Everybody has an opinion about their GP

Do you know that situation – usually at a party – when someone tells you what they do for a living, and mention a cool sounding job description like ‘product innovation manager’ or ‘advertising account executive’? I always want to know: what does that mean and what do you actually do?

Well, people never ask me what I do when I say I’m a GP. Instead, they usually tell me what their GP does. Or did. Or said.

Everybody always knows what I do, and that’s not surprising because the Australian general practice statistics are mind-blowing: Over 134 million GP consultations take place each year. Every year almost 9 out of 10 Australians make at least one contact with a general practitioner.

Professor Max Kamien said in the latest BEACH study:

“Mothers, children, the elderly and those with chronic conditions, such as diabetes, asthma and hypertension, have many more contacts than that. As a result of these personal contacts everyone has a view about general practice. Ministers of Health have been known to base their views about general practice on their contact with their own GP.

I’m privileged to have a job that’s smack-bang in the middle of life. One could indeed argue that we’re specialists in life, as we deal with just about everything: mental health, paediatrics, cancer, skin disorders, respiratory problems, grief, heart failure, domestic violence, emergencies, pregnancy, end-of-life care, immunisations, screening… you name it.

The latests RACGP commercial tells the story of diversity – the diversity of GPs, their patients and their conditions. I love the commercial because it captures in 60 seconds the wide range of issues people bring to the consulting room of the family doctor.

So if you want to find out what really happens in my office, have a look at this video.

The family doctor – old-fashioned or the key to a healthy future? (Part 2)

Is the family doctor who provides ongoing care a thing of the past? Not really.

In part 1 I mentioned the three types of continuity of care: informational, management and relational continuity. Continuity in primary care results in improved patient health outcomes and satisfaction. Evidence also shows that primary care, in contrast to specialty care, is associated with a more equitable distribution of health.

Receiving care from one general practitioner is beneficial for a variety of health outcomes. For example, relational continuity reduces both elective and emergency admissions. In other words, the rate of hospital admissions drops when people have their own GP.

6 mechanisms that improve our health

Primary care researcher Barbara Starfield identified six mechanisms that, alone and in combination, may account for the beneficial impact of primary care on population health:

  1. Primary care increases access to health services for relatively deprived population groups
  2. The quality of clinical care by primary care physicians is at least similar to specialist care for specific common diseases
  3. The positive impact of primary care on prevention
  4. The beneficial impact of primary care on the early management of health problems
  5. The accumulated contribution of primary care characteristics to whole-of-person care
  6. The role of primary care in reducing unnecessary or inappropriate specialty care.
Barbara Starfield
Barbara Starfield: “(…) good primary care is associated with better health outcomes, lower costs, and greater equity in health.” Source: Wonca

Starfield: “There is now good evidence, from a variety of studies at national, state, regional, local, and individual levels that good primary care is associated with better health outcomes (on average), lower costs (robustly and consistently), and greater equity in health.”

General practice can deliver long-term, cost-effective continuity of care. A visit to the GP is on average ten times cheaper than a visit to the emergency department. Dr Sebastian Seidel mentioned at a Senate Inquiry last month that GP services in Australia cost taxpayers only $250 per person a year – cheaper than car insurance.

In Australasia, chronic conditions account for about 85% of the total burden of disease, and in 9 out of 10 deaths a chronic disease was a contributing factor.

Unfortunately there is currently inadequate support for the continuity of care required to improve outcomes for patients with complex or multiple chronic conditions and comorbidities.

The Australian government is developing a National Strategic Framework for Chronic Conditions and recently, the Primary Health Care Advisory Group has investigated options into the reform of primary health care to support patients with complex and chronic illnesses. The group’s reform paper is complete and handed to the Federal Health Minister. It will be very interesting to see what happens next.

Conclusion

Although I am more than likely biased, it is obvious to me that primary care has a lot to offer. Continuity of care by general practitioners and their teams has many proven benefits as outlined in part 1 and part 2 of this blog post series.

GPs see about 85% of Australians each year but general practice spending represents less than 8% of the overall government healthcare budget. What we need is better aligned funding that supports primary care practitioners to deliver long-term quality care.

A sustainable health system should free up GP teams and other health practitioners to deliver coordination and integration of care across disciplines, especially for people living with complex and chronic health conditions. Looking at the reform processes that are under way in Australia, we may be getting closer to a better and more sustainable solution.

The family doctor – old-fashioned or the key to a healthy future? (Part 1)

A few years ago, when I was boarding a plane I picked up The Times newspaper and noticed a big headline stating: ‘The family doctor is going out of fashion’. In the article journalist Matthew Parris explained why young people prefer to go to the emergency department. I kept the article as I thought it would be a great blog topic, but for some reason I forgot about it – until something jolted my memory.

