In my last post, I mentioned the issue of lack of trust in institutions. It appears that our world is increasingly running on financial incentives and regulation. Psychologist Barry Schwartz states that this undermines our will to do the right thing.
This week Dr Todd Cameron, GP and practice owner in Victoria, posted an excellent four-minute LinkedIn video about why financial incentives are not as effective as we sometimes think. He mentioned the following issues with financial performance systems:
They assume people are lazy
They are not supported by scientific evidence
They ignore activities that are difficult to measure
They reduce the flexibility of organisations
They take away resources for system improvement
KPIs often work against each other or against other goals, values or purposes
KPIs can undermine collaboration.
Research confirms that incentives, big or small, usually backfire. Like punishments, they affect internal motivation and creativity. Social scientist and author Alfie Kohn wrote about the ‘bonus effect’ in Psychology Today:
“When people are promised a monetary reward for doing a task well, the primary outcome is that they get more excited about money. This happens even when they don’t meet the standard for getting paid.”
Kohn states that rewards not only make people lose interest in whatever they had to do to get the reward but incentive systems also reduce the quality of their performance.
I believe Todd is right, money should be the byproduct of doing a great job. Pay is clearly not a motivator to improve performance. Most people get out of bed in the morning because they want to do the right thing – this is usually something we’re good at or passionate about.
Great examples and a work environment that gives people freedom and sets a clear direction at the same time are more powerful than monetary bonuses. Todd recommends that KPI funds should be used to improve systems and collaborative platforms and that targets should not be tied to financial rewards.
Trust is an essential ingredient of effective healthcare delivery. It’s important for interprofessional as well as inter-organisational collaboration.
A 2018 literature review concluded that collaboration leads to more job satisfaction, improved morale and a better working atmosphere. Unfortunately, health providers don’t always trust each other. The authors of the review found 5 sources of distrust:
Doubting the other’s motivation in providing care and the perceived benefit for him/her
Feeling threatened by the other’s involvement and being afraid of losing some territory
A difference in philosophies and scope of practice
Negative images of the profession
Lack of confidence in the other’s skills and lack of awareness of the other’s role in patient care.
Other ingredients of effective collaboration include adequate communication, respect, mutual acquaintanceship, equal power-distribution, shared goals, congruent philosophies and values, consensus, patient-centeredness and environmental factors.
The authors did not explore the level of importance of each factor but I am putting my money on trust as the secret ingredient. If we continue to distrust each other, collaboration will remain a challenge. The question is, how to change this?
“I do know that when primary care doesn’t connect, collaborate and work together – patients see and feel that disconnection. And I have a feeling that those working in primary care see and feel it too.
Labor’s health spokeswoman Catherine King announced that her party will create a permanent health reform commission if it wins the federal election. I thought this sounds like a step in the right direction as long-term planning of health reform is much needed in Australia.
On the other hand, there have been many government committees, task forces, reviews and reports that haven’t made a dent in the primary care landscape.
If only we could put together some of the ideas coming from Australia’s health and consumer groups. These organisations, often working at the coal face of primary care, have an excellent understanding of the urgent needs and requirements.
I was pleased to see that some of this year’s pre-budget submissions by primary care organisations contain similar ideas. For example, the pre-budget submissions from AMA, ACRRM and RACGP all argue for funded telehealth services.
As expected, there is a strong push for adequate patient Medicare rebates and reduced patient out-of-pocket costs. The general practice profession also believes that spending more quality time with patients should be encouraged through better remuneration of longer consultations.
One of the main themes is improving care for people living with chronic and complex conditions. The Australian Medical Association is proposing a chronic disease quarterly care coordination payment to GPs to support team-based care.
The Pharmaceutical Society of Australia wants pharmacists in residential aged care facilities. The Consumers Health Forum argues for an Australian Co-Creating Health initiativeto support people with chronic conditions to actively manage their own health.
Rural doctors, RDAA and ACRRM, are asking for more junior doctor training places in rural and remote settings and a move to the rollout phase of the National Rural Generalist Pathway.
This is just a selection of some of the budget submissions. What struck me is that there is a lot of merit in many of the proposals. They are often not mutually exclusive.
Unfortunately, most budget submissions seem to end up in a large pile on the minister’s desk. Many great ideas never see the light of day, because there is no sector-driven vision or strategy.
Is this the best we can do? I believe it is time to work towards a shared vision for primary care. Why not start by looking at what the various organisations and groups have in common?
Health professionals often complain about software and IT. It doesn’t always do what we want it to do. It slows us down, makes us do extra work.
A common problem is lack of interoperability. Computer systems are not talking to each other, a bit like Microsoft and Apple many years ago. Patients have also noticed that important information is not always available, which leads to inconvenience, delays and sometimes more tests.
At the same time GPs are unhappy that the hospital doesn’t provide essential info, for example when a patient has passed away, and hospital staff complain that referral letters don’t contain important triage information. Etc etc.
This raises the question, how ‘interoperable’ are health professionals? Do we know how we can best facilitate transfers and improve clinical handovers? What information do our colleagues need and when? How often do we meet to sort out issues in a collegial way?
