It is time to leave the Machiavellian era of Australian healthcare behind

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.

Pushback

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?

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

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.

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.

The doctor will see you… never. Issues with online referral services.

There are many benefits of online health services and they can complement traditional face-to-face GP visits. But there are also examples that raise questions.

The young woman was in tears. When she came in she had initially asked for a referral to a surgeon for a breast augmentation. During the conversation it turned out that her partner had made it clear her breasts were too small.

We ended up having a chat about relationships and body image. At the end of the consultation she 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.

The problem with online referrals

At first sight, the Qoctor website seems an easy, convenient online medical service that provides sick certificates and referrals.

The site tells visitors: “(…) we understand that a well person who simply needs a letter to see a specialist should be able to get one without requiring a GP consultation.”

I’d like to challenge that. The woman in the example above was well but did she need a referral to undergo an expensive procedure that would change her body?

There are many issues with a system that allows access to specialist care without a review by a primary care doctor. Unnecessary referrals, increased costs and further pressure on the hospital system are just the beginning.

Once a visitor has selected a specialist the system asks a few simple questions about allergies and previous surgery and there are some boxes to tick (see image). I wonder how many people will just enter through to get to the section where you pay and automatically receive the referral letter (as pdf file).

How many people will just enter through to get to the section where you pay and receive the referral letter?

Good telehealth principles

Sometimes writing referrals is a straightforward process but often it is not. What is missing here are the safeguards with regards to other management options, coordination of care, the communication between the usual doctor and specialist, and follow-up. What about whole patient care?

Interestingly the service seems to assume that – after automatically cashing in the online referral fee – the patient’s usual GP will be responsible for the follow-up if required.

The Royal Australian College of General Practitioners (RACGP) has developed some common-sense principles for telehealth services, including on-demand online health services. These principles include the following:

  • On-demand telehealth services should preferably be provided by a patient’s usual GP or practice
  • On-demand telehealth services to unknown patients should only be provided when the patient’s usual practice cannot provide care for them, either in person (at the practice or by a home visit) or online, and no other general practices are physically accessible
  • Patient notes should always be sent to the patient’s usual GP or practice (with the patient’s permission). This ensures continuity of care and centralises patient records.

Commercially enticing 

I suspect that most people are aware of the risks of online health services and will consult their GP first. At the same time there will always be people who are attracted to these services because they are quick and easy. It is also commercially enticing: if you sign up for Qoctor you may win a $100 Coles Meyer gift card.

The patient testimonials on the website, which probably go against AHPRA’s advertising guidelines for regulated health services, seem positive. The question is usually: are these real testimonials?

As always with disruptive technologies there is the convenience aspect for consumers – but is bypassing the most efficient and cost-effective part of healthcare by printing out an online ticket to the expensive part in the best interest of Australians? I doubt it.

The (patient) case discussion in this blog post is fictional and based on similar consultations. Disclaimer and disclosure notice. Follow me on Twitter: @EdwinKruys.

Pharmacy vax claims need a pinch of salt

The success of new health services in community pharmacies should be measured by the way they integrate and communicate with the rest of primary care including general practice.

A trial in WA reported earlier this month that more than 15,000 influenza vaccinations were administered last year with no adverse effects. The Curtin University researchers declared the program a success, saying there was scope to expand pharmacist vaccination services to other vaccines and younger children.

Recently we’ve heard about the ‘success’ of pharmacy trials in several states. However, the question arises: by what measure are the trials a success?

Many of my patients tell me they’ve been vaccinated at a pharmacy but have forgotten where, when and with what exactly – and communication from the pharmacy is usually missing.

One of my frail elderly patients who came to see me for something else declined a government-funded influenza vaccination by our practice nurse because she was booked in to have a private vaccination at the pharmacy the following week, and felt she couldn’t cancel that appointment.

This goes against the argument that pharmacy vaccinations are only targeting people who don’t have a GP, or people who fall outside the national immunisation program.

