WANTED: shared vision for primary care

“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.

Belinda MacLeod-Smith, health consumer (BridgeBuilders.vision)

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 Royal Australian College of General Practitioners is advocating for comprehensive reform that includes blended funding, based on the Vision for general practice and a sustainable healthcare system.

The Pharmaceutical Society of Australia wants pharmacists in residential aged care facilities. The Consumers Health Forum argues for an Australian Co-Creating Health initiative to 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?

Who is the real winner in the latest stoush between pharmacists and doctors?

Last week a state Pharmacy Guild president made a few negative comments about general practice. I thought it was neither here nor there, but what happened next was interesting.

I could not find the original column (admittedly I didn’t look very hard) so I can’t verify his exact words but apparently, he said that increased funding for GPs will only incentivise five-minute ‘turnstile’ medicine.

Most GPs would not have read or been aware of the column until, on the eighth of February, Australian Doctor Magazine, owned by the Australian Doctor Group (ADG), posted an article on their website titled “Pharmacy Guild says GPs working ‘turnstile operations’ filling time-slots with easy patients.”

Then all hell broke loose. There were 170 comments on the article from mostly angry GPs.

A few days later, on the eleventh of February, Pharmacy News published this piece: “Guild takes aim at GPs who favour wealthy, healthy patients”. 

Interestingly, Pharmacy News is also owned by ADG.

Then the response came. On the thirteenth of February a reply penned by the RACGP president was published. And you guessed it, that same day Australian Doctor posted: “Turnstile, cream-skim medicine? RACGP hits back at Pharmacy Guild.”

The ADG publications got hundreds of clicks and views of their website content out of the latest stoush between pharmacists and doctors.

Good on them, one could argue. But hang on, there’s more to it. The ADG website explains how it works:

“We know that GPs are increasingly time-poor and less reliant on [pharmaceutical] sales reps,” says Bryn McGeever, Managing Director of Australian Doctor Group. “They’re looking elsewhere for information.”

“While readership of medical print publications remains strong, digital channels are becoming increasingly popular with almost eight in 10 GPs now reading online medical publications monthly.”

“In recognition of this continuing shift in GP behaviour, Australian Doctor Group last week launched AccessPLUS, a bespoke digital sales channel designed to fill the space left behind as rep engagement continues to fall.”

And the real winner is….

It is sad, but not surprising, that the medical media are fuelling the tensions within primary care. Of course, like other media, ADG is just doing its job. I do wonder how many GPs and pharmacists are aware that they are the product on sale here.

I have had my fair share of altercations with the Pharmacy Guild – but it’s a road to nowhere. I prefer to listen to people like pharmacist Debbie Rigbie, who rightly says, “We must build bridges across our differences to pursue the common good.”

MBS Review: A stronger primary care system in sight?

Implementing healthcare reform in Australia is always an uphill battle. After a disappointing outcome of the much-anticipated Healthcare Homes program, some of the members of the Primary Health Care Advisory Group regrouped when they were appointed to the Medicare Benefits Schedule (MBS) Review Taskforce.

The recommendations by the taskforce to improve the MBS are refreshing in many ways. There is a move towards strengthening GP stewardship, voluntary patient enrolment, more non face-to-face care, a simpler careplan program and increased support for home visits – which seems sensible and is addressing the frustrations of many about the current Medicare system.

It appears there are a few things missing. For example, there is no recommendation to spend more time with our patients by committing to an increase in the schedule fee of longer consultations (item numbers 36 and 44). This would have been more useful for most patient encounters than a new one-hour plus item number.

I believe the residential aged-care item numbers will need more investment when the SIP incentive ceases to exist. There is mention of outcome-based payments which requires an explanation. The lack of detail about the dollar values makes it challenging to predict the impact on general practice and primary care.

In an ideal world the recommendations could result in an invigorated, modern, patient-centred health system. However, if history repeats itself, the result will be a simple cost-saving exercise, dressed up as clinician-led, evidence-based healthcare reform.

A typical case of make it or break it.

Doctors from overseas

“G’day doc, I’m right off me tucker and crook azadog. Yesterday arvo me neighbour said it’s just the collywobbles but crikey, he’s mad as a cut snake so I thought I’d better find out what the doc has to say. I know youse are flat out but waddaya reckon, she’ll be right? I feel weak as a wet whistle. Not droppin off the perch yet am I? Probably just old age. Howyagoin anyway, settlinin all right? Gotta love the top end mate, heaps better than the big smoke.”