It’s good to see there are passionate people working on these issues – but they need help. Computer systems are a reflection of the silos we work in. First fix human interoperability and our IT systems will follow.
The other day I attended a leadership event at our local hospital. One of the speakers asked us “How many days of the week start with the letter T?”
The obvious answer is of course two, Tuesday and Thursday – but he said there’s another answer someone once gave him during a workshop, which is also correct: Tuesday, Thursday, today and tomorrow.
The point he made was that together people often solve problems in ways they wouldn’t have thought of on their own. Transformational ideas and break-through inventions are usually incremental processes that occur when different minds work together or build on each other’s work.
Steve Job’s iPod was based on existing mp3-players. Thomas Edison didn’t invent the lightbulb but improved it. The invention of the automobile and the airplane was the work of many; Henry Ford and the Wright Brothers just refined the ideas.
It never ceases to amaze me how people in a group – when the circumstances are right – develop creative ideas to solve challenging problems.
That evening, during dinner, I asked my children ‘Who knows how many days of the week start with T?” We had a bit of a discussion as a family until my 10-year old daughter said, “Seven days dad, because I always start my day with a tea.”
Although doctors look after their patients, they don’t always look after each other.
What has happened to collegiality? Why are doctors so unkind to each other? Anaesthetist Dr David Brewster and surgeon Dr Bruce Waxman ask these questions in the Medical Journal of Australia.
The authors are of the opinion that doctors have become too judgemental of their peers and that constant negative commentary has affected the workplace environment.
They write: “We have all been guilty of uttering critical colloquialisms in the workplace that resist positive interdisciplinary relationships. Unfortunately, our apprentice junior doctors adopt these expressions that promote lack of collegiality. Doctors learn to criticise and blame each other, rather than understand the differences we all face in providing the best care to our patients.”
Kindness can be as simple as saying thank you or acknowledging the work of a colleague, and a smile or a cup of coffee also go a long way, they argue.
Reading this in our medical journal gives me hope. It is not easy to discuss this topic publicly in a highly judgmental culture.
This week saw another low point in the communication and relationships between health groups in Australia. We must find a better way.
It began after the release of a report from the Queensland parliamentary inquiry into pharmacy, which recommends that pharmacists should be able to prescribe and dispense ‘low-risk emergency and repeat prescriptions’ and ‘low risk vaccinations’, subject to consultation with a ‘13HEALTH GP’ or checking ‘the patient’s medical record’ through MyHealthRecord.
Medical groups including the AMA and RACGP indicated they will not support the recommendations. This is hardly surprising as the results of the deliberations by the parliamentary committee led by Chair Aaron Harper MP are not based on mutually agreed principles or a collaborative care model.
Although the report repeatedly mentions a shared prescribing model, the recommendations, if implemented, will not result in effective collaboration. For example, checking the MyHealthRecord (which is not always available or complete) or calling a health-line can hardly be seen as supporting team care and collaboration with treating doctors. Cooperation between pharmacists and medical teams should be more than a box ticking exercise.
I believe we can do better than this.
Community pharmacists feel that their scope of practice is restricted and that they can contribute in a more meaningful way to patient care. Medical groups are concerned that more prescribers can lead to fragmentation of care and poor health outcomes, especially in the absence of meaningful collaboration.
Both arguments are valid and should be explored further. There is always a better way but this requires a willingness to work together and find mutually agreed solutions. Indeed, not an easy task, but we can’t leave this to a group of parliamentarians.
On a positive note, it was good to see that the Pharmaceutical Society of Australia (PSA) recently organised a low-key summit between medical and pharmacy groups to discuss patient safety. PSA president Shane Jackson said that the summit will seek to develop a set of principles to support respectful and collaborative practice between pharmacists and doctors.
Reaffirming these principles is a useful exercise and a good place to start. My colleague Dr Ashlea Broomfield and I spoke with Shane Jackson about collaborative models of care (listen to the BridgeBuilders podcast here). Although doctors and pharmacists may never agree on everything, which is absolutely fine, we must find a better way forward in the interest of our patients.
Collaboration can be very rewarding. It is often talked about but not easy to achieve, and it doesn’t always make the top of the priority list.
Although it’s not the solution to everything, effective collaboration can be a source of satisfaction and has the potential to make work, and life, more fun. Of course, collaboration does not mean that we have to agree on everything.
I’d like to share some thoughts on the ‘ingredients’ of successful collaboration:
#1: Letting go of control
No one is as smart as all of us, said Ken Blanchard. It’s ok to not have all the answers. In collaborative cultures outcomes are largely dependent on organic group processes. It is important to empower others and trust in the wisdom of the group and diversity of thought.
#2: Celebrating diversity
Interesting things happen when people bring different backgrounds, disciplines, skills and ideas to the table. We need to be open to a dialogue that celebrates differences. This is not always easy as our tendency is to engage with like-minded people.
Diversity improves decision-making as it stimulates critical evaluation and prevents groupthink. Diversity also means accepting that we can have differences of opinion.