Walk-in convenience at pharmacies is often mentioned as a benefit of the scheme, but the preferred model seems to be an appointment during specific pharmacy trading hours.

Narrow vision of health

Public health arguments, such as increased vaccination rates, are intuitively compelling; to a public health advocate, it doesn’t matter where vaccinations are delivered.

Most of these stand-alone models have failed to look at the impact on primary care as a whole

However, most of these stand-alone pharmacy models have failed to look at the impact on primary care as a whole, including general practice teams, at a time when primary care is supposed to be moving towards more integration and collaboration.

Other issues that have often been overlooked are clinical benefit to the public, costs to the patient and health system, and conflicts of interest within the pharmacy industry.

Data reported from Queensland immunisation trials, for example, were superficial, selective and showed elements of observer bias. The trials did not reveal evidence about the impact on vaccine-preventable disease outbreaks. There was no comparison with alternatives, such as walk-in vaccination clinics in general practice.

The impact of missed opportunities for screening and other preventive care in general practice was not looked at, and neither did the trials focus on much-needed better integration of care delivery.

Yet, there is ample evidence that increasing general practice comprehensiveness of care is associated with decreasing costs and hospitalisations. Each time a task is given to other providers, the effectiveness and safety of our current proven GP-model is eroded, and this will ultimately have consequences for the care delivered to Australian communities.

Communication, upselling and out-of-pocket costs

The trials also failed to look at whether the standard elements of privacy, documentation or GP notification were met.

Furthermore, there has been no mention of whether commercial practices have been monitored, such as using vaccinations as a means to onsell other products. There is a well-known potential conflict of interest in pharmacists delivering health services including vaccinations.

Australians already pay more out-of-pocket costs than in many other countries

One of the strengths of medication prescribing in Australia is the high degree of separation between the prescriber and the medication dispenser. It enables more objective prescribing, free of pecuniary interests and leads to better allocation of resources. This is another strong argument against moving more health services into the pharmacy environment.

However, it seems that the goal posts are shifting.

Australians already pay more out-of-pocket costs than in many other countries. It is likely that health services delivered in the commercial pharmacy environment will further increase costs to patients. For example, administration of the quadrivalent influenza vaccine by WA pharmacists came at a cost of $30-$40.

Not surprisingly, the recent Review of Pharmacy Remuneration and Regulation posed 140 thought-provoking questions about the current community pharmacy model. It is hoped that some of the issues will be resolved as a result of the review.

It is clear to me that the claimed success of pharmacy vaccinations has to be taken with a pinch of salt.

If community pharmacy is able to better integrate their services with the rest of primary care, including general practice, the resulting model has the potential to become truly successful.

This article was originally published in Australian Doctor magazine (edited).

Here’s a challenge for the Pharmacy Guild

One of the big questions in primary care is: will the community pharmacy sector and general practice be able to work together without fragmenting care or duplicating services? If we don’t solve the issues and start to work as team, patient care will suffer.

For that reason, I’d like to take the Pharmacy Guild up on their suggestion to collaborate.

The relationship between doctors and community pharmacists is an interesting one: the two professions rely heavily on each other. For example, I find the advice and support from pharmacists invaluable when trying to solve difficult medication problems with my patients. Pharmacists also act as a ‘second pair of eyes’ checking my prescriptions.

Both doctors and pharmacists are highly valued by consumers and are, with nurses, in the top three most trusted professions.

On another level doctors and community pharmacists are often at loggerheads. Issues that come up time and time again are differences of opinion about the commercial aspects of healthcare, conflicts of interest with regards to prescribing and dispensing, and who does what.

In the eyes of many doctors, community pharmacy has gone off track with little connection at policy level with other primary care providers. Pharmacist will tell a different story. For example, some pharmacists – not all – seem to think that the main agenda of doctors is to protect their ‘turf’ – but there’s much more to it as I’ll explain below.

