I don’t know how you make a living, doc

One of my patients often tells me that she used to say to my predecessor, “I don’t know how you make a living, doc, cause I’m never sick.”

Things changed when she was diagnosed with a TIA and we found an irregular heartbeat. She now often expresses her gratitude for the care available, close to home.

Like so often in life, we only value something when we perceive a need for it. Emeritus Professor Max Kamien recently reminded me of this when he quoted James Dickinson in a comment on this blog post.

Dickinson, a professor in family medicine, used to work in the Federal Department of Health. He said that health policy is devised by young, healthy, non-medical advisers who do not have a need for a personal GP and instead use impersonal walk-in practices.

They often regard these experiences as being substandard medical practice. As a result, he said, they do not understand the multiple tasks required for good quality general practice and do not perceive its relevance.

This could perhaps explain the incomprehensible decisions that often come out of the department, such as defunding ECGs in general practice (a test which was crucial in the diagnosis and management of my patient).

I sometimes wonder, is it worthwhile spending more time and effort on educating policy-makers in the department of health?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

This article was originally published in NewsGP.