#3: Aiming for mutual benefit
In collaborative cultures mutually beneficial solutions become more important than winning and personal gain. We need to attend to the needs of all parties and not just our own.
Consensus improves the quality of decision-making through genuinly addressing individual concerns. Asking questions and finding out what outcome the other party needs is key to finding common ground for agreement.
#4: Formulating shared values or goals
Often we want to jump to the ‘how’ without having explored the ‘why’. Universal values are motivating! They answer the why question and are the reason we get out of bed in the morning. Providing excellent care to our patients is an example of a universal value/goal most of us share.
#5: Building relationships
If we focus on outcomes without investing in relationships, there is a good chance that we will fail. Building trust and relationships are key components of effective collaboration. This is never a once-off tick-box exercise but should be an ongoing activity.
Community pharmacy groups are lobbying for pharmacy prescribing, a topic that has been on the wish list for a long time. Medical groups are concerned about patient safety and fragmentation and are pushing back. Is this Australian conflict model what we want or is there a better way forward?
Some pharmacists want to be able to write prescriptions as they believe it is in the scope of practice of a pharmacist and more convenient for patients.
Examples from abroad are used as an argument why Australia must follow suit. A ‘collaborative prescribing pilot’ is underway and the pharmacy sector is looking forward to the soon-to-be released results.
Pharmacists expect that their proposal will be cost-saving as people will not need to see the family doctor for prescriptions.
Not surprisingly, medical groups are upset and believe the proposal is not helpful and not in the best interest of patients.
Doctors are concerned that soon the head doesn’t know what the tail is doing or, in other words, that more prescribers will lead to more fragmentation and adverse health outcomes.
Concerns have been raised that warning signs or significant (mental) health conditions will be missed and screening opportunities lost. Some have also argued that pharmacists prescribing and selling medications at the same time creates commercial conflicts of interest.
As a result there will likely be pushback from medical groups. It is to be expected that when the debate heats up some unpleasant words will be said in the media before the Health Minister of the day makes a decision based on evidence, opinion or political expedience.
Then there will be a loser (usually not the Health Minister) and a winner, and the relationship between pharmacists and doctors remains sour at the expense of patient care.
A better way
This series of events has become a familiar scenario in Australian healthcare. What’s missing is of course a joint strategy or a solution that would benefit both parties as well as our patients (a win-win-win solution).
Community pharmacists play an essential role within primary care teams. The pharmacy sector is under pressure and is attempting to implement strategies to remain viable into the future, such as introducing services currently provided by doctors, nurses and others.
An obvious way forward would be for pharmacists and doctors to explore models that are not competitive but complement each other. This is a joint process that requires broad support from both parties.
We desperately need genuine collaborative models of care, such as pharmacists working in general practice, but there may be other models too.
This is of course easier said than done. It is, however, time to leave the Machiavellian era of Australian healthcare behind. Who’s going to take the first step?
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.
Many GPs feel disempowered in the current climate of cuts and freezes. It is indeed hard to comprehend why governments slash funding to the most efficient and cost-saving part of the health system.
We are all concerned about the lack of continuity of care and increasing fragmentation in our healthcare system, but what about the divisions within our own ranks?
Part of what makes general practice attractive is its diversity, but it also makes general practice prone to divisiveness. Think, for example, of the stereotypical dichotomies: generalists vs partialists, private practice vs corporates, rural medicine vs metropolitan general practice, etc.
GPs are highly respected in the community, but have become an easy target because of marginalisation and fragmentation. It is a well-known secret that governments play different GP groups off against each other, choosing to include or ignore organisations in their deliberations and negotiations.
Lack of unity also opens the door for disruption by third parties.
It is clear that general practice needs an urgent cultural change. Just like surgeons are working on improving the bullying culture, we must address the disharmony and division that afflicts us.
How good would it be if practices worked together instead of competing? If GPs could get together and agree on issues important for their area? If peak bodies would team up and better coordinate strategy, policy development, campaigns, conferences and membership services?
There is a whole generation of GPs that don’t understand why we have so many representative organisations. These young doctors are concerned about the disadvantages. Why don’t general practice organisations support each other, why are there multiple memberships and so much duplication? I believe they are right.
We have much more in common than what sets us apart, so why are we so tribal?
I can think of a few reasons. The first that comes to mind stems from social psychology; our brains may be programmed to organise us into small tribes because of evolutionary advantages, such as social bonding and survival.
There are also economic motivations, for example, GP clinics currently compete for patients. Our peak bodies are based on membership and need to offer benefits; this encourages competition rather than collaboration.
Reform fatigue may be another reason why some of us have stopped caring about achieving common goals. Experienced GPs can tell us the tales of the many system changes they have witnessed over the years; reform comes and goes and often disrupts our day-to-day practice. The risk is that we become cynical about what our profession can achieve in Canberra.
Perhaps there is also a selection bias. It is possible that GPs prefer more autonomy than our hospital colleagues, and although we work increasingly in teams, we may be less group-oriented or prefer smaller tribes.
Finally, doctors are trained to be leaders. We’re masters in problem solving and good at making difficult decisions, often in challenging and stressful situations.