Unintended consequences 

A while back I published an article on behalf of RACGP Queensland, drafted with input from a diverse group of academic and non-academic GPs. I outlined various issues with the Queensland immunisation trials, which have led to a change in Queensland’s legislation allowing community pharmacists to administer certain private vaccinations to adults.

The idea behind pharmacy vaccinations is to improve vaccination rates in people who don’t receive care through GP services. This sounds appealing from a public health point of view, but the impact on existing services has not been reviewed or taken into account during the trials.

Unfortunately the change impacts on the care delivered by family doctors and their teams. For example, my patients now regularly tell me that they’ve been vaccinated at a community pharmacy but have forgotten where, when and what exactly – and communication from the pharmacy is usually missing.

One of my frail elderly patients who came to see me for something else declined a government-funded influenza vaccination by our practice nurse because she was booked in to have a private vaccination at the pharmacy the following week, and felt she couldn’t cancel that appointment.

This goes against the argument that pharmacy vaccinations are only targeting people who don’t have a GP or people who fall outside the national immunisation program.

Moving services away from general practice also has an impact on opportunistic screening and prevention of health conditions by GP teams. So far this season I have been able to pick up several health problems in people who came in for vaccinations, including an aortic stenosis, pneumonia and two melanomas.

We are all connected

The Pharmacy Guild’s Strategic Direction for Community Pharmacy. Source: Pharmacy Guild
The Pharmacy Guild’s strategic direction for community pharmacy. Source: Pharmacy Guild

The main message here is that a change in one part of the health sector always affects the other parts. We’re all connected – this has nothing to do with money or turf but is all about providing high value, coordinated care.

It would have been nice if RACGP Queensland had been involved in the recent Queensland immunisation trials; we could have flagged and perhaps solved some of the many issues at an earlier stage.

Will the My Health Record fix these problems? Not entirely, because uploading data to an electronic health record on its own will not replace the need for good communication and collaboration.

In the article we also warned against introducing further changes to care delivery in community pharmacies (see image) that may result in poorly coordinated, duplicated or fragmented health services.

How to move forward?

After voicing our concerns in the article various debates occurred on this blog and in the pharmacy press, for example here and here.

The response from the Pharmacy Guild in Cirrus Media’s Pharmacy News however contained incorrect information:

Response from the Pharmacy Guild

This statement is wrong for several reasons: part of my work as a family doctor involves giving advice to travellers but I am not a proprietor of a travel clinic and I don’t profit from the sale of vaccines or other products.

So how to move forward from here? I thought this response from Tim Logan was more encouraging:

“(…) it profits society more for GPs to work with pharmacists, citing a presentation at the Australian Pharmacy Professional conference earlier this year by US expert Dr Paul Grundy, who demonstrated the benefits provided by a model which encouraged GPs to do so.”

I’d like to take Tim up on his suggestion to work more closely together and invite the Pharmacy Guild to meet with RACGP Queensland. I acknowledge that there are always two sides to every story. Let’s see if there is common ground and room for agreement on how our professions can work better together at policy level, without duplicating services or creating more fragmentation of care.

As said before, the RACGP remains committed to working collaboratively with other primary care providers and government to develop innovative and effective models of care such as the patient-centered medical home, and we strongly advocate for solutions that support genuine integration of care, not more fragmentation.

At the time of writing Dr Edwin Kruys was Chair of RACGP Queensland.

Pharmacy vaccinations in Queensland and the slippery slope of health services in community pharmacies

New legislation in Queensland supports pharmacy-based health care services on the basis of pilots of feasibility, embellished as evidence of effectiveness. Family doctors are concerned and disappointed that, despite lack of independent analysis, these pilots have resulted in new legislation with little consideration given to the broader health impacts.

The move is paving the way for an expansion into other pharmacy-based health services, which have been successfully delivered in general practice for decades. It is also threatening the medical home model, which the federal government ostensibly supports.