When I arrived in Australia – in Cooktown of all places – one of my biggest challenges was understanding the accent and the slang. I also struggled with basic expressions. I remember being invited ‘for tea’ one night – so after dinner I went over expecting a cup of tea or coffee only; to my surprise our host had prepared a delicious roast. On another occasion I was asked ‘to bring a plate’; I took a few plates and, just to be sure, some cups and cutlery too.

I thought the communication was problematic because I come from a non-English speaking country. It turned out that most immigrants struggle with language, communication and the often slightly different meaning of common expressions, not to mention the bureaucratic jargon. For example, as doctor Jennifer May wrote in the Medical Journal of Australia, a term such as ‘reciprocal recognition of qualifications’ has a different meaning in different jurisdictions.

The first six months were a crash course in ‘Strine’. The patients were wonderful and seemed to strangely feel sorry for the new overseas doctor in town. They taught me all the basics; some gave me Australian slang dictionaries and Indigenous Australians told me stories about their culture. Still, it took a few years before I could fully understand most conversations.

The preparation

For most immigrants the challenges begin long before entry to Australia. The paperwork and background checks required by the Australian government and healthcare organisations – which can take one to two years to complete – are only a small part.

Croc drama: A crocodile dragged a fisherman from his tent on the riverbank and a woman jumped on its back in an attempt to stop the giant reptile. Source: Cooktown Local News

Even though the decision to emigrate is mostly a voluntary one, and it is a privilege to be welcomed to Australia, it doesn’t mean that there are no downsides. Emigrating doctors and their families have to give up their lives in the home country and say goodbye to loved-ones, familiar neighbourhoods, cultures, customs and careers.

It is not uncommon for overseas doctors and their family members to experience some adjustment problems. Many tears have been shed when settling in a remote Australian outback town or new suburb. It can be stressful when a spouse struggles or the children have problems at the local school.

Often well-established and respected at home, immigrant doctors start all over again. They are initially temporary residents with limited rights and no access to Medicare. Their medical registration is conditional, they have to work in places where many Australian trained health professionals don’t want to work, and their future is uncertain and dependent on passing health checks, police checks, language tests, assessments and exams.

My arrival in Cooktown reported in the local newspaper (2004). Full story below.

It can be difficult to negotiate employment conditions or discuss real or perceived injustices – as a conflict may lead to cancellation of sponsorship or visa. Financial challenges are common as starting over in a new country does not come cheap. There are all sorts of legal and tax problems, such as dual taxation. I had to give up my Dutch citizenship when I became an Australian citizen.

For the immigrant there is always ‘the other world’ of their home country. They often use the holidays to fly ‘home’ and visit family and friends for a few weeks, which is joyful but can be intense and emotional. Migrants may never feel one hundred percent part of the Australian society and at the same time they often don’t fit in anymore in the home country, which can affect their sense of belonging and create feelings of loneliness.

Rural medicine

For me another culture shock was rural medicine. The contrast with Amsterdam, where I trained as a doctor, could not have been greater. I quickly had to learn about tropical diseases, snake bites and Irukandji – just to name a few. Shortly after I arrived a 4.2 meter saltwater crocodile dragged a fisherman from his tent on the riverbank when a woman jumped on its back to stop the giant reptile; the story appeared in all the newspapers.

Although many of the medical textbooks back home were written in English, learning to speak the medical jargon in another language was yet another challenge. Names and doses of commonly used drugs differ between countries, not to mention the different guidelines.

I was able to do a few up skilling courses including trauma and emergency medicine and with assistance from helpful and skilled colleagues – sometimes over the phone – and a great nursing team, we were able to manage many problems locally. I am grateful for all those who have welcomed and taught me over the years – patients, staff, nurses, fellow doctors and others.

Not unique

For a long time I thought my ‘adventures’ were unique but over the years I learned about similar stories, not only from overseas doctors but also from Australian graduates, all struggling during their first placements in rural and regional hospitals and GP practices.

These stories are often tales of incredible resilience and courage and what always amazes me is to hear how valued health professionals are in their communities – even though we may often feel ill-prepared or have doubts about our skills and knowledge.

The demands on doctors in small towns can be high, not seldom 24 hours per day. Working towards another degree or fellowship is taxing for anyone, but for international medical graduates coming from a different background there are many extra challenges. The working hours and fatigue don’t go well with training and exam preparation.

The workload and the tyranny of distance can make supervision suboptimal; there is often limited support and the amount of bureaucracy can be perceived as overwhelming.

On the bright side, there are many people who warmly welcome and support the newcomers. Professional bodies and colleges offer introductory, support and exam preparation programs, but often the local and individual initiatives make the difference. An example is Dr Farooq Ahmad who, after passing his Australian fellowship exam, decided to support others and has helped hundreds of doctors pass their exams.