We’re independent thinkers, skilled at arriving at our own conclusions and giving strong opinions. But we are not a profession of followers. The success of organisations depends on how well their leaders lead and how well their followers follow.
United General Practice Australia (UGPA) could connect the dots here. It’s an umbrella group for all the main groups, including the RACGP, ACRRM, AMA, RDAA. Those taking part have shown a desire to put aside their differences to a certain extent.
However, the status and governance of UGPA is somewhat vague. There is also no website or official spokesperson. But it is a start, and I would love to see this organisation be given the opportunity to grow and represent us all.
Lastly, we need to find common ground and partner with patient health organisations, as governments listen to the public more than they do to doctors.
The time has come to stop and think about where we want to go. More unity would require a cultural shift, excellent skills in following others, trust and willingness to compromise — not just from our leaders, but from all of us.
This article was originally published in Australian Doctor Magazine.
Many people are still getting over the disappointment of Medicare Locals. I get that. Although some MLs were able to make a difference, too many were not. The new Primary Health Networks (PHNs) may be a different kettle of fish. One thing is for sure: they are here for the long haul.
There is an enormous opportunity for PHNs to add value where they support quality primary healthcare services to the community. For that reason the RACGP is keen to work with the new organisations. I believe there are at least three areas where grassroots support from local PHNs can make a big difference.
The first area is relationship building and teamwork. We all know there are too many silos and tribes in healthcare. On the other hand, long-term relationships positively influence knowledge exchange, understanding and trust.
Where possible, health providers should be freed up to have the option to discuss clinical care with each other. This is important all for health professionals, and even more so for those working in rural and remote areas.
We should ensure that non-clinicians do not get in the way of effective inter-collegial communication. For example, referral letters have to contain the necessary information to allow the next health provider to do their job properly, but we must avoid overly bureaucratic referral rules. A clinical override mechanism of these rules must always be available.
PHNs could assist, for example, with developing shared clinical priorities and organising site visits, breakfasts, lunches, dinners and conferences that cross disciplinary and organisational boundaries.
Continuity of care
The second area is improving continuity of care. This is not a catchphrase, but a crucial element of general practice with numerous proven long-term health benefits. Unfortunately it seems this principle is often sacrificed in new initiatives and models for the sake of short-term results, convenience or commercial interests.
It is helpful to distinguish the three types of continuity of care, as explained by Haggerty et al: informational continuity (sharing data), management continuity (sharing a consistent approach) and relational continuity (fostering an ongoing therapeutic relationship).
Electronic health records will assist with informational continuity, but not necessarily with management continuity and relational continuity.
“New models of care should not further fragment care
There is ample evidence that comprehensive, continuous care by GPs results in improved patient health outcomes and satisfaction. Continuity of care is cost-effective and reduces both elective and emergency hospital admissions.
GPs play a key role in keeping people out of hospital. It is important however that hospital avoidance projects help to build capacity, facilitate access in primary care and respect the principle of continuity of care.
New integrated models of care should carefully be evaluated to make sure they don’t do the opposite and fragment care thereby negatively impacting on health outcomes – often with the best intentions. PHNs can play a big role here.
Data exchange and communication
A third area where PHNs should assist general practice is electronic data exchange and communication. Because of its central position in primary care, general practice is the natural collection point of clinical information. Direct, secure, electronic communication between GPs, specialists, community pharmacists and allied health providers is beneficial for optimal patient care, but remains problematic in many regions.
“Delayed information from hospitals is still one of the biggest problems
Delayed or absent correspondence from hospitals to referring doctors is still one of the biggest problems for GPs who are frequently trying to deal with returning patients without any information from the hospital.
All necessary information should be supplied in hospital discharge summaries, and it should not be left to the GP or practice staff to chase up any information from the hospital.
General practitioners need to ensure their referrals are of sufficient quality, consistent with RACGP standards, and useful for practitioners who continue the patient care in different settings of the health system. That means the referral information must be complete, accurate and timely.
Hospital referral criteria may require additional, locally agreed-on information, but extensive extra information (such as patient questionnaires) is the responsibility of the requesting institutions, and GPs should not be made responsible for its collection and supply.
There is room for improvement of communication between GPs. Getting the different healthcare computer systems to talk to each other is a big issue in many parts of the country. This is problematic as Australia has a mobile population. Low-cost software solutions such as GP2GP, used in New Zealand and the UK, could solve this.
The MyHealthRecord (formerly PCEHR) is, due to its many technical and medicolegal issues, not yet widely accepted as a reliable clinical tool and we see more alternative, locally developed e-health solutions in the near future.
In conclusion there are substantial opportunities for PHNs in supporting and adequately resourcing general practice and its interactions with other parts of the health system. To quote the National Health and Hospitals Reform Commission (NHHRC): “We believe that strengthened primary health care services in the community, building on the vital role of general practice, should be the ‘first contact’ for providing care for most health needs of Australian people.”
This article was originally published in The Medical Republic.
Historically, campaigns against bad government health policies have been predominantly doctor-centric. And the usual government response is to divide doctors and patient organisations.