When doctors speak about concerns with pharmacy vaccination programs, they talk about evidence, quality, patient safety and fragmentation of care. However, these messages are heard as ‘self interest’.

Pharmacists on the other hand talk about better access, availability, and gaps in healthcare delivery due to excessive GP waiting times. Pharmacists are not heard as being self-interested, rather as providing a beneficial service for the community. Public health arguments are also intuitively compelling; to a public health advocate it doesn’t matter where vaccinations are delivered.

However, these arguments need to be examined further. We have to look at the bigger picture and take into account adverse effects on our proven Australian general practice model, costs to the consumer, conflicts of interest of the pharmacy industry and issues with the Queensland vaccination trials.

Proven general practice model

Australia’s large network of general practitioners and their teams have been very successful in keeping Australians healthy at a low cost, compared to international standards.

National surveillance data on vaccine-preventable diseases in Australia documents a remarkable success story for vaccinations delivered by general practice, which have caused extraordinary declines in child and adult morbidity, mortality and hospitalisations over the years.

“Vaccinations delivered by general practice have caused extraordinary declines in morbidity, mortality and hospitalisations

Major changes to our primary care model must be based on evidence and not just sound like ‘a good idea’. There is little evidence that delivering vaccinations and other health services via pharmacists will improve efficiency, safety or quality of care for patients. Although there is a convenience factor, people need to ask how commercial interests have been allowed to be placed before health benefits to the Queensland population.

Issues with the trials

In 2014 the Queensland Department of Health approved an application by the Queensland branches of the Pharmacy Guild Australia and the Pharmaceutical Society of Australia, which led to the start of two trials to vaccinate adults over the age of 18 at community pharmacies against influenza, dTPa (diphtheria, tetanus and whooping cough) and MMR (measles, mumps, rubella).

Interestingly, no independent analysis of the trials seems to have been performed. The data that has been reported is superficial, selective and shows elements of observer bias. No analysis was undertaken to establish the clinical need for the vaccinations. No analysis was undertaken to determine what proportion of these vaccinations were high risk.

The trials did not reveal evidence about the impact on vaccine-preventable disease outbreaks. There was no comparison with alternatives such as walk-in vaccination clinics in general practice. General practitioners frequently conduct opportunistic screening and preventive healthcare during consultations for vaccinations, but the impact of missed opportunities for screening and other preventative care in general practice was not looked at, and neither did the trials focus on much-needed better integration of care delivery.

It seems no independent analysis was undertaken to determine whether the standard elements of privacy, documentation or GP notification were met. Further, no mention of commercial add-on practices was monitored, for example, using vaccinations as a means to on-sell other products. As we know the pharmacy business model relies heavily on upselling products to consumers.

The argument seems to be to improve vaccination coverage with claims of managing people ‘who have not been vaccinated’ – these claims are neither verified, nor explained; for example, are these new patients or inappropriate patients? It is a reasonable question as to why these claims have not been subject to closer scrutiny.

The stakeholders’ evaluation contained leading questions, such as: “The results of the trials show that there is increased uptake of influenza vaccination among adults who have never previously been vaccinated or who were not regularly vaccinated. Do you consider this an important public health function?” This raises questions about the objectivity of the process.

Conflicts of interest

There is an inherent conflict of interest in pharmacists delivering general practice services including vaccinations. One of the great strengths of medication prescribing in Australia is the high degree of separation between the prescriber and the medication dispenser. This enables more objective prescribing, free of pecuniary interests and leads to better allocation of resources. This is a strong argument against moving more health services into the pharmacy environment.

“One of the great strengths of medication prescribing in Australia is the separation between prescriber and medication dispenser

The core role of pharmacy is to dispense medication safely and effectively, but the financial viability of pharmacies depends on operating successfully as small retail businesses. Concerns have been raised regarding the environment of pharmacy being more conducive to medication sales than primary care services. The pharmacy sector is seeking new ways to broaden its health services to provide new income streams, sometimes in conjunction with pharmaceutical companies with the prime purpose of profit.