In the video below Kenyan born Dr Ken Wanguhu describes the importance of being welcomed by a community as well as the rewards of contributing and ‘giving back’.

Concerns

Although many areas of Australia are relying heavily on international medical graduates, not everyone is happy with the influx of doctors from overseas. Critics of the Australian skilled immigration policy have often mentioned the ‘brain drain effect’ on developing countries: the recruitment of healthcare professionals compromises the, often already struggling, healthcare systems in the developing world.

Concerns have publicly been expressed about doctors from non-Western training backgrounds and the uncertainty around standards and relevance of knowledge and skills to the Australian situation.

The regulation changed in the aftermath of the Dr Jayant Patel case. Dr Patel, nicknamed ‘Dr Death’, was permanently barred from practising medicine in Australia in 2015. Legislation introduced in 2009 now protects patients by ensuring that only health practitioners who are suitably trained and qualified to practise in a competent and ethical manner can be registered.

This example is not unique to Australia nor to international medical graduates. Many countries have similar stories, think for example about Dr Harold Shipman in the UK and Dr Christopher Duntsch in the US.

Although there is anecdotal evidence that patients sometimes avoid seeking treatment by international medical graduates, research indicates that there is no difference in patient satisfaction with, and acceptance of, care by Australian and international medical graduates.

Diversity

The ‘doctors from overseas’ bring diversity, expertise, experiences, cultures, innovation and stories to Australia. Cross-cultural experience appears to be valuable in many ways; some have argued that immigrants are more entrepreneurial, resilient and creative. Whether this is true or not, one thing is for sure, starting a new life in a different country takes courage and perseverance.

My wife Nancy and I have never looked back. Although we miss our family and friends in The Netherlands, we’re grateful for the opportunities Australia has given us. I can only hope I am able to give back what I have received.

Source: Cooktown Local News (2004).

My Health Record: what’s next?

The end of the My Health Record opt-out period is in sight. Unless the government decides otherwise, next month the vast majority of Australians will have a digital national shared health record. What’s next?

A while ago I saw a patient who was passing through my town, on her way home from Cairns to Sydney. She had been seen at the emergency department in Cairns and was told to visit a GP for follow-up. She had no hospital letter or medical records but with a few clicks I was able to get access to the hospital discharge summary through the My Health Record, which included results of blood tests, ECG and chest x-ray, and I could see what medications were prescribed.

This is a rare example of the benefits of the MyHR; once the system will be used at a larger scale this could become an everyday reality.

The Australian Digital Health Agency (ADHA) says that about 1.14M Australians have opted out and apparently the opt-out rate is slowing down. At the same time others are signing up and there is an expectation, based on the opt-out trials, that many of those who opted out will eventually opt back in.

The Australian My Health Record is a compromise between a consumer record and a clinical record. This means that there will always be people in both camps who are not completely satisfied. Despite everything we’ve come a long way.

Work in progress

The My Health Record, currently in version 9.4.2, continues to evolve. Looking back over the years progress has been slow but significant.

For example, the software is far less clunky these days; accessing a record or preparing and uploading a shared health summary can now be done within seconds; we got rid of the dreadful participation contracts; there is a secondary use of data framework and users can choose to opt-out of secondary use of their data.

It is expected that more pathology and imaging providers will come on board next year and the legal framework will be further adjusted to improve privacy of Australians, including complete deletion of data if people decide they don’t want a record anymore.

Awareness?

According to ADHA over 87% of Australians know about the record and more than 85% of general practice is registered.

It is likely though that this awareness is rudimentary despite hundreds of engagement activities by the agency and Primary Health Networks (PHNs). Most Australians will not be aware that they have control over who-can-access-what in their records and how to change the privacy settings.

The RACGP has held many PHN-based peer-to-peer workshops across the country as well as webinars for general practitioners and staff, and around 2000 people attended – which is a lot but probably not enough. Most non-GP specialists are not yet on board.

Then there are still the concerns about for example privacy, workflow and accuracy, many of which are summarised in this year’s senate inquiry report. It appears there is still work to do.

The next stage

The agency has started preparing for the ‘post opt-out period’. As it stands around mid December empty shell records will be created, and activated once accessed by providers or consumers.

ADHA says the aims of the next stage of the consumer campaign will be maintaining awareness, taking control of the My Health Record and encouraging consumers to discuss the MyHR with providers.

The provider campaign will focus on the expected benefits including improved efficiency, such as less search-time, and better health outcomes – although skeptics will question the latter claim by the agency.

There will also be a focus on getting specialists on board, aged care access, improved family safety and child protection and education for vulnerable consumer groups.

International review

Meanwhile ADHA has released an international review of digital health record systems. The findings show that the Australian MyHR empowers consumers to access and personally control their information, including what’s in it and who can see it.