Many politicians have mastered playing the ‘greedy doctor’ card, which is an effective way of making doctors’ objections seem less trustworthy.
A while back, I interviewed the influential patient advocate Jen Morris for my blog. Ms Morris is a researcher in healthcare quality and safety at the University of Melbourne.
We spoke about the untapped power of the patient–doctor alliance. She strongly feels that we can achieve so much more in Canberra if patients and doctors joined forces more often.
“At a strategic level, it’s a numbers game,” she said. “There are approximately 26,000 GPs in Australia, and about 82,000 registered medical practitioners. But there are over 23 million patients. That is an enormous bloc of voters and lobbyists to leave untapped.”
The RACGP’s ‘You’ve been targeted’ campaign earlier this year against the co-pay plan was an example of what happens if patients stand united with GPs to protect primary care. The Consumers Health Forum of Australia (CHF) issued a joint press release with the RACGP and the Australasian College for Emergency Medicine to reject the co-payment scheme. The RACGP’s change.org online petition had obtained 44,800 signatures within a week.
Other organisations including the AMA followed suit. The broad approach seemed to have an impact, first in the media and eventually in the corridors of power, and GP co-payment and extended level A consultations were dropped.
More recently, the RACGP, the Royal Australasian College of Physicians, and the CHF partnered in a joint submission to the Federal Health Minister regarding the deregulation of pharmacy locations and ownership.
Although these are great developments, there are also concerns. What if our goals are in opposition?
Take for example the PCEHR. Patient organisations want full control of the data, which makes it less useful as a clinical tool for doctors.
Understandably, there is scepticism from both sides. Patient organisations may be wary of working with powerful medical organisations setting the agenda. Patients may feel that doctors are not genuinely interested in their opinions. Doctors on the other hand may be concerned about increasing demands and consumerism.
Morris: “It is important to remember that disagreement doesn’t only pose an obstacle in ‘patients and providers’ scenarios. Neither patients nor providers are homogeneous groups, and we do well to remember that. It is worth asking how providers approach the problem when they disagree on an issue or project, and source lessons from that.”
So, the answer lies in building trusting relationships. GPs are good at this on an individual level. It is one of the strengths of general practice. We should be doing the same at an organisational level. Working closely with patient organisations will improve the mutual understanding of our values and beliefs.
According to Ms Morris, we should be looking for common ground. More often than we acknowledge, patients and doctors are really advocating for the same outcomes. But too often, she added, we don’t take the time to really analyse where the crux of disagreement actually lies. Morris: “(…) if we find that the aims of doctors and patient organisations are so distinct as to be deemed incompatible, we should be re-evaluating those aims urgently.”
‘Them and us’
Of course, the ‘them and us’ thinking also occurs between providers. This can be confusing for patients and third parties including government organisations. For that reason, I’m a great believer in the power of United General Practice Australia. It is made up of the main GP groups, including the colleges, the rural groups, the AMA, registrars and supervisors and the divisions network. These organisations have shown a desire to collaborate and put aside their differences.
A similar structural working relationship should be developed between doctors and patient organisations. This alliance should exist not just to respond to new developments, but also to proactively set out a future course and lobby governments accordingly. It would make primary care less vulnerable to the rapidly changing preferences and priorities of the government of the day.
It is good to see the willingness from both sides to work together, and I hope it is the beginning of a fruitful collaboration in years to come. We must harness the potential power of the patient–doctor alliance to protect what’s good and, where needed, improve the care for our patients.
This article was originally published in Australian Doctor Magazine.
As frequent readers of this blog may know, I am very unimpressed with the recent pharmacy agreement negotiated by the Pharmacy Guild of Australia. We need more teamwork and integration of health services, not fragmentation, and therefore it’s a real shame the Health Minister has signed off on this deal with the pharmacy owners union.
A better proposal has come from the Pharmaceutical Society of Australia (PSA) and the Australian Medical Association. For those who don’t know: The PSA represents Australia’s 28,000 pharmacists working in all sectors and across all locations. The new model encourages close collaboration between pharmacists and GPs.
The PSA and AMA recommend integration of non-dispensing pharmacists in general practice, to improve medication management. The idea is not new. Doctors and pharmacists have argued for this model in the past. There is enough evidence to support collaboration as a way to improve patient care.
Here are the aims of the cooperative model:
Medication management reviews conducted in the practice, an Aboriginal Health Service, the home or a Residential Aged Care Facility
Patient medication advice to facilitate increased medication compliance and medication optimisation
Supporting GP prescribing
Liaising with outreach services and hospitals when patients with complex medication regimes are discharged from hospital
Updating GPs on new drugs
Quality or medication safety audits
Developing and managing drug safety monitoring systems.
Medication reviews by a pharmacists in the hospital do not appear to reduce mortality or hospital readmissions, although they seem to reduce emergency department contacts. Similarly, medication reviews for nursing home residents do not to reduce mortality or hospitalisation – which is disappointing.
However, in these studies pharmacists and doctors are not working closely together as suggested by the PSA and AMA. This matters because studies have shown that doctors are more likely to change their medication management when there is a close collaboration with a pharmacist. This is not surprising as the basic requirements for effective teams are mutual trust, good communication and shared ideas.
A systematic review of pharmacists working in collaboration with GPs showed significant improvements in blood pressure, diabetes control, cholesterol levels and cardiovascular risk. Another review suggested similar benefits as well as a positive impact on drug-related problems.
A recent trial confirmed that pharmacists working in primary health clinics are succesful in identifying and resolving medication related problems and improving medication adherance. The PINCER trial concluded that pharmacist feedback, educational outreach and dedicated support in a general practice setting was cost-effective and reduced medication errors.
Whether the pharmacist-doctor partnership reduces hospital admissions is less clear-cut. An independent analysis by Deloitte Access Economics (commissioned by the AMA) suggests that every $1 invested in the PSA-AMA model would generate $1.56 in savings to the health system, delivering a net saving of $544.8 million over four years.
I spoke to Dr Steve Wilson, Chairman of the AMA (WA) Council of General Practice and senior Lecturer at the School of Medicine, University of Notre Dame.
“We recognised the need for, and the advantage of, having pharmacists within the practice team,” says Wilson. “We have looked at both sides of the coin, the good and the bad, advantages and risks. We have explored the various financial models, for example whether pharmacists should be employed directly, or contracted, and whether to follow the Practice Nurse incentive Payment model or the Mental Health Nurse model.”
Dr Wilson said the strengths of the proposal are:
Quality use of medications as over-arching principle
In-house reviews as opposed to out-of-house
Medication interaction checking
Reviewing the currency of medications, for example deleting old antibiotics still on the list
Screening for adverse medication events or omissions such as whether medications can be reduced or stopped, or whether certain checks have been performed
Checking currency of tests, for example renal function for those on diuretics
Explaining medications to people, for example what side effects to look for
Working with those from culturally and linguistically diverse people or a non-English speaking background, people more than five medications, people with early cognitive impairment etc
Quality Use of Medications meetings within the practice, attracting CPD points
The Pharmacist in General Practice Incentive (PIGPI) system would be structured in the same way as the existing incentive payments provided for nurses working in general practice.
Dr Wilson: “The risk of the program is low, it’s voluntary, doctors and patients don’t have to participate. It’s up to the GP practice to make it work and customise it to their circumstances. There are financial incentives for rural practices. Also practices can share a pharmacist, particularly when closely located to one another.”
“The evidence will build over time. The evaluation component will require input from hospitals and there may be a role for the Primary Health Networks and Local Hospital Networks.”
The proposal has been welcomed by the Consumers Health Forum (they’re requesting feedback here). Although there are clear benefits for patients, evidence-based medicine purists may argue that the evidence for cost-savings through a cooperative model is thin. However, the alternative may be no change at all.
Pharmacies will be handed $1.26 billion for delivering healthcare services. Good for them. But meanwhile the government is not prepared to increase the Medicare rebates patients receive when they see a doctor.
As a result of the new health policies, visits to the doctor will become more expensive in the years to come, whereas pharmacies will be paid more to deal with health problems. With this move Health Minister Susan Ley seems to make a clear statement: Don’t go to your doctor, see the pharmacist instead.
A vague agreement
It could be me but I’m not entirely sure what the Health Minister will sign off on – it’s all still a bit vague:
The Pharmacy Guild says on its website: “The Government has committed to $50 million over the Agreement for a Pharmacy Trial Program to trial new and expanded community pharmacy programs which seek to improve clinical outcomes for consumers and extend the role of pharmacists in the delivery of healthcare services through community pharmacy.”
National President of the Pharmaceutical Society of Australia Grant Kardachi says: “PSA particularly welcomes the doubling in this agreement to $1.26 billion of funding for the provision of patient-focussed professional services.”
According to Australian Doctor magazine, “some $600 million will be spent on ‘new and expanded’ services, but there is no detail on what services this will cover.”
One thing is certain: Pharmacies are going to deliver more healthcare services – and at the same time the freeze on indexation of the Medicare rebates comes at a cost for patients.
Here re my questions:
Is Minister Ley’s decision helping to improve teamwork within primary care, or is it creating more confusion and frustration for patients and their doctors?
Can pharmacists and their assistants offer the same quality healthcare as doctors and practice nurses?
Can the person who is selling the drugs give independent health advice?
Why not spend part of the money on increasing the rebate patients get back from Medicare after visiting their doctor?
Why not spend part of the money on improving access to practice nurses and GPs?
Does this mean that doctors will miss opportunities to pick up on health problems, because patients will see the pharmacy assistant instead?
When the Pharmacy Guild talks about ‘evidence-based’ services, what do they mean? (given the fact that many community pharmacies also sell unproven remedies and products).
Traditionally campaigns against poorly thought-out Government policies have predominantly been doctor-centric, and the usual Government response is to divide consumer and medical organisations.
Jen Morris is a patient advocate and researcher in healthcare quality and safety at the University of Melbourne. She feels strongly that cooperation is required if we want to make more impact in Canberra.