Commercialisation of pharmacy vaccinations has occurred overseas and here in Australia. For example, a pharmaceutical company which produced vaccines involved in the trials, provided financial support to a pharmacy chain for their vaccination training. This illustrates the problem with delivering health services in pharmacies – but this was not reported in the evaluation of the trials.

If it ain’t broke…

There is ample evidence that increasing general practice comprehensiveness of care is associated with decreasing costs and hospitalisations. However, each time a task is given to other providers, the effectiveness and safety of our current proven GP-model is eroded and this will ultimately have consequences for the care delivered to Australian communities.

Despite concerns from doctors’ groups, the Queensland government announced in April 2016 that an amendment to the legislation now allows registered pharmacists to administer influenza vaccinations, diphtheria-tetanus-acellular pertussis vaccinations, measles-mumps-rubella vaccinations to adults.

“We should avoid a trade-off between our values and creating monetary value

Pharmacists are ready to roll out more ‘enhanced pharmacy support services’ in the near future. The impact of patients presenting to pharmacies instead of general practice will result in more fragmentation of care, missed opportunities for screening and preventive health care, unnecessary and non-evidence based care, and possibly increased risk and wasted health resources. It also clashes with the innovative national medical home model.

We should avoid a trade-off between our values and creating monetary value; recommendations for treatment and prescribing must only be evidence-based and should not be influenced by commercial factors.

Medical groups should continue to monitor these developments, highlighting the risks to policy makers and reinforce the message that we need evidence-based decision making in healthcare. It is dangerous to rely on short-term financial benefits at the expense of long-term, whole-of-system considerations. In the interest of all Queenslanders, decision makers should focus on strengthening general practice, not dismantling it.

The RACGP remains committed to working collaboratively with both state and federal governments to develop innovative and effective models of care, and strongly advocates for solutions that support integration, not fragmentation.

This article was originally published in AMA QLD’s Doctor Q. At the time of writing Dr Edwin Kruys was Chair of RACGP Queensland and member of the AMA Queensland Council of General Practice.

If only we worked together (instead of competing)

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.

Our culture

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?

Why tribalism?

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.

More unity

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.

Continuity of care is more than just a catchphrase

Continuity of care

The practice I work for recently took over another practice. As is not uncommon in acquisitions, this caused a temporary increase in staff turnover, including GPs.

The response from patients was interesting: just about every other patient asked if I was going to stay. And most patients – not just those with chronic or complex health conditions – expressed their dissatisfaction with the lack of continuity of care.

I’m sure that many colleagues can recall similar anecdotes. This seems to indicate that our patients value personal and longitudinal primary care. Yet, we are seeing many proposals, trials and projects at the moment that threaten this model, and will create fragmented care.

Two examples

For example, Queensland Health is running several trials at the moment that bypass the usual GP, including a hospital-avoidance project where the ambulance service brings patients to selected GP clinics that receive state funding.

However, usual practices do not receive funding or support to increase capacity to manage these extra presentations. Although projects like the one in Queensland may reduce visits to the ED, they don’t support a stable and enduring relationship between GPs and patients.

In another Queensland Health project, pharmacies are being encouraged to administer MMR vaccinations. That vaccinations in general practice are an opportunity for screening and prevention does not seem important to policy-makers.

In primary care literature, ‘continuity’ is often described as the relationship between a practitioner and a patient that extends beyond specific episodes of illness or disease. Unfortunately, other terms are often used synonymously, such as ‘care co-ordination’, ‘integration’, ‘care planning’, ‘case management’ and ‘discharge planning’.

The experience of continuity may be different for the patient and the health practitioner, adding to more misunderstandings.

According to a 2003 BMJ article by Haggerty et al, there are three types of continuity of care: informational continuity, management continuity and relational continuity. Of course, continuity is more than just sending a message to another health practitioner, or uploading a piece of information to an e-health database.