ADHA emphasised that, although many countries have laws that allow users to view their health information, only Australia and a limited number of other countries allow citizens to control who sees their information and request corrections to their own health data.

The MyHR PR machine is in full swing. It will be interesting to see what the response to the senate inquiry will be and what happens next year. I hope the momentum of recent times will continue.

What needs to change?

From a usability point of view the wow-factor is still missing and although that’s nothing new in healthcare, some work in this area would go down well.

For example, it would improve workflow and safety if doctors could download MyHR information not just as PDF but import new medications straight into a local medication list.

The secondary use of data framework is fairly broad, and could be tightened up a bit further. Many have commented that the messaging around the MyHR should be less promotional and more about benefits versus limitations – but I’m not holding my breath here.

What change do you want to see?

Details have been changed in the case above to ensure patient confidentiality.

10 podcasts for GPs (and their patients)

I always enjoy a good podcast. There is something appealing about listening to people’s stories via the cloud – and at a convenient time and place. I usually listen in the car on the way to work.

In 2014 I posted 6 great podcasts for primary care, one of the most visited articles on this blog. As podcasting seems to be more popular then ever and new podcasts for family doctors have been launched since my last post, it is time for an update (October 2018).

So here is my top 10. Since I’ve been involved with the BridgeBuilders podcast (shamelessly placed @ no.4) my respect for podcasters has grown even more; it takes many hours to edit one episode.

Click on the iTunes or SoundCloud logo to listen, and feel free to share your favourites in the comments section. Big thanks to all podcasters – keep going!

#1: The Good GP

The Good GP

The Good GP has been around since September 2016 and has grown into one of the most popular education podcast ‘for busy GPs’, hosted by Western Australian GPs Dr Tim Koh and Dr Sean Stevens, in collaboration with RACGP WA.

Guests are GPs or other specialists and a range of mainly medical topics is covered, for example: acute pain, allergies, immunisations, the future of general practice, euthanasia and the registrar -supervisor relationship.

Listen on iTunes or SoundCloud

#2: The GP Show

This is another popular medical education podcast – hosted by Queensland GP and medical educator Dr Sam Manger.

Sam interviews guests covering a wide variety of topics including case studies and guideline reviews. The podcast is aimed general practitioners, family physicians, other specialists, allied health, nurses, registrars/residents, medical students and anybody interested in health, science and medicine.

Listen on iTunes or Libsyn

#3: Just a GP

Just a GP is a popular newcomer in 2018, run in collaboration with RACGP New South Wales. Hosts Dr Ashlea Broomfield, Dr Charlotte Hespe and Dr Rebekah Hoffman discuss leadership, quality in clinical practice, self care and wellbeing, difficult consultations, starting or running a private practice and GP research.

They explore the layered complexities with each other and other GPs with expertise in these areas. In each episode they share a favourite resource or clinical pearl.

Listen on iTunes or SoundCloud

#4: BridgeBuilders

Hosted by Dr Edwin Kruys, Dr Ashlea Broomfield and Dr Jaspreet Saini, the themes of the BridgeBuilders podcast are collaboration in healthcare, fragmentation, team care and working together to the benefit of our patients.

A wide variety of guests, including some of our healthcare and thought leaders from e.g. the RACGP, ACRRM, Consumers Health Forum (CHF) and the Pharmaceutical Society of Australia (PSA), give their view on trust, integrated care, quality care, leadership and what needs to happen to make Australian healthcare an even better connected place.

The BridgeBuilders podcast was launched in 2018.

Listen on iTunes or SoundCloud

#5: GP Sceptics

GP ScepticsSuperstar GPs Dr Justin Coleman and Dr Liz Sturgiss team up to ‘dissect, analyse and sometimes trash’ medical research relevant to GPs.

A common theme in their broadcasts is the influence of the pharmaceutical industry and other big corporates on doctors and our health.

Liz and Justin have a good sense of humour and recommend their podcast to ‘sceptical clinicians and their patients’.

Listen on iTunes or SoundCloud

#6: The Medical Journal of Australia

The Medical Journal of Australia (MJA) needs no introduction. Listen to interviews with leading health professionals and authors of MJA articles.

Listen on iTunes

#7: Broomedocs Podcast

Broome GP & emergency doctor Casey Parker has been podcasting since 2012. He discusses topics related to emergency medicine and (procedural) general practice . In the Broomedocs journal club relevant research studies are critically appraised, often with guests.

Listen on iTunes

#8: The Health Report

The Health ReportThe Health Report by Norman Swan and other ABC reporters features health topics such as ‘fishy fish oil’, insomnia, asthma, chiropractic controversies, the cranberry myth and lyme disease. Often several national and international guest discuss various topics in one episode.

Listen on iTunes

#9: BS without the BS

Best Science Medicine PodcastThe Best Science (BS) medicine podcast is a Canadian show which critically examines the evidence behind commons drug therapies. GP and associate professor Michael Allan and professor James McCormack present many myth busters and topics relevant to general practice, such as the treatment of back pain, osteoporosis and common cold.

Listen on iTunes

#10: Inside Health 

A BBC podcast discussing several topics per episode with UK GP Dr Mark Porter, demystifying myths about everything health: vitamins, supplements, obesity, smoking, organ donation, and much more.

Listen on iTunes or SoundCloud

An earlier version of this post was published in March 2017.

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?

Is value based healthcare devaluing care?

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

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

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

The right things

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

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

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

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

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

Learning together

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

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

Is the medical software industry holding us back?

There’s a Dutch theory called ‘De wet van de remmende voorsprong’ which, according to Wikipedia, translates as ‘The law of the handicap of a head start’. The theory suggests that an initial head start by an individual, group or company often results in stagnation due to lack of competition or growth stimuli. This may eventually lead to losing pole position.

General practice was one of the first fully digitalised, more or less paperless, medical disciplines in Australia. The question is, are GP software packages keeping up with the times or is the profession at risk of falling behind and being overtaking by others?

Good job

Overall I am satisfied with the desktop software I use to look after my patients. It does the basics very well such as recording patient demographics and medical history, medication management, printing scripts and investigation referrals.

It also checks if medications agree with each other and if the patient happens to be allergic to a new pill I am about to prescribe.

But compared to, let’s say, ten years ago there haven’t been any breakthrough innovations. Sure, we can now check the national My Health Record and upload a shared health summary, but there’s also a lot to wish for.

GP Desktop Software
Are GP desktop software vendors holding general practice back?

We’re still relying on the good old fax machine and over the years I have seen more and more third-party software solutions appear on our system to perform tasks the desktop software can’t. Occasionally these packages clash with each other or slow the practice system down.

The wish list

Here’s a list of 7 basic things that should be included in all GP desktop software. I believe it would improve patient care and satisfaction.

  1. I’d love to have the option to communicate securely with patients and other providers, asynchronously or via video link.
  2. Our patients should be able to send digital health data or electronic script requests via a secure connection.
  3. An online appointments booking system.
  4. GPs should be able to send scripts electronically to the pharmacy.
  5. It would be really nice if the software would help us to write (and send) smart electronic referrals by automatically inserting the data required by the specialty or provider we are referring our patients to.
  6. Decision support tools offer benefits such as increased diagnostic accuracy and a reduction of unnecessary tests.
  7. We also need integrated data analysis and data cleansing tools to help improve the quality of general practice data, so it can be better used for in-practice quality improvement processes.

What’s on your wish list?

Less is more

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

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

To refer or not to refer?

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

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

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

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

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

Issues with online referral services

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

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

Never just about a script

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

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

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

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

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

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

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

High value care

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

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

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

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

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

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

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

Health Care Homes

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

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

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

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

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

Pay-for-performance

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

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

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

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

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

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

Slow down

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

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

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

Government health spending
Source: AIHW

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

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

4 take-home messages

I have four take-home messages for you today:

#1: Take the good, leave the bad

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

#2: Slow down

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

#3: Convenience ≠ high value

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

#4: Keep people well in the community

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

Take home messages

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

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

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

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

Some of the key messages from the report:

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

The bad news

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

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

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

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

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

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

The good news

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

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

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

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

More time with patients

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

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

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

 

Download the report here.

 

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

High confidence in GPs

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

This is of course good news.

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

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

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

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

 

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

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

More bizarre conclusions

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

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

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

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

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

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

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

Not helpful

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

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

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

Promising breakthrough: dramatic miracle cure offers hope to victims

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

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

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

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

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

Dramatic & miraculous examples

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

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

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

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

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

 

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

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

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

Promising breakthroughs

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

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

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

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

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.

No new governance model for GPs yet – Just what the doctor ordered?

A majority of members of the Royal Australian College of General Practitioners (RACGP) voted against the proposed modernisation of their 16-year old governance structure.

As the saying goes, in the end we only regret the chances we didn’t take – I sincerely hope this will not be one of them.

At yesterday’s RACGP member meeting 45.87 percent voted for, and 54.13 percent voted against the resolution. As a result the College will continue with its 13-member representative Council model.

The modernisation proposal was the result of a member-initiated governance review process that started 3 years ago. The proposed model would have introduced skills-based board positions and a representative council that would have better reflected the membership.

The two GP-led governance structures were set up to hold each other accountable. The model was designed to create a greater diversity of voices and thinking within the College.

But it wasn’t to be. Some of the arguments against the proposal were that the board of 7 members was too small, would contain non-GPs, and that the Board-Council model was wrong.

In the end RACGP members have decided and that needs to be respected. It looks like College records have been broken with regards to voter turnout which is always a good thing – and possibly the result of the technology which allowed members to participate in the online member meeting and vote from their digital devices anywhere in Australia.

I thought it was great to see so many GPs participating in the various discussions about governance and I’d like to thank everyone for their input.

The current model has served us well. It has allowed the RACGP to grow successfully over the past years – even though it has its flaws. At some stage the College engine will need replacement, but for now we’ll continue to drive with the old one. Time for reflection.

Talking governance: Getting rid of the disconnect

As the Royal Australian College of General Practitioners (RACGP) has been growing rapidly to 34,000 members, one of the big issues the College grapples with is the perceived ‘disconnect’ between the College and its members. A new proposed governance model aims to better connect the membership with College leaders.

Every organisation needs to review itself once in a while. The RACGP last did this 16 years ago so it’s about time for an organisational update. The proposal includes a GP-led, partly skills-based Board and a larger representative Council. The two structures would be set up to hold each other accountable.

Conflicted

One of the reasons behind the proposed governance model is that the old structure is somewhat conflicted. The problem all Councillors have had up to now is that they represent a group or state within the College on the one hand, and are directors on the other.

This can lead to Councillors having to take a position such as this: “The group I am representing wants A but, putting my directors hat on, I think we should do B in the interest of the organisation” (excuse the simple example to illustrate the point).

In other words: Council, at present, may be faced with situations where it is not able to represent the membership well because directors’ duties, by law, take priority. We can’t be good directors and good representatives at the same time – but are probably managing ok overall. However, this is one of the reasons why there is a perceived structural ‘disconnect’ in the organisation.

Fresh approach

The proposed new governance model splits these two functions (representation vs directorship) between a Council and a Board which will hold each other accountable. This is an essential, but much overlooked, purpose of the new model.

It will improve the representative function of Councillors by freeing them up to work purely on behalf of our members, while Board members (directors) will mainly look after the business side of the RACGP. This model is not new and is used in other colleges and not-for-profit organisations to manage this very issue.

I believe the proposed model breathes new life into the RACGP and general practice by creating a Council that will better reflect its membership. The model creates places for New Fellows as well as Registrars and will foster new leaders with a greater diversity of voices and thinking.

Over to members now – please vote on May 30.

Disclaimer and disclosure notice. Follow me on Twitter: @EdwinKruys.

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.

Health Care Homes: not yet where the heart is

Doctors have called on the Federal Government to delay the implementation of the Health Care Homes model from the current starting date of 1 July 2017 by at least three to six months. Here’s why.

United General Practice Australia, which comprises the leading general practice organisations RACGP, AMA, RDAA, GPSA, GPRA, ACRRM and AGPN, has serious concerns regarding capitated funding for chronic disease management and treatment. It may harm patients, and it may undermine GP-led care when funding runs out.

Additional time to plan for the Health Care Home model is required to get the nation’s healthcare system right and properly consider, design, and implement the supporting tools, information and adequate funding mechanisms.

The extended timeline would allow stakeholders time to ensure the instruments and tools being used are appropriate and validated by evidence.

Health Care Homes: the background

A Health Care Home (HCH) is not a place but a partnership between a patient, their GP and the primary care team. Health Care Homes are general practices and Aboriginal Community Controlled Health Services that coordinate the ongoing comprehensive care of patients with chronic and complex conditions.

As part of the 2016-17 Federal Budget, the Government announced the Healthier Medicare: Reform of the Primary Health Care System package. The core element of the package was the staged rollout of Health Care Homes in selected Primary Health Network regions starting in July 2017.

The Government has re-directed $21.3 million from the Practice Incentive Program and is redirecting a further $93 million in MBS funding to support the HCH trial.

HCHs have the potential to drive a fundamental shift in Australia’s health services toward patient-focused health care practices and are a modified version of the Patient-Centred Medical Home (the Medical Home).

The HCH aims to facilitate a partnership between individual patients, their preferred GP, and the extended healthcare team. The model should enable better-targeted and effective coordination of clinical resources to meet patients’ needs.

Patient-centred Medical Homes have been associated with increased access to appropriate care and decreased use of inappropriate services – particularly emergency departments – for patients with chronic and complex conditions.

