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 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.
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.
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.
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.
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.
The 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.
The 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.
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:
Mental health is today’s biggest health problem and will continue to be an issue in the future
The GP is the most accessible health professional and should be utilised to keep Australia well
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.
In an earlier post I mentioned the bizarre article published by a paediatrician from the University of Melbourne.
The article concluded incorrectly that “confidence with GPs is an issue for parents of many walks of life”. The paper was rejected by the Royal Australian College of General Practitioners (RACGP) and the Australian Medical Association (AMA).
The odd conclusions from the authors were reported by prime time media which in turn drew the attention of the ABC TV show Media Watch.
The article and subsequent reporting by some journalists attracted harsh criticism from presenter Paul Barry. And rightly so…
The authors reported the results of a survey about the confidence parents have in the paediatric care by Australian GPs. The survey was published in the Journal of Paediatrics and Child Health.
The findings showed that most parents are confident in their GP (only 2% of respondents was not very confident), yet the authors stated that “fewer than half of parents are completely confident in their GP to provide general care to their child (…).”
The authors conveniently omitted the ‘mostly confident’ category (45%) and only reported the ‘completely confident’ category (44%) as their main result. They then went on to conclude that this could potentially lead to “greater numbers of ED presentations for children with lower urgency conditions” and also suggested that GPs needed more paediatric training.
Record set straight
The poor research quality coming from the University of Melbourne has raised eyebrows. GPs voiced concerns that, as a result of the paper and the incorrectly informed media coverage, some parents may take their sick children to the emergency department (ED) instead of the GP.
But ABC’s Media Watch has now set the record straight.
In a reply on this blog lead author Professor Gary Freed previously said: “If you do not like how we presented the results of this parent survey, for whatever reason, I respect that. However, I sincerely hope that does not result in you and others ignoring the underlying issue of worrisome changes in paediatric care and education among GPs.”
We now know that these ‘worrisome changes’ are not confirmed by the results of Professor Freed’s survey which clearly shows that most parents have no problem with the care provided by 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.
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.
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.
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).
This joke was posted by a colleague. He pointed out that the scenario is very applicable to general practice. Indeed, it nicely illustrates the cost benefits of a good doctor who can often make a diagnosis without many expensive tests…
A woman brought a very limp duck into a veterinary surgeon. As she laid her pet on the table, the vet pulled out his stethoscope and listened to the bird’s chest.
After a moment or two, the vet shook his head and sadly said: “I’m sorry, your duck, Cuddles, has passed away.”
The distressed woman wailed: “Are you sure?”
“Yes, I am sure. Your duck is dead,” replied the vet.
“How can you be so sure?” she protested. “I mean you haven’t done any testing on him or anything. He might just be in a coma or something.”
The vet rolled his eyes, turned around and left the room. He returned a few minutes later with a black Labrador Retriever. As the duck’s owner looked on in amazement, the dog stood on his hind legs, put his front paws on the examination table and sniffed the duck from top to bottom.
He then looked up at the vet with sad eyes and shook his head. The vet patted the dog on the head and took it out of the room.
A few minutes later he returned with a cat. The cat jumped on the table and also delicately sniffed the bird from head to foot. The cat sat back on its haunches, shook its head, meowed softly and strolled out of the room.
The vet looked at the woman and said: “I’m sorry, but as I said, this is most definitely, 100% certifiably, a dead duck.”
The vet turned to his computer terminal, hit a few keys and produced a bill, which he handed to the woman.
The duck’s owner, still in shock, took the bill. “$150!” she cried, “$150 just to tell me my duck is dead!”
The vet shrugged. “I’m sorry. If you had just taken my word for it, the bill would have been $20, but with the Lab Report and the Cat Scan, it’s now $150.”
The co-payment is coming back. Australians will have to pay more for a visit to the GP or specialist. The freeze on your Medicare rebate means you will get less back from Medicare. It is expected that many practices will stop bulk billing. Join the ‘You’ve been targeted’ campaign and let your local member know that you oppose the freeze on your Medicare rebates.
The Federal Government is reducing its investment in your healthcare by freezing your Medicare rebates. This means your Medicare rebates will remain the same until 1 July 2020, despite the cost of delivering healthcare services increasing (see graph below).
The freeze is a co-payment by stealth and the Government has implemented this measure to reduce the amount it spends on all Medicare subsidised services, including general practice services.
Your health is important. Please do not let the freeze on your Medicare rebates stop you from seeking the healthcare you need.
What can you do?
Join the ‘You’ve been targeted’ campaign which aims to lift the freeze on your Medicare rebates. Go to the website of the Royal Australian College of General Practitioners (RACGP): yourgp.racgp.org.au/targeted to access campaign materials including a template letter you can send to your local political candidates demanding the freeze be lifted.
Indexation of MBS patient rebates should keep pace with the costs associated with providing quality health services and employing highly trained and skilled staff, while supporting patient access to services. This illogical decision further demonstrates the government’s continuous disinvestment in general practice.
How will the freeze affect you & your GP practice?
The MBS rebate freeze will affect all practices, GPs and patients
The cost of providing services will continue to increase while MBS rebates remain frozen
Practices where most services are privately billed will need to meet those costs through increasing out-of-pocket payments
Practices where a large proportion or all services are bulk billed will be significantly affected. The rebate freeze will have a detrimental impact on the viability of the practice. These practices may need to consider introducing or increasing out-of-pocket expenses to ensure the sustainability of the practice
The impacts will be magnified for GPs and practices providing patient services in lower socio-economic areas, where a majority of patients are from vulnerable groups (such as pensioners, Aboriginal and Torres Strait Islander peoples and people on very low incomes). Many people in these areas cannot afford to meet out-of-pocket costs for care
Unable to absorb the reduced rebate over time, some general practices will have no option other than to close, leaving the most vulnerable groups unable to access care.
The next government
Doctors call on the newly elected government to invest in quality and sustainable general practice and strengthen patient services by:
Many GPs feel disempowered in the current climate of cuts and freezes. It is indeed hard to comprehend why governments slash funding to the most efficient and cost-saving part of the health system.
We are all concerned about the lack of continuity of care and increasing fragmentation in our healthcare system, but what about the divisions within our own ranks?
Part of what makes general practice attractive is its diversity, but it also makes general practice prone to divisiveness. Think, for example, of the stereotypical dichotomies: generalists vs partialists, private practice vs corporates, rural medicine vs metropolitan general practice, etc.
GPs are highly respected in the community, but have become an easy target because of marginalisation and fragmentation. It is a well-known secret that governments play different GP groups off against each other, choosing to include or ignore organisations in their deliberations and negotiations.
Lack of unity also opens the door for disruption by third parties.
It is clear that general practice needs an urgent cultural change. Just like surgeons are working on improving the bullying culture, we must address the disharmony and division that afflicts us.
How good would it be if practices worked together instead of competing? If GPs could get together and agree on issues important for their area? If peak bodies would team up and better coordinate strategy, policy development, campaigns, conferences and membership services?
There is a whole generation of GPs that don’t understand why we have so many representative organisations. These young doctors are concerned about the disadvantages. Why don’t general practice organisations support each other, why are there multiple memberships and so much duplication? I believe they are right.
We have much more in common than what sets us apart, so why are we so tribal?
I can think of a few reasons. The first that comes to mind stems from social psychology; our brains may be programmed to organise us into small tribes because of evolutionary advantages, such as social bonding and survival.
There are also economic motivations, for example, GP clinics currently compete for patients. Our peak bodies are based on membership and need to offer benefits; this encourages competition rather than collaboration.
Reform fatigue may be another reason why some of us have stopped caring about achieving common goals. Experienced GPs can tell us the tales of the many system changes they have witnessed over the years; reform comes and goes and often disrupts our day-to-day practice. The risk is that we become cynical about what our profession can achieve in Canberra.
Perhaps there is also a selection bias. It is possible that GPs prefer more autonomy than our hospital colleagues, and although we work increasingly in teams, we may be less group-oriented or prefer smaller tribes.
Finally, doctors are trained to be leaders. We’re masters in problem solving and good at making difficult decisions, often in challenging and stressful situations.
We’re independent thinkers, skilled at arriving at our own conclusions and giving strong opinions. But we are not a profession of followers. The success of organisations depends on how well their leaders lead and how well their followers follow.
United General Practice Australia (UGPA) could connect the dots here. It’s an umbrella group for all the main groups, including the RACGP, ACRRM, AMA, RDAA. Those taking part have shown a desire to put aside their differences to a certain extent.
However, the status and governance of UGPA is somewhat vague. There is also no website or official spokesperson. But it is a start, and I would love to see this organisation be given the opportunity to grow and represent us all.
Lastly, we need to find common ground and partner with patient health organisations, as governments listen to the public more than they do to doctors.
The time has come to stop and think about where we want to go. More unity would require a cultural shift, excellent skills in following others, trust and willingness to compromise — not just from our leaders, but from all of us.
This article was originally published in Australian Doctor Magazine.
The passionate country doctors featuring in these videos with their patients are great examples for rural general practice. Warning: After watching the interviews you may feel the sudden urge to pack your bags and move to the country.
Dr Ken Wanguhu: “Being a GP has taught me that there is a lot more to medicine than disease… It goes beyond the disease to the patient and their family and to the community, and that’s general practice.”
The second video features Dr Mel Considine and her patient Phil from rural South Australia. Phil: “And the first thing I remember was this lovely lady leaning over me, and she said ‘I’m Doctor Mel, the duty doctor today, and I’m here to look after you.'”
Do you know that situation – usually at a party – when someone tells you what they do for a living, and mention a cool sounding job description like ‘product innovation manager’ or ‘advertising account executive’? I always want to know: what does that mean and what do you actually do?
Well, people never ask me what I do when I say I’m a GP. Instead, they usually tell me what their GP does. Or did. Or said.
Everybody always knows what I do, and that’s not surprising because the Australian general practice statistics are mind-blowing: Over 134 million GP consultations take place each year. Every year almost 9 out of 10 Australians make at least one contact with a general practitioner.
“Mothers, children, the elderly and those with chronic conditions, such as diabetes, asthma and hypertension, have many more contacts than that. As a result of these personal contacts everyone has a view about general practice. Ministers of Health have been known to base their views about general practice on their contact with their own GP.
I’m privileged to have a job that’s smack-bang in the middle of life. One could indeed argue that we’re specialists in life, as we deal with just about everything: mental health, paediatrics, cancer, skin disorders, respiratory problems, grief, heart failure, domestic violence, emergencies, pregnancy, end-of-life care, immunisations, screening… you name it.
The latests RACGP commercial tells the story of diversity – the diversity of GPs, their patients and their conditions. I love the commercial because it captures in 60 seconds the wide range of issues people bring to the consulting room of the family doctor.
So if you want to find out what really happens in my office, have a look at this video.
Is the family doctor who provides ongoing care a thing of the past? Not really.
In part 1 I mentioned the three types of continuity of care: informational, management and relational continuity. Continuity in primary care results in improved patient health outcomes and satisfaction. Evidence also shows that primary care, in contrast to specialty care, is associated with a more equitable distribution of health.
Receiving care from one general practitioner is beneficial for a variety of health outcomes. For example, relational continuity reduces both elective and emergency admissions. In other words, the rate of hospital admissions drops when people have their own GP.
6 mechanisms that improve our health
Primary care researcher Barbara Starfield identified six mechanisms that, alone and in combination, may account for the beneficial impact of primary care on population health:
Primary care increases access to health services for relatively deprived population groups
The quality of clinical care by primary care physicians is at least similar to specialist care for specific common diseases
The positive impact of primary care on prevention
The beneficial impact of primary care on the early management of health problems
The accumulated contribution of primary care characteristics to whole-of-person care
The role of primary care in reducing unnecessary or inappropriate specialty care.