What is continuity of care?

Understanding individual patients’ preferences, values, background and circumstances cannot always be captured in health records. Practitioners who have longstanding relationships with their patients often know this information.

The RACGP 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”.

There is abundant evidence that continuity in primary care results in improved patient health outcomes and satisfaction, and reduced costs. 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.

Better aligned funding that supports primary care practitioners to provide long-term quality care is much needed at the moment.

Team care

A sustainable health system should free up GP teams and other health practitioners to deliver clinical co-ordination and integration of care across disciplines, especially for people living with complex and chronic health conditions.

Avoiding hospital admissions and increasing immunisation rates are laudable objectives, but it’s not a good idea to do this at the expense of continuity of care by the GP. If patients don’t have a GP they should be encouraged or assisted to find a doctor of their choice.

There is nothing wrong with new models of care as long as they don’t impact on the many benefits general practice has to offer.

This article was originally published in Australian Doctor Magazine.

Follow me on Twitter: @EdwinKruysDisclaimer and disclosure notice.

The looming war between pharmacists and doctors

The looming war between pharmacists and doctors
Image: Pixabay.com
The war (…) was an unnecessary condition of affairs, and might have been avoided if forbearance and wisdom had been practised on both sides ~ Robert E. Lee

Separating the medication prescribers from the dispensers has merit. One of the advantages is that doctors and pharmacists don’t get tempted to diagnose problems to sell more drugs.

The Australian Pharmacy Guild wants to change this. They prefer pharmacists to do health checks, give advice and perform interventions such as vaccinations – while at the same time selling the solution to the problems they identify.

The Guild’s strategy is marketed as providing better access to patient care, and is apparently based on overwhelming international evidence. Indeed, in some countries pharmacists offer a wider range of services.

I’m not sure it’s always better overseas. One New Zealand doctor seemed very unhappy about pharmacists managing medical problems (and I have heard similar stories from other countries):

“I practise in New Zealand where pharmacists are allowed to treat ‘easy’ diagnoses like urinary tract infection [UTI]. Last week I consulted with a young lady who had had two diagnoses of UTI and two courses of trimethoprim [an antibiotic]. When I examined her she had a significant UTI, thrush and the possibility of a chlamydia infection, results awaited. Nothing is ‘easy’ in medicine!

The Pharmacy Guild may be a politically clever bunch, but they should have suggested a multidisciplinary solution here. Their strategy will create a backlash. In the end nobody will be better off.

Where to from here?

The signs are on the wall. Dispensing medications is not sustainable for pharmacies. Just like video rental shops had to change their business model because people started downloading movies and using automated DVD rental kiosks, this particular part of the pharmacist’s job may soon be history. The authors of an article in the British Pharmaceutical Journal ‘Dispensing: it’s time to let it go’ said: “If the aspirations of pharmacy fulfilling a clinical role integral to public healthcare is ever to be realised, community pharmacists must shift their focus away from dispensing and towards NHS service provision.”

The key here is integration. According to the authors medications could be provided in-house by health care organisations or delivered by mail, and the focus of pharmacists should be on providing integrated services like medication reviews and drug utilisation reviews. This would indeed employ the skills of pharmacists and at the same time ad value to patient care provided by other health professionals.

Or maybe pharmacists should be made responsible for quality control of over-the-counter medicines and help to stamp out misleading claims made by the domestic complementary medicines industry.

We need honest medication advice. “(…) It comes as a shock to walk into some pharmacies to see them urging products on customers where there is no evidence base of effectiveness,” said NHMRC boss Professor Warwick Anderson recently. “If you’re providing advice and care to patients, you should be clear about the evidence for the treatment.”

The pharmacy industry is comfortably protected by their community pharmacy agreement with the Federal Government, and state laws stipulate only pharmacists can own a pharmacy. A new pharmacy cannot set up shop close to an existing pharmacy. Other professions, like doctors and lawyers, don’t have this competition protection.