The clinical team– which may include GPs, nurses, nurse practitioners, Aboriginal health workers, care coordinators, allied health professionals and other medical specialists – collectively provides care for patients.

The HCH aims to meet as many of the patient’s healthcare needs as possible and for collaborating with other health and community services.

In the current proposal Health Care Homes will receive monthly ‘bundled payments’ on a per patient basis, depending on each eligible patient’s level of complexity and need. The payments will be paid to the Health Care Homes, not GPs.

All general practice healthcare associated with the patient’s chronic conditions, previously funded through the MBS, will be funded through the bundled payment. Regular fee-for-service will remain for routine non-chronic disease-related care patients.

Funding for services provided by allied health professionals and specialists, as well as for diagnostic and imaging services are not included in HCH bundled payments and will continue to be funded through the MBS.

Stage one is limited to Medicare-eligible patients with two or more complex or chronic conditions. Patients that fall within three identified tiers will be eligible to enrol in a Health Care Home.

The Department of Health is developing a patient identification tool to be used by HCHs to identify eligible patients as per the tiers. The Department states that the tool will attribute a risk score to each patient, which will determine the level of care required and subsequently the value of quarterly bundled payments that HCH will receive.

Unfortunately details on the eligibility assessment tool have not yet been released, but will likely draw upon information the practice already has on the patient (for example previous hospital admissions, diagnosis, medications, clinical risks), as well as non-clinical information such as demographic and psychosocial factors.

The patient identification process will be the same across all stage-one HCHs, regardless of whether or not they are in rural and remote areas.

The Practice Incentives program (PIP), a key driver of quality care in general practice, is currently undergoing reform. The redesigned PIP program will reportedly introduce a quality improvement incentive to replace the clinical specific incentives in the current PIP and provide a ‘flexible and supportive structure to the HCH implementation’.

Stage one of the implementation is currently set to commence on 1 July 2017 and run for two years until 30 June 2019. It will involve approximately 65,000 patients and up to 200 general practices or Aboriginal Community Controlled Health Services.

Medical Home RACGP
Key elements of the medical home. Source: RACGP

Why doctors have expressed concerns

One of the key recommendations by the Primary Health Care Advisory group was to encourage patients to be engaged in their care (recommendation 3). Although the model was intended to be ‘patient-centred’, the patient somehow seems to have been lost in the discussion around the current model.

For example, it is not clear how the proposed model will encourage better coordination or comprehensiveness of care to improve the patient journey (recommendation 7).

For a long time the RACGP and other professional groups have been actively offering to work with the Government on the development of an appropriate model, but the RACGP and other GP groups were not consulted in this case. The general practice representatives on the Government’s implementation committees are not representing their professional associations and furthermore have had to sign confidentiality agreements so therefore cannot discuss ideas and recommendations with peers or policy development staff.

The Government claims that it is implementing a model based on the RACGP vision. Unfortunately the current Health Care Homes proposal by the Department of Health does not reflect the RACGP’s evidence-based, best practice model of the Medical Home, as outlined in the RACGP Vision for general practice and a sustainable healthcare system.

The RACGP has called for a rigorous trial subject to academic and scientific evaluation, rather than rushing into a phased rollout. The HCH implementation evaluation methodology is still under development. Health policy needs to be evidence-based and the evidence should to be carefully developed – otherwise it will fail patients and the Australian health system.

A correctly designed trial will properly address the challenges facing Australia, strengthen access to the delivery of high-quality care and ensure patients have a stable and ongoing relationship with a general practice.

The proposed model capitates funding for chronic disease management and treatment in general practice. It may harm patients and undermines GP-led care when funding runs out.

This major reform, which is expected to save millions of dollars in hospital care, did not receive additional funding. GP groups are concerned that the federal Government’s Health Care Homes model is inadequately funded and will not improve health outcomes for millions of Australians living with chronic and complex conditions.

An example of concerns

HCHs will be required to have a service or care coordinator for enrolled patients. As funding allocated to the HCH is in fact reallocated funding from PIP and Medicare, there is no additional money available to support this role.

There is presently not enough information available for practices to make an informed business decision about their involvement with the HCH.

Information released by the Government does not provide details on any additional support for e.g. practices in rural and remote areas and no additional funding is being provided for these areas, where there are higher costs and complexity in providing chronic health care.

The original RACGP Medical Home vision includes incentives for practices and GPs to facilitate patient-centered care, for example a complexity loading to support the delivery of patient services in areas of community need.

The RACGP vision also recommends a comprehensiveness loading: GPs and general practices that provide a comprehensive range of services can respond to the needs of the community they serve. Enhancing the comprehensiveness of services provided in the primary health sector will reduce demand for more complex and expensive services in the secondary and tertiary health sectors.

Medical Home model (RACGP)
Table: Activities and infrastructure required to achieve healthcare sustainability according to RACGP. There is a clear distinction between the Government’s HCH funding model and the RACGP Medical Home model. Source: RACGP.

The Department has indicated that payments made to a HCH are also intended to cover after-hours services where they are provided in the practice rooms. Some practices may achieve efficiencies by providing some care for enrolled patients over the phone or electronically.

Each practice will need to determine if the allocated funding in the proposed model is sufficient to provide the additional care required under the HCH model.

The Department has stated that successful HCH applicants will receive a one-off payment of $10,000. The RACGP believes that an appropriately funded HCH trial would require an average of $100,000 per practice per annum, in addition to current funding allocations for chronic disease management items and other MBS items.

As the funding of the HCH by the Federal Government is minimal, additional funding from State Governments and Private Health Funds may be necessary to make the model a success. The federal Government could assist by negotiating such payment levels as part of the HCH.

The RACGP is prepared and ready to work closely with the Federal Government on this major health reform – let’s not miss the opportunity to make Health Care Homes a success.

This article was originally posted on Croaky. Dr Edwin Kruys is vice-president of the Royal Australian College of General Practitioners (RACGP). 

The information in this article is based on public material provided by the Department of Health. Whilst all efforts have been made to ensure the details are accurate, information regarding Health Care Homes is subject to change.
Follow me on Twitter: @EdwinKruysDisclaimer and disclosure notice.

Table: Health Care Home requirements

(Source: Department of Health)

A general practice or Aboriginal Community Controlled Health Service applying to be a Health Care Home must be within one of the ten selected PHN regions and needs to:

  • be accredited and maintain accreditation, or be registered for accreditation, against the RACGP Standards for general practices;
  • participate in, or be prepared to participate in, the Practice Incentives Program (PIP) eHealth Incentive;
  • register and connect to the My Health Record system and contribute to their enrolled patients’ My Health Records;
  • participate in the stage one HCH training program;
  • use the patient identification tool to identify the eligible patient cohort in their practice or service, assess individual patient eligibility and stratify their care needs to one of three complexity tiers according to their level of risk;
  • ensure that all enrolled patients have a My Health Record;
  • contribute up to date clinically relevant information to their patients’ My Health Records;
  • develop, implement and regularly review each enrolled patient’s shared care plan;
  • provide care coordination for enrolled patients;
  • provide care for enrolled patients using a team-based approach;
  • ensure that all team members have roles that utilise their qualifications and allow them to work to their scope of practice;
  • provide enhanced access for enrolled patients through in-hours telephone support, email or video-conferencing, as well as access to after-hours care where clinically appropriate;
  • ensure that all enrolled patients are aware of what to do if they require access to after-hours care;
  • collect data for the evaluation of stage one and for internal quality improvement processes.

Why the proposed Health Care Homes are not about patient-centred care

Many of my patients ask for better quality of life, independence or patient-centred care. Patients also want their care teams to be on the same page. The government’s Health Care Home model seems to be about capitation and to some extent hospital avoidance, and may not address the needs of patients.

Data extraction
The government will be extracting patient data from general practice in various ways

Although the model has some elements that may reduce potentially avoidable hospitalisations, it does so half heartedly. Participating GP practices will likely have to categorise their patients using a data extraction tool based on the UK’s QAdmissions algorithm and the Hospital Admission Risk Profile (HARP) questionnaire.

The patient risk selection tool, which has not yet been released by the government, will be going through GP patient databases like a big vacuum cleaner to determine disease complexity and predicted demand for unplanned acute care services. Higher risk categories will attract a slightly higher practice payment.

What’s missing is just about everything else – in particular a comprehensive multi-pronged approach shared by primary care providers and hospitals, incentivising multidisciplinary patient-centred team care.

Capitation model

Although the government talks about a new bundled payment approach, practices are paid a lump sum per patient regardless of how many services the patient receives – as far as I know this is the definition of a capitation system.

How will the proposed model further improve the way care is delivered to people with chronic and complex health conditions? Will it incentivise multidisciplinary care? Does it reach across silos and improve communication? Is the proposed change of payment system in combination with a hospital avoidance risk stratification tool enough to deliver the comprehensive, coordinated care many of our patients need?

The government’s Health Care Homes model does not reflect the RACGP’s best practice model of the medical home, as outlined in the RACGP Vision for general practice and a sustainable healthcare system, released in September 2015.

The ‘biggest health reform in a generation’ did not receive extra funding from the government. I’m concerned that this is not yet the fundamental shift towards patient-focused healthcare as asked for by consumers and health professionals. What do you think?

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).