Starfield: “There is now good evidence, from a variety of studies at national, state, regional, local, and individual levels that good primary care is associated with better health outcomes (on average), lower costs (robustly and consistently), and greater equity in health.”
General practice can deliver long-term, cost-effective continuity of care. A visit to the GP is on average ten times cheaper than a visit to the emergency department. Dr Sebastian Seidel mentioned at a Senate Inquiry last month that GP services in Australia cost taxpayers only $250 per person a year – cheaper than car insurance.
In Australasia, chronic conditions account for about 85% of the total burden of disease, and in 9 out of 10 deaths a chronic disease was a contributing factor.
Unfortunately there is currently inadequate support for the continuity of care required to improve outcomes for patients with complex or multiple chronic conditions and comorbidities.
The Australian government is developing a National Strategic Framework for Chronic Conditions and recently, the Primary Health Care Advisory Group has investigated options into the reform of primary health care to support patients with complex and chronic illnesses. The group’s reform paper is complete and handed to the Federal Health Minister. It will be very interesting to see what happens next.
Although I am more than likely biased, it is obvious to me that primary care has a lot to offer. Continuity of care by general practitioners and their teams has many proven benefits as outlined in part 1 and part 2 of this blog post series.
GPs see about 85% of Australians each year but general practice spending represents less than 8% of the overall government healthcare budget. What we need is better aligned funding that supports primary care practitioners to deliver long-term quality care.
A sustainable health system should free up GP teams and other health practitioners to deliver coordination and integration of care across disciplines, especially for people living with complex and chronic health conditions. Looking at the reform processes that are under way in Australia, we may be getting closer to a better and more sustainable solution.
A few years ago, when I was boarding a plane I picked up The Times newspaper and noticed a big headline stating: ‘The family doctor is going out of fashion’. In the article journalist Matthew Parris explained why young people prefer to go to the emergency department. I kept the article as I thought it would be a great blog topic, but for some reason I forgot about it – until something jolted my memory.
Last month I had the pleasure of meeting with the Board of Health Consumers Queensland. I enjoy conversations with consumer representatives as I always learn something, even though these exchanges are usually slightly confronting. One of the topics we touched on was continuity of care, or better, the perceived lack thereof in general practice by consumers. During the drive back home to the Sunshine Coast I suddenly remembered the article in The Times.
In 2013 Parris wrote: “Very gradually the era of the personal physician is drawing to a close.” He said he noticed a trend in the UK where younger, busier people were going directly to specialist accident & emergency departments and argued that they don’t want a local GP because working men and women in a hurry will be attracted to a place where they can walk from one room to another and access the specialism they need.
So, I wondered, is the family doctor who provides ongoing care a thing of the past? Am I really a dying breed – the last of the Mohicans?
What exactly is continuity of care?
In primary care literature continuity is often described as the relationship between a single practitioner and a patient that extends beyond specific episodes of illness or disease. To confuse the situation other terms are used synonymously, such as ‘care coordination’, ‘integration’, ‘care planning’, ‘case management’ and ‘discharge planning’. On top of that the experience of continuity may be different for the patient and the health practitioner, adding to even more misunderstandings.
Continuity is how individual patients experience integration and coordination of care.
The authors of an article in the BMJ titled ‘Continuity of care: a multidisciplinary review’ said that continuity is not an attribute of practitioners or organisations. They defined continuity as the way in which individual patients experience integration of services and coordination. And also: “In family medicine, continuity is different from coordination of care, although better coordination follows from continuity. By contrast, a trade-off is required between accessibility of healthcare providers and continuity.”
There are three types of continuity of care:
Informational continuity: The use of information on past events and personal circumstances to make current care appropriate for each individual
Management continuity: A consistent and coherent approach to the management of a health condition that is responsive to a patient’s changing needs
Relational continuity: An ongoing therapeutic relationship between a patient and one or more providers.
Continuity is more than just sending a message to another health practitioner, or uploading a piece of information to an e-health database. Understanding of individual patients’ preferences, values, background and circumstances cannot always be captured in health records; health providers who have a longstanding relationship with their patients often have this information in their heads.