This makes sense. It looks like the time is right for a novel approach – and it is much needed too, as the discussion about healthcare so far has been about dollars instead of quality. What are the benefits of a patient-doctor alliance and how do we overcome our differences?
The numbers game
“At a strategic level, it’s a numbers game,” says Jen Morris. “There are approximately 26,000 GPs in Australia, and about 82,000 registered medical practitioners. But there are over 23 million patients. That is an enormous bloc of voters and lobbyists to leave untapped.”
“When campaigns are too doctor-centric, that leaves this bloc ‘in play’ – sparking a spin and PR war between doctors and the government, vying for public support. But if doctors and patients can capitalise on common ground and present a united front from the outset, the weight of political force will rest with us.”
“More importantly, putting patients and their care at the centre of pro-healthcare campaigning recognises healthcare exists wholly for, and because of, patients. Sometimes, public debates amplify some of the worst features of traditional hierarchies in clinical healthcare. Authority figures argue over who knows what’s better for patients, and best represents their interests.”
“All the while, patients pushed to the sidelines quietly await a chance to speak for themselves. If we’re serious about changing the culture of paternalism in healthcare, and empowering patients, that change in approach needs to permeate right through from the consulting room to the campaign platform. ”
What if we disagree?
There may be topics where patients and health providers don’t agree, such as certain aspects about the PCEHR. This can really paralyse a project. How should we approach this?
Morris: “It is important to remember that disagreement doesn’t only pose an obstacle in ‘patients and providers’ scenarios. Neither patients nor providers are homogeneous groups, and we do well to remember that. It is worth asking how providers approach the problem when they disagree on an issue or project, and source lessons from that.”
“It’s worthwhile looking for points of common ground, and building upon those
“The possibility that some parties may disagree is not, for example, a reason to exclude likely dissenting practitioners from a committee of doctors. In the same way, it is not a reason to exclude patients from healthcare policy discussions. Moreover, the fact that patients and providers may not always agree is not a reason to close our minds to collaborating when we do.”
“We should approach such disagreement on policy and projects the way we should in any sector. That is, give relevant stakeholders of all perspectives a fair opportunity to be heard. And, where possible, try not to speak for others in lieu of them speaking for themselves first.”
“It’s worthwhile looking for points of common ground, and building upon those. More often than we acknowledge, patients and doctors are really advocating for the same outcomes. But too often we don’t take the time to really analyse where the crux of disagreement actually lies.”
“So it’s worth trying to identify when disagreement is about what the end goal should be, and when it’s about how we should best get there. That helps to clarify how the points of difference, and points to potential solutions.”
“In cases where viewpoints really do differ substantially, all parties should have the opportunity to make a case for their proposal, then let the policy and law makers evaluate those on their merits.”
Is there a will to cooperate?
Morris: “Because I don’t work for or represent a consumer organisation, I can’t speak for them with any authority. However, I will say that in my experience, there is reflexive and entrenched suspicion on both sides.”
“If we find that the aims of doctors’ and patients’ organisations are so distinct as to be deemed incompatible, we should be re-evaluating those aims urgently
“Patient organisations are concerned about being seen to endorse a situation in which doctors’ organisations dominate and speak ‘on behalf of’ patients. Because such situations hark back to unhelpful, dictatorial hierarchies which have traditionally silenced the patient voice.”
“On the other hand, doctors’ organisations have expressed concern that patients do not understand the complexities of health policy and systems, the challenges faced by practitioners, and the broader potential consequences of proposals.”
“But in my experience, if and where these issues exist, it is in working together that parties learn from each about about how they can all do better. And the result is stronger organisations, and a more robust campaign.”
“It is healthy for organisations to remain vigilant about being faithful to their purpose and mandates. However, if we find that the aims of doctors and patient organisations are so distinct as to be deemed incompatible, we should be re-evaluating those aims urgently.”
“As a patient advocate, I would be delighted to have the opportunity to campaign alongside doctors and their organisations when appropriate. And indeed, on several issues I have done just that.”
“I have the privilege of working alongside many doctors in my role, who have taught me a great deal about the everyday realities of being a doctor. And I am a better advocate as a result. I hope that working with patients and advocate affords doctors similar insights.”
So there is a budget crisis. There’s also a new federal Health Minister. And, here it comes, community pharmacies are negotiating over a billion-dollar deal with the Government: The Community Pharmacy Agreement sets out the Government funding pharmacists receive for dispensing PBS medicines.
If it’s up to the Pharmacy Guild, pharmacists will be:
Filling repeat prescriptions to ‘free up doctors time’
Treating ‘easy’ minor ailments
Giving more vaccinations (e.g. a flu-shot for $25 with no Medicare rebate)
Doing ‘easy’ health checks, screening and preventive health services
Giving mental health support.
At first glance this improves access to health services and saves tax payers bucket loads of health dollars. Here are 5 reasons why role and task substitution by pharmacists needs more thought:
#1: Avoiding the doctor is probably not going to help
A repeat prescription or a vaccination is a valuable opportunity for a family doctor to screen for, and treat health issues before they escalate. This is one of the strengths of general practice. If people don’t come in because they get their cholesterol or blood pressure scripts from the pharmacist every 6 months, this system will come at a cost.
#2: We are treating people (not ailments)
People are more than the sum of their ailments. Over the years there have been many attempts to replace the doctor with algorithms, machines and computers, and they have all failed.
The human body and mind are complicated. As they say, if you think a professional is expensive, wait until you hire an amateur.
#3: Don’t put the cart before the horse
If it’s improved access or multi-disciplinary care we’re after, then strengthen general practice. Unfortunately the opposite is happening: Practice nurse support has been cancelled, and I won’t mention the Medicare rebate cuts and freeze.
#4: Disruption is not innovation
A common mistake is to assume that disruption is the same as innovation. Disruptive services – like those suggested by community pharmacists – may be simple or convenient, but the quality will be poorer.
A recent study showed that only 3 out of 32 fish oil supplements contain what the label says; I believe pharmacies should focus on evidence-based medication advice and quality control of over-the-counter drugs.
#5: Conflicts of interest
A question we should ask is: Can the person who is selling the drugs give independent health advice? Pharmacies face reduced profits because the Government has set lower prices for generic medications under the price disclosure arrangements.
Although it is understandable pharmacies are looking for other income streams, it is unlikely that the proposal by the Pharmacist Guild is a win-win solution. There is value in team work, but only if we work genuinly together.
Five doctors went duck hunting one day. Included in the group were a general practitioner, a paediatrician, a psychiatrist, a surgeon and a pathologist.
After a time, a bird came winging overhead. The first to react was the GP who raised his shotgun, but then hesitated. “I’m not quite sure it’s a duck,” he said, “I think that I will have to get a second opinion.” And of course by that time, the bird was long gone.
Another bird appeared in the sky thereafter. This time, the paediatrician drew a bead on it. He too, however, was unsure if it was really a duck in his sights and besides, it might have babies. “I’ll have to do some more investigations,” he muttered, as the creature made good its escape.
Next to spy a bird flying was the sharp-eyed psychiatrist. Shotgun shouldered, he was more certain of his intended prey’s identity. “Now, I know it’s a duck, but does it know it’s a duck?” The fortunate bird disappeared while the fellow wrestled with this dilemma.
Finally, a fourth fowl sped past and this time the surgeon’s weapon pointed skywards. BOOM!!
The surgeon lowered his smoking gun and turned nonchalantly to the pathologist beside him and said: “Go see if that was a duck, will you?”
What’s great about this joke is not just the stereotype behaviour of the five doctors – which most people working in healthcare immediately will recognise. What is wonderful here, is the different disciplines doing some team building. They may not be very efficient as a team yet, and they could have picked a different activity, but at least they have found a common goal: hunting.
In the real world of medicine we sometimes seem to have forgotten our purpose. The inconvenient truth is that we’re often acting as a dysfunctional team where every member’s main goal is to finish their own little task, and where other team members and disciplines are sometimes regarded as ‘the enemy’.
A while back I was privileged to hear Dr Victoria Brazil speak at a conference of the Royal Australian College of General Practitioners in Brisbane. Dr Brazil is an emergency physician and passionate about the topic of medical tribalism. Instead of the more primitive tribal behaviour – characterised by hostility towards other tribes and the unwillingness to take responsibility for a bigger cause – we should move to a kinder tribalism driven by mission and purpose, without common enemies, she argues.
Dr Brazil reminds us that we cannot achieve the best patient outcome without other disciplines. Building relationships, communicating and networking are the key to success. This sounds obvious but it’s not very often that we make time to sit down and have a yarn with members of other teams.
You don’t have to go duck hunting together, but next time you talk to someone belonging to a different tribe, maybe just introduce yourself and ask how they’re going.
If you would like to know more about this fascinating topic: In the video below Dr Brazil, who is also a gifted speaker, addresses a room full of medical tribes (but with a common interest in emergency medicine). She explains how we can overcome the dark side of medical tribalism. Enjoy.
Teamwork is essential in healthcare. Yet, too often, we act as individuals looking after our own interests. Solving problems together, even if the objectives seem opposed, is beneficial for all parties for many reasons.
Stephen Covey introduced the principle of win-win in his book the Seven habits of highly effective people. It’s still a great principle for conflict resolution, incl in teams, groups, organisations etc. Covey:
Win-win sees life as a cooperative arena, not a competitive one. Win-win is a frame of mind and heart that constantly seeks mutual benefit in all human interactions. Win-win means agreements or solutions are mutually beneficial and satisfying. We both get to eat the pie, and it tastes pretty darn good!
A win-loose outcome is bad for all parties. Even though the winner may feel triumphant, the loser may not want to deal with the winner ever again.
So what’s required for a win-win result? First of all it requires an open mind. Black & white or good & bad thinking is not helpful and often not realistic either. Secondly, understanding the other party is crucial: Where do they stand? What is important for them? Where is the common ground? And finally: flexibility, as there are always more solutions to a problem.
Win-win is not about being nice, as Covey said. It’s about being courageous and considerate at the same time.