Last month I had the pleasure of meeting with the Board of Health Consumers Queensland. I enjoy conversations with consumer representatives as I always learn something, even though these exchanges are usually slightly confronting. One of the topics we touched on was continuity of care, or better, the perceived lack thereof in general practice by consumers. During the drive back home to the Sunshine Coast I suddenly remembered the article in The Times.

In 2013 Parris wrote: “Very gradually the era of the personal physician is drawing to a close.” He said he noticed a trend in the UK where younger, busier people were going directly to specialist accident & emergency departments and argued that they don’t want a local GP because working men and women in a hurry will be attracted to a place where they can walk from one room to another and access the specialism they need.

So, I wondered, is the family doctor who provides ongoing care a thing of the past? Am I really a dying breed – the last of the Mohicans?

What exactly is continuity of care?

In primary care literature continuity is often described as the relationship between a single practitioner and a patient that extends beyond specific episodes of illness or disease. To confuse the situation other terms are used synonymously, such as ‘care coordination’, ‘integration’, ‘care planning’, ‘case management’ and ‘discharge planning’. On top of that the experience of continuity may be different for the patient and the health practitioner, adding to even more misunderstandings.

Continuity is how individual patients experience integration and coordination of care.

The authors of an article in the BMJ titled ‘Continuity of care: a multidisciplinary review’ said that continuity is not an attribute of practitioners or organisations. They defined continuity as the way in which individual patients experience integration of services and coordination. And also: “In family medicine, continuity is different from coordination of care, although better coordination follows from continuity. By contrast, a trade-off is required between accessibility of healthcare providers and continuity.”

There are three types of continuity of care:

  1. Informational continuity: The use of information on past events and personal circumstances to make current care appropriate for each individual
  2. Management continuity: A consistent and coherent approach to the management of a health condition that is responsive to a patient’s changing needs
  3. Relational continuity: An ongoing therapeutic relationship between a patient and one or more providers.

Continuity is more than just sending a message to another health practitioner, or uploading a piece of information to an e-health database. Understanding of individual patients’ preferences, values, background and circumstances cannot always be captured in health records; health providers who have a longstanding relationship with their patients often have this information in their heads.

“Poor continuity gives rise to high risk medicine

In 2010 Dr Frank Jones wrote in Medicus: “Poor continuity gives rise to high risk medicine. Ideally continuity should be personal and longitudinal – the essence of the traditional general practitioner. However the very concept of continuity gets more complicated nowadays. How does it apply to single-handed GPs or to group practices?”

Indeed, continuity of care exceeds disciplinary and organisational boundaries. The Royal Australian College of General Practitioners describes continuity of care as “the situation where patients experience an episode of care as complete, or consistent, or seamless even if it is provided in a number of different consultations by different providers.”

The benefits of continuity

There is abundant evidence that continuity in primary care results in improved patient health outcomes and satisfaction. Evidence also indicates that primary care (in contrast to specialty care) is associated with a more equitable distribution of health.

GPs often manage up to 4 problems per visit, which is of course more efficient than walking ‘from one room to another’ in an emergency department or hospital outpatient department. Overall, primary care is associated with lower total costs of health services.

Looking at the primary care reform processes that are under way in Australia, it is not unlikely that the multidisciplinary general practice team will be the key component in the care for people with chronic and complex health conditions.

In part 2 I will discuss the six methods GPs use to improve our health, according to world-renowned primary care researcher Professor Barbara Starfield, and why primary care plays an important role in a sustainable health system.

Image sources: The Family Doctor in 1948, Nedhardy.com and The Times.

Is family medicine going out of fashion?

The video that made doctors cry

The first video of a national awareness campaign by the Royal Australian College of General Practitioners (RACGP) highlighting the value of general practice, has brought tears to the eyes of many GPs.

The clip starts in the seventies, when home pregnancy tests were not widely available. The young, fresh GP is visibly happy to bring the good news to a couple in his consulting room (“You have a baby on the way”). There is no computer in the room, lots of paperwork on the doctor’s desk, and we see furniture and filing cabinets from times gone by.

As we follow the couple and the doctor over the years, the consulting room changes too. If you look closely (admittedly this may be of interest to medicos only) you will see a beautiful old mercury sphygmomanometer on the trolley. Computers begin to appear on the desk. Time flies in the video; in a matter of seconds the GP and his patients age and new family members enter the consulting room.

The lifelong journey

Towards the end one of the children has become a mother. The GP, now with grey hair, says to her “we have quite the journey ahead of us,” as he gets up from his chair with the visible difficulty of an older man.