The service expansion drift of pharmacy-owners will eventually provoke a response from the AMA and RACGP and other medical organisations. The idea of the pharmacist in general practice has been floating around for a while. Doctors may demand dispensing rights and lobby for an end to the pharmacy cartel.

A study in the Medical Journal of Australia showed that dispensing doctors issued fewer PBS scripts than non-dispensing doctors. This is one argument for dispensaries in GP surgeries; other arguments are evidence-based medication advice and consumer convenience. Think about it: What’s easier than, after having seen the doctor, walking to the dispensing machine in the hallway, scanning your script and receiving your medications? Robotic dispensing reduces medication errors (see video below) and nobody is suggesting multivitamins, supplements or probiotics at the same time.

But just because a service is more convenient, doesn’t mean that it is a good solution. Doctors should not do the pharmacist’s job, just like pharmacists would do well to stay away from medical services.

There is still time

Pharmacy-owners face reduced profits because the Government has set lower prices for generic medications under the price disclosure arrangements. Although it is understandable they are looking for other income streams, this is a dead-end. The last thing we need is a war between pharmacists and doctors.

Needless to say it’s not in the interest of health consumers. It will create confusion, duplication, false reassurance, frustration, missed screening opportunities, fragmentation of care and higher costs.

Doctors have to accept change too. If people feel they cannot access a GP when they need to, we should improve this. One solution would be to fund nurse-lead walk-in vaccination services within the safe, clinical environment of the GP surgery. The pharmacist can play a role as part of the multidisciplinary team.

The current community pharmacy agreement expires in June 2015. There is still time.

Follow me on Twitter: @EdwinKruys

Disruption in healthcare is happening (whether we like it or not)

Disruption in healthcare can lead to fragmentation
Disruption in healthcare may lead to fragmentation and loss of opportunistic screening.

Healthcare, and particularly medicine, are slow-moving beasts. This doesn’t mean that innovation isn’t happening – in fact it’s happening at an alarming speed, and doctors are grappling with a quickly expanding knowledge base.

But the highly regulated, traditional industry is vulnerable to external disruption, and we’re seeing more and more examples:

  • DIY tests like skin cancer apps and pap smears
  • Online script services
  • Skin checks at the pharmacy
  • Vaccination services outside medical practices
  • Medical tourism

The flip side of convenience

Disruption is not necessarily the same as innovation. Disruptive services or products are simpler and more convenient to use, but their quality is often poorer.

In healthcare, the risk of disruption is that it affects health outcomes. It may lead to fragmentation and loss of opportunistic screening. I’ll give two examples:

Example 1:  More providers does not equal better care

A busy family doesn’t have the time to visit the doctor and decides to use convenient online health services. As a result they hardly ever visit their family doctor, and if they do, their doctor does not have the complete picture as more health providers are involved in the care.

Example 2: Convenience does not equal safety

Women doing their own pap smears at home may take incorrect samples. Although avoiding the ‘stirrups’ in the doctor’s office is a big plus, the risk of avoiding an expert examination is that things get missed.

The way forward

Disruption in healthcare is happening, whether we like it or not. “Successful entrepreneurs naturally look at opportunities in terms of the jobs they can do for customers,” say the authors of this article. Although it is unlikely that the doctor can be replaced by technology, certain aspects of the healthcare process can.

I believe there are 3 ways the healthcare industry should respond to external disruption:

  1. Continue to listen to health consumers
  2. Develop our own disruption processes
  3. Communicate the strengths and qualities of our services

Marcus Tan, GP and CEO of HealthEngine said in Australian Doctor magazine: “GPs are ideally suited to lead this cultural shift. GPs are highly skilled in managing risk and uncertainty, and are well equipped to make the leaps required to innovate.”

If we don’t do it ourselves, others will.

Follow me on Twitter: @EdwinKruys

Sources: