reported the ‘completely confident’ category (44%) as their main result, stating that “fewer than half of parents were completely confident” in a GP.

I wonder how many consumer satisfaction studies show a 100% score all the time… The bottom line is that many people inherently have fears when it comes to their own health and especially the health of their children. This may be reflected in their attitudes in confidence of health care services, but this is often a natural fear and as a profession we need to support our patients and address their fears and concerns.

More bizarre conclusions

It appears the authors have a different agenda, as they went on: “Given that GPs in training are having limited experience in child health and that GPs are seeing fewer children overall, more intensive training pathways for paediatric care may be beneficial. One option would be for additional training similar to the certificate for GP provision of antenatal care.”

Additional training? Current GP training already includes childhood conditions as this is core general practice business. GP waiting rooms are full of children and most childhood conditions and preventive health are managed successfully by GPs.

We know that Australia has one of the highest life expectancies in the world, partly because Australian general practice is accessible and offers longitudinal care.

The findings of the study also confirm that parental confidence is greater for those with a regular GP, so instead of providing advice about more intensive training pathways, it would have been useful if the authors had recommended that parents find a regular family GP they trust.

Seeing a GP who is a RACGP Fellow (Royal Australian College of General Practitioners) should serve as reassurance to parents that they are seeing a specialist GP who has trained at the highest possible general practice standard in Australia – including child health and antenatal care.

There are of course challenges with doctors coming into GP training in this area. In recent years, the access of junior hospital doctors to paediatric experience in hospitals before entering GP training has decreased. Like all training and learning needs, this is taken into account when supervising GP trainees to ensure patient safety.

National study of parental confidence in general practitioners
It would have been useful if the authors had recommended that parents find a regular family GP they trust. Source: Journal of Paediatrics and Child Health.

Not helpful

If there is some area we need to do better, we need to know that but based on the findings of this study I don’t see a major problem with the paediatric care provided by Australian GPs.

My take-home message from this study is first of all that this style of reporting research findings is, at best, not helpful.

Secondly, the study clearly demonstrates the need for quality research in general practice, in terms of improving access to high value treatments and the appropriate use of limited health resources.

Promising breakthrough: dramatic miracle cure offers hope to victims

The problem with headlines about medical breakthroughs and miracle cures is that they never live up to the expectations. On the other hand, the breakthroughs happening every day in primary care do not attract much media attention.

Seventeen years ago medical journalist professor Schwitzer published the seven words you shouldn’t use in medical news: ‘promise’, ‘breakthrough’, ‘dramatic’, ‘miracle’, ‘cure’, ‘hope’ and ‘victim’. Has Schwitzer’s taboo list made an impact?

Words you shouldn't use in medical news
Source: Twitter

Not really. A quick Google search shows that the same words are still used to celebrate ‘heroic medicine’ – often surgical interventions, new drugs or medical technologies. Scientific progress and developments are important but not always easily translated to every day care for every day Australians. They are never ‘miracle cures’.

At the same time we are seeing an increase in spending on hospital treatments but little investment in keeping Australians healthy and out of hospital. Although the breakthroughs in primary care are not regarded as newsworthy, they are often life-changing.

Dramatic & miraculous examples

Here are some of the amazing health ‘breakthroughs’ that are happening every day in Australian communities:

The patient who, supported by her general practice team, feels so much better after getting control of her diabetes. The person with a mental health condition who, after many months of hard work, and treatment by his psychologist and GP, is able to do the groceries again without a panic attack.

The woman who died peacefully at home, according to her wishes with close family around and supported by her GP and the palliative care team. The obese man who has been able to lose weight as a result of determination and regular contact with his GP and allied health team.

The patients who were glad they came in for a blood pressure check or immunisation because the general practice team picked up a heart murmur or melanoma. The highly anxious child who returned to school with help from the multidisciplinary team – much to the relief of the parents.

Medical news: wrong headlines
News headlines: room for improvement?

 

The courageous person who opened up and told his GP or practice nurse what he has never shared with anyone else before – and made a start to change his life. The worried parents demanding antibiotics for their feverish baby, but eventually leaving the GP practice relieved and without a script because they know the infection is self-limiting.

The hospital admissions avoided through a phone call by the GP – with a concerned patient, allied health professional, aged care facility nurse or hospital doctor. The elderly, isolated and malnourished patient who improved and continued to live independently with support from community nurses and the general practice team.

The consultation around the plastic bag of medication boxes brought in by a patient after a visit to the hospital – an essential chat about which tablets to take and when, to make sure she gets better.

Promising breakthroughs

Professor Lesley Russell Wolpe wrote in Inside Story about the value of incremental care. She said: “Heroic medicine has its place, but treating it as the core of medicine means that the majority of government funding goes to hospitals, acute care and elective surgery, a situation that is reinforced by the political imperative to deliver visible returns in a short election cycle.”

She said: “Treating general practice as a speciality in its own right — along the lines of the current advertising campaign ‘I’m not just a GP. I’m your specialist in life’ run by the Royal Australian College of General Practitioners — would help. Ensuring that primary care has the resources to keep up with its central role in the healthcare system is also vital.”

In the years ahead more ‘dramatic breakthroughs’ will continue to come from primary care teams who, day in and day out, assist people with important health decisions and adjustments in their lives. It is time to change the headlines. It is time for decision-makers to increase their support for primary care.

As RACGP president Dr Bastian Seidel said in The Australian: “Our patients want health, they don’t necessarily want treatment”.

Disruption by the after-hours industry and why you should care

After-hours medical home visiting services are important for patients and their doctors but we need an ethical and sustainable model that integrates with day-time services.

Doctors and professional medical bodies including the RACGP and AMA regularly express concerns about healthcare models that compromise on quality, fragment and duplicate care or fail to use scarce health dollars efficiently.

The Medicare Benefits Schedule (MBS) Review Taskforce has voiced similar concerns in relation to some of the home visiting services. In its recently published interim report the taskforce notes that the growth in claiming of urgent attendances by after-hours medical services is showing an increase far in excess of population growth.

The taskforce believes the services often interfere with continuity of care by the patient’s regular GP and represent low value care. It is not convinced that the rise of urgent after-hours home visits has had a significant impact on hospital emergency department services.

Inappropriate use of funding?

Indeed, there are indications that funding for after-hours medical services in the community may be used inappropriately. For example, I have received reports from some of these services delivering repeat prescriptions after-hours to patients’ homes. The care is often not provided by GPs but by less qualified practitioners.

An after-hours visit classified as ‘urgent’ attracts a Medicare rebate which can be $100 more compared with the same service provided at a GP practice. This has created a lucrative standalone after-hours industry which doesn’t always represent value for money for the taxpayer.

No reduction of emergency department presentations
The assumption that increased provision of urgent, after-hours consultations (MBS item 597) would reduce demand for emergency departments has not been confirmed. Source: AFP

Let’s look at the ACT: since the arrival of the bulk-billing National Home Doctor Service in the capital, home visits rose from 1588 in 2013–14 to 20,556 in the previous financial year.

According to the Medicare Benefits Schedule Review Taskforce, Medicare benefits paid for urgent after-hours services have increased by 170 per cent, from $90.8m in 2010–11 to $245.9m in 2015–16, whilst benefits paid for normal GP services increased by 27 per cent.

There is no reasonable explanation for the exponential growth. The taskforce is of the opinion that MBS funding should continue to be available for home visits in the after-hours period but has made some sensible recommendations to improve the model.

After-hours lobby 

The response from the after-hours lobby speaks for itself: The National Association for Medical Deputising Services started an aggressive lobbying campaign to ‘protect home visits’.

Although several after-hours services left the corporate lobby group – including the Canberra After-Hours Locum Medical Service, the Melbourne-based DoctorDoctor service and the Western Australian Deputising Medical Service – the campaign continues to target consumers and politicians.

The actions of the lobby group and some after-hours services have raised eyebrows. Mass media advertising and marketing campaigns via television, newspapers, and billboards will drive unnecessary use and should be avoided. Similarly bookings for after-hours deputising services during daytime hours should stop.

A sensible solution

It’s not rocket science: As after-hours home deputising services do not offer comprehensive GP care, they should only be used when a patient’s usual GP or general practice is not available and the patient has a health concern that cannot wait until the following day.

It is time to use these Medicare-funded services wisely – when genuinely needed, not wanted or promoted.

A victory for common sense (and patient care)

Yesterday Sonic Healthcare pulled out of their deal with Sigma’s AMCAL pharmacy chain to sell blood tests to pharmacy customers. I believe it was a wise decision to withdraw from this so-called ‘screening program’.

Just think about it. If it is up to AMCAL pharmacies their customers will be able to purchase for example a vitamin D blood test for $89.50 to ‘screen’ for vitamin D deficiency.

Initially the president of the Royal College of Pathologists of Australasia (RCPA) said: “They are all valid tests and they can all be done on patients without symptoms or abnormalities in those areas.”

But look at the recent Choosing Wisely recommendation by the RCPA:

Vitamin D screening

The RCPA’s position statement on the use and interpretation of vitamin D testing also clearly states: “The testing of healthy individuals will reveal a significant subgroup with low 25OH‐D (vitamin D) levels. This leads to treatment and perpetuates repeat testing without information as to whether such patients will benefit from vitamin D supplementation.”

Although I am sure that AMCAL’s ethical standards would not have allowed staff to push vitamin D pills for customers with low levels, I understand why Sonic has withdrawn from the initiative as it wasn’t exactly the best example of ‘screening’.

It looks like it was just about commercial stand-alone pathology testing without pre-agreed collaboration with doctors. There was no medical involvement or integration with other healthcare providers and the out-of-pocket costs for patients would have been high – with no Medicare rebate.

I imagine there were also some ethical dilemmas. Take the RCPA’s Code of Ethics, which contains the following principle:

To protect patients from harm. This includes commitment by each individual to the achievement and maintenance of clinical competence and professional standards; to referring issues beyond their clinical competence, scope of practice or accreditation; and, taking appropriate action when the conduct or lack of competence of others places patients at risk of harm.”

I really like the online RCPA library. For example, I found an excellent document titled ‘Making sense of testing; a guide to why scans and health tests for well people aren’t always a good idea.’ It explains why and how testing can cause harm (see image).

Why and how medical tests can cause harm
Source RCPA Library: ‘Making sense of testing; a guide to why scans and health tests for well people aren’t always a good idea.’

The RCPA Code of Ethics further urges fellows and members of the pathology college to “maintain professional integrity” and to “recognise and eliminate conflicts of interest that interfere with free and independent medical or scientific judgment.” As it happens, the President of the RCPA is also CEO of one of Sonic’s pathology companies.

I congratulate Sonic Healthcare on its decision and I’m pleased to see that a corporate giant in Australia seems to have made the decision to follow ethical principles instead of prioritising commercial interests over professional standards. Let’s see what the pharmacy sector will do next.

Blood tests at the chemist is like getting your car serviced at the lawn mower shop

Pharmacies are the right place to get your medicines and receive medication advice, but they are the wrong place to get a blood test.

AMCAL chemists are offering customers pathology tests at a cost of up to $220.

Ordering a test through a pharmacy chain rather than your local GP creates risks for patients including fragmentation of care, unnecessary duplication of tests, confusion about the interpretation of the results and increased out-of-pocket costs.

It may lead to incorrect, incomplete and unnecessary tests as well as wrong conclusions and false reassurance.

A pathology test should be recommended based on a medical assessment which may include your personal medical history, symptoms and a physical examination. Pharmacists do not have the diagnostic skills required to provide this kind of care safely.

AMCAL customers will be paying out-of pocket and are not eligible for a Medicare rebate. For example, a vitamin D blood test will cost $89.50, a ‘fatigue screening’ $149.50 and a ‘general health screening’ $219.50.

Our Australian Medicare system reimburses patients for a range of pathology tests after an appropriate assessment by a doctor.

The standard packages sold by AMCAL may not include the tests that are required for your unique circumstances or health problems.

We really need better integration of health services in Australia. We need pharmacies to work together with GP teams, not introduce more commercially driven duplication and fragmentation of services.

Ordering a pathology test through the chemist is like getting your car checked at the lawn mower shop. Nothing wrong with the lawn mower shop but it just isn’t the right place.