Indeed, sharing the journey through life is one of the aspects that sets the GP apart from other disciplines. And just like in the video we’re there for the minor ailments – the nits – as well as the big and often emotional life events, such as a cancer diagnosis or the death of a spouse. I think the video brings this message across very well and that may be why it triggers an emotional response.

But the video also contains another message. Observant viewers will have noticed that the GP has two framed certificates hanging on the wall at the beginning of the clip and, as time moves on, more certificates follow.

The importance of education and learning gained through fellowship of the RACGP is a key message of the campaign. A voiceover at the end tells us: “The good GP is with the Royal Australian College of General Practitioners, because the good GP never stops learning.”

Criticism

There is of course, as always, criticism. Some have commented that telling patients they have to do something may not be the most effective way to encourage change – like smoking cessation. Good GPs have a conversation with their patients. Others have mentioned the video doesn’t reflect our multicultural society or the gender diversity in medicine.

Fellows of the Australian College of Rural and Remote Medicine (ACRRM) may rightly say that they too are good GPs. And lastly, there seems to be a disconnect between the clip and the message about lifelong-learning at the end. It may be easier to brand general practice than a GP college.

I believe some of the criticism will be addressed in future campaign material – but it is also good not to lose sight of the bigger picture. The campaign aims to improve the recognition of GPs and general practice. If it’s as successful as the RACGP’s You’ve been targeted campaign, the promotion of general practice will benefit all those working in primary care, and more importantly, our patients.

Strong general practice

Personally I hope the campaign opens the eyes of some politicians. Australians rate their doctors in the top-3 of most honest and trusted professions and they visit the GP on average 5-6 times per year. GPs are good value when it comes to spending tax payers money: The average GP consultation costs $50, compared to for example $400-600 per service in a hospital emergency department.

It is a good idea to reduce waste and duplication in healthcare, but poorly targeted cuts and freezes will do more harm than good to the health of Australians. We must also reduce the amount of red tape and stay away from more bureaucracy, like NHS-style revalidation – so doctors can look after their patients instead.

The success of a campaign depends on the people who support it. In a video message directed at doctors RACGP president Dr Frank Jones said: “Talk to your patients and key people in your community about the importance of general practice. Our training and the accreditation standards are why the good GP never stops learning.”

The video touched the hearts of many GPs, but in the end it’s the impact on patients that matters most. I hope its positivity will be contagious.

Everything you always wanted to know about bulk billing (Video)

My patients often ask: “Doctor, do you  bulk bill?” and “Why do I have to pay a gap?”

Although there are certainly circumstances where I bulk bill, it has many risks. Lowering the quality of Australian Family Doctor services is one them. In this video I have tried to explain how it all works.

Doctor do you bulk bill?

Since 1984 Medicare is the health insurance scheme from the Commonwealth Government, providing free treatment in public hospitals and subsidised treatment for other crucial health services such as the care by GP’s.

Medicare has set a list of fees it is willing to pay for medical services. The fees in the Medicare Benefit Schedule are not recommended fees, but merely what Medicare is prepared to contribute to a consultation or operation.

Unfortunately, as the picture below illustrates, the Medicare fees have not kept up with inflation and costs. While the cost of running a GP practice is going up every year (the upper line in the picture), Medicare has only slightly increased their fees over the years (the lower line in the picture).

Bulk billing
The fees doctors charge are set at a level that enables them to look after patients properly. The cost of providing good medical care is rising (the upper line) but the Medicare fees are falling behind (the lower line). That is why you may find your doctor’s practice does not bulk bill as a rule. AWE: average weekly earnings. CPI: consumer price index. Source: Australian Medical Association.

The Government entirely funds public hospitals, but not GP practices. As a result, GP’s who own their practices need to cover the costs of running a business – just like electricians and hairdressers. Costs include for example paying rent, wages of receptionists, nurses and trainee doctors, and medical equipment.

GP’s who follow the Medicare fees are effectively taking a pay cut every year (the shaded area between the upper and lower line in the picture is getting bigger each year). Eventually GP’s would not be able to invest in their businesses, pay their staff and provide good care to their patients. This is the reason many GP’s charge more than the Medicare fees, and why the gap between the doctors’ fee and the rebate you get back from Medicare continues to rise.

Many doctors follow the list of suggested fees by the Australian Medical Association. Unlike the Medicare Benefit Schedule, this list has been updated annually to keep up with inflation and the costs of running a practice.

Bulk billing is where doctors accept the Medicare fee as payment of their services. But as said, these fees are decreasing in real terms each year. Bulk billing has a real risk that quality of care is affected. Asking a doctor to bulk bill has more consequences than people think. For that reason many GP’s are not bulk billing as a rule – although they can make exceptions based on circumstances such as financial hardship.