“Poor continuity gives rise to high risk medicine
In 2010 Dr Frank Jones wrote in Medicus: “Poor continuity gives rise to high risk medicine. Ideally continuity should be personal and longitudinal – the essence of the traditional general practitioner. However the very concept of continuity gets more complicated nowadays. How does it apply to single-handed GPs or to group practices?”
Indeed, continuity of care exceeds disciplinary and organisational boundaries. The Royal Australian College of General Practitioners describes continuity of care as “the situation where patients experience an episode of care as complete, or consistent, or seamless even if it is provided in a number of different consultations by different providers.”
The benefits of continuity
There is abundant evidence that continuity in primary care results in improved patient health outcomes and satisfaction. Evidence also indicates that primary care (in contrast to specialty care) is associated with a more equitable distribution of health.
GPs often manage up to 4 problems per visit, which is of course more efficient than walking ‘from one room to another’ in an emergency department or hospital outpatient department. Overall, primary care is associated with lower total costs of health services.
Looking at the primary care reform processes that are under way in Australia, it is not unlikely that the multidisciplinary general practice team will be the key component in the care for people with chronic and complex health conditions.
In part 2 I will discuss the six methods GPs use to improve our health, according to world-renowned primary care researcher Professor Barbara Starfield, and why primary care plays an important role in a sustainable health system.
The only thing worse than being blind is having sight but no vision (~ Helen Keller)
I am really pleased to say that we now have an excellent vision for a sustainable Australian healthcare system and general practice.
The final version of the vision was released by RACGP president Dr Frank Jones at the GP15 conference in Melbourne this week. It is based on feedback from over 1,000 GPs, stakeholders and consumer groups.
There are 2 elements of the vision that make it remarkable:
#1: the medical home
A stable and enduring relationship between a patient and a GP has a positive impact on health outcomes. The medical home encourages voluntary patient registration with a preferred practice. It will benefit patients and doctors as it allows for continuity of care and effective, better-targeted coordination of care to meet patient needs.
Patients may choose whether to enrol with a practice of their choice. Likewise, GPs and practices may choose to take part in the program.
Patients will be able to visit any general practice for standard care, but chronic disease management, integration of care and preventive health will be limited to their medical home.
#2: a new funding model
The RACGP proposes a major overhaul of the current funding system. It’s a flexible model and includes support for GPs and their teams to deliver multidisciplinary teamwork and coordination work on behalf of their patients.
A comprehensiveness payment made to a practice would recognise the practices and practitioners that provide a broad range of services to the community.
The current PIP and SIP regimes need to be replaced by practitioner support and practice support payments as outlined in detail in the vision document.
The story of general practice is told in this new RACGP video, spoken by Sigrid Thornton. It’s made really well and it nicely captures the broad spectrum of care delivered by Australian general practitioners.
On his blog Dr Yong shares ideas about healthy living: “It’s about getting back to basics and building a strong foundation of health. It’s about turning your good intentions into lasting change. It’s about you taking control and living a better life.” Very inspiring.
‘The healthy GP – Live intentionally, love relentlessly and enjoy your health.’ By Dr Jonathan Ramachenderan
Dr Ramachenderan and his family live in the country in Western Australia where he practices as a General Practitioner and anaesthetist. He has some excellent advice for men and dads.
“We are in the busy, child rearing season of life coupled with the beginning of my career and hence achieving a balance is important. I am passionate about men’s health, helping and communicating with other dads, building stronger relationships with our wives and becoming wiser, stronger and more insightful men.”
‘Armchair rants from Dr Deloony, musings on Medicine and Life.’ By Dr Claire Noonan
Dr Noonan is a country GP and freelance writer. “My interests, medical and otherwise include but are not limited to: humans, science, general practice, bariatric medicine and surgery, fiction, music, travel, food/nutrition, mental health, philosophy and kittens. I am VERY interested in kittens.” Personal and well-written posts.
‘DrJustinColeman – Medical writer, editor, blogger.’ By Dr Justin Coleman
Dr Justin Coleman is a well-known GP-writer who looks sceptically at health interventions where the evidence suggests they might not actually be worthwhile. This is part of his broader interest in the public health concept of equity – fair access to primary health care for everyone.
As he writes on his blog: Despite earnest intentions, he frequently breaks out into lighter reflections on GP practice, with its quirks and oddities – often discovering the oddest person in the room is him!
‘Genevieve’s anthology – Writings to amuse, teach, inspire and entertain.’ By Dr Genevieve Yates
The multi-talented Dr Yates is not only a freelance columnist and novel/play writer, but she also finds the time to play and teach violin and piano, sing, and play in two orchestras.
“This website features a collection of my writings. Here you will find links to and samples of my newspaper columns, novel, short stories, plays and creative medical educational material, plus the odd blog or two.”
‘Dr Charles – The blog musings of Dr Charles Alpren.’ By Dr Charles Alpren
Dr Alpren worked at (and blogged about!) the Ebola Treatment Centre in Sierra Leone. He is currently a locum GP who works all over Australia. He has an interest in children’s health, vaccinations and infectious disease, and is also interested in teaching and Public Health.
‘KarenPriceBlog – Hippocrates meets Xanthippe.’ By Dr Karen Price
Miscellaneous topics and reblogged posts – often with thought-provoking commentary by Dr Price. Dr Price is Chair of the Women In General Practice Committee of the Victorian RACGP.
“I am active on Twitter and interested in technology as it relates to health. I am prone to an occasional rant so the picture of me with a thistle is probably appropriate. I welcome respectful debate as it contributes to the Science and Art of Medicine.”
‘FOAM4GP – Free Open Access Meducation 4 General Practice.’ Various authors
Excellent and comprehensive collection of blog posts and podcasts by various rural and city GPs.
“This blog and podcast is for Australian General practitioners, training to be one or already working as one. We cover the whole range of our medical specialty and give you what you need to pass your exams and keep learning in your clinical practice.”
The blog was founded by Dr Rob Park, Dr Minh Le Cong, Dr Casey Parker, Dr Tim Leeuwenburg, Dr Jonathan Ramachenderan, Dr Melanie Considine and Dr Gerry Considine.
‘Michael Tam – Publications archive.’ By Dr Micheal Tam
Michael Tam is a Staff Specialist in General Practice at the Academic General Practice Unit in Fairfield Hospital, in Sydney. His blog is a collection of interesting research articles and interviews.
Dr Tam’s clinical interest is in comorbid substance use disorder and mental health disorders. His research interests are in the detection of at-risk drinking in the primary care setting, and in e-learning in medical education.
‘GreenGP – Reflections of a Rural GP.’ By Dr Melanie Considine
An interesting blog with lots of medical conference reports, tips for students and GP registrars – including how to use social media. Dr Considine is a board member of the SA/NT RACGP Faculty and the RACGP National Rural Faculty.
‘Broome Docs – Medical education blog for rural GPs.’ By Dr Casey Parker
Top blog intended to provide a single source of up-to-date educational material for country doctors.
“I hope this site can expand this brain pool of rural doctors – please feel free to leave comments on the cases and posts presented – we can all learn from one another – no matter how far we are from the really smart guys in the big centres.”
‘THE PHARM – Prehospital and retrieval medicine.’ By Dr Minh Le Cong
Dr Le Cong’s comprehensive blog is for the health professionals working in remote locations, outside a hospital, on aircraft, ambulances, in outposts who have to deal with emergencies and the unexpected.
“My focus is rural Australia but my journey will be international, hearing from folks in other countries and how they deal with out-of-hospital emergencies. Of course I am a flying doctor so there will be a healthy dose of aeromedicine.”
‘KI Doc – Kangaroo Island doctor blogging about Rural Medicine in Australia.’ By Dr Tim Leeuwenburg
Encouraged by emergency medicine and retrieval medicine blogs such as EmCrit, Resus.me, BroomeDocs and Prehospitalmed, Dr Leeuwenburg has embraced the #FOAMed paradigm: “Whilst the lifeinthefastlane emergency physicians have lead this in Australasia, I reckon #FOAMed has a lot to offer rural doctors.” Excellent blog.
Ginni Mansberg is a well-known, celebrity doctor in Australia. She is a Sydney GP sidelining for Sunrise & Morning Show, various magazines, and is a self-proclaimed wannabe Masterchef and caffeine addict.
‘Do It Yourself Health DIY Health), Healthy Living and Health Information from Dr Joe.’ By Dr Joe Kosterich
Dr Kosterich is a well-known GP, author, and keynote speaker. “Your well-being is the most important thing you have. My passion is empowering you to take charge of your own health through easy to understand steps enabling you to live well for longer.”
‘PartridgeGP – professional, comprehensive and empowering healthcare.’ By Dr Nick Tellis
This is a great example of a practice website with health tips and interesting newspaper articles and reblogged posts including comments by Dr Tellis. Dr Tellis is passionate about great quality General Practice and is enjoying beach-side practice after seven years in rural South Australia.
Dr George Forgan-Smith is a GP and passionate gay doctor in Melbourne Australia: “I have a strong interest in male health, mental health and health promotion. I enjoy writing and teaching and I hope that this website may help to inspire other men to move towards health in all aspects of their life.”
‘The Influence of the Tricorder.’ By Dr Tim Senior
Dr Senior has an interest in Aboriginal health & medical education. Other themes he often writes about are environments that keep us well and social justice.
His blog is an amazing collection of various articles he has published over the years. “I write stuff. It ends up in various places on the web. This site keeps track by linking to it all from one place.”
A well-written and beautiful blog about solving healthcare problems with creativity, intuition and insight with lean and inexpensive innovations. Dr Jiwa is Professor of Health Innovation at Curtin University and a GP practicing in Western Australia. He is also the Editor in Chief of The Australasian Medical Journal.
‘Dr Thinus’ musings – This is Canberra calling.’ By Dr Thinus van Rensburg
“Canberra – we love it and, despite what the rest of Australia might think, it is not just about pollies and Public Servants. It has it’s ups and downs but this is our hometown and I hope readers enjoy my occasional posts.” Honest commentary on a variety of articles and reblogged posts by Dr Van Rensburg.
There were a few interesting tech news facts this week. I thought this one was interesting: a Dutch campaign group used a drone to deliver abortion pills to Polish women, in an attempt to highlight Poland’s restrictive laws against pregnancy terminations.
There was scary news too: a private health insurer encouraged its members to use a Facebook-owned exercise app to qualify for free cinema tickets. Not surprisingly, Facebook was entitled to disclose all information shared via the app, including personal identity information, to its affiliates.
But there was also this: Telstra has launched its ReadyCare telehealth service. For those willing to pay $76, a doctor on the other end of the phone or video link is ready to care for you. No need to visit a GP or emergency department.
The telecom provider will offer the service to other parties like aged-care facilities and health insurance funds. Telstra is aiming for a $1 billion annual revenue.
Digital developments increasingly create new opportunities, challenges and risks, but we have yet to find ways to incorporate the new technologies in our existing healthcare system.
In an interview in the Weekend Australian Magazine Google Australia boss Maile Carnegie warned that the digital revolution has only just started and that Australia is not ready for the digital challenges ahead.
Carnegie said that 99% of the internet’s uses have yet to be discovered and although Australia is the 12th largest economy in the world, it ranks only 17th on the Global Innovation Index.
She said that Australia has become a world expert at risk-minimisation and rule-making. Unfortunately this seems to slow down innovation.
“We are either going to put in place the incentives and the enablers to create the next version of Australia as a best-in-class innovation country or we’re not,” she said. “And I think it’s going to be a very stark choice that we have to make as a community.”
Who’s taking the lead?
In the last ten years we have seen major progress in for example mobile technology, but my day-to-day work hasn’t changed much. Healthcare has difficulty harnessing the benefits of the digital revolution.
Is the industry leading the way and letting governments, software developers and other parties know what is required? Do we have industry-wide think tanks to prepare for the near future? Have we listened to what our patients need and expect from us in the 21st century? And will Medicare eventually reimburse services delivered via modern technologies, such as pioneered by Telstra?
Many of us use Google to look up health information. Even doctors google. I often use the search engine to show my patients for example images of anatomy or skin problems. As more people become tech-savvy and websites get better, I expect that Dr Google will be even more popular in the near future.
A study published in the Australian Family Physician in 2014 found that 63 percent of patients accessed the internet in the previous month; 28 percent had sought health information online; and 17 percent had obtained information related to problems addressed during a GP visit.
The challenge is of course to find reliable information. To help you pick the right sources here’s a list of trustworthy websites containing useful general information about common health problems. These sites often show up in search results.
It is recommended to check with your GP or specialist that the information is applicable to you. Your doctor may be able to recommend some good resources too.
Of course this is only a basic list of Australian websites. There are many other Australian and international sites with disease specific information. If you know of a particular good source, please feel free to mention it in the comments section below.
One word of warning: Information on the web is sometimes outdated or incomplete. But occasionally it is deliberately incorrect or manipulated, for example to make you buy something. To help you differentiate the good from the bad, have a look at this post: 6 warning signs that online health information may be unreliable.
In the ‘Blogging on Demand’ series you get to choose the topic. If you have a great idea you want the world to know about, feel free to contact me. Northern NSW GP and technophile Dr David Guest feels that one particular low-cost health-IT solution from New Zealand, called GP2GP, is worthy of more discussion and would make a big difference in Australia.
I admit it’s odd: Every time a new patient presents, the receptionist will see to it that a huge pile of paper notes ends up on my desk, often held together by paperclips or elastic bands.
I usually move the pile over to one side and look at it for a couple of days to see if the documents will disappear which, so far, hasn’t happened. Then, during a lunch break, I bite the bullet and trawl through the record, under while entering the data into the computer: allergies, medications, history, family history etc.
Important documents are scanned and shredded. When a patient at any stage decides to leave the practice, the receptionist prints the record and faxes it to the next GP. When it’s a large record she will make sure it’s held firmly together by paperclips or an elastic band before it goes to the post office in a big envelope.
Getting computers to solve this problem for us is an issue in Australia, because our IT systems don’t communicate. But in New Zealand and the UK they have found a way to transfer health records electronically. It’s called e-mail. Well, not really, but there are similarities.
Simply put, GP2GP is a software application that securely transfers an electronic health record from one practice to another, and automatically stores information in the relevant sections of a patient’s record.
Dr Guest: “Although I support the PCEHR one cannot help but feel frustrated by the slow pace of change and the limited functionality it provides. In recent times I have become much more interested in simple low-cost achievable IT solutions.”
“It would be great to emulate the UK and NZ ability to transfer medical records from one practice to another. Auto-populating medical lists, health summaries, allergies and vaccinations will save time and reduce medical errors. New Zealand has reportedly done this for less than a million dollars. Given the lack of progress in Australian health IT, it seems a no-brainer to replicate this.”
“Patients have a reasonable expectation and entitlement that information can be easily transferred to their new practice
RACGP e-health spokesperson Dr Nathan Pinskier says: “Australians legitimately change their GP and general practice for a number of reasons, for example because their GP retires, practices merge or people relocate. Approximately 10% of Australians move home each year. Patients have a reasonable expectation and entitlement that personal healthcare information held by their current general practice can be easily transferred to their new practice.”
“Transferring data via a physical medium, like discs and USBs, is problematic as they only work well between compatible systems. The PCEHR allows for the sharing of some clinical documents via a point to share environment, however this requires the patient and both the old and the new general practices to be registered with the PCEHR.”
“Furthermore the documents that may be available for transfer may not always be the information required by the new general practitioner, as documents can be restricted or removed by the consumer. The PCEHR is after all, by definition, the consumer’s personally controlled healthcare record.”
Dr Guest: “The elements enabling this transfer of data already exist in Australian electronic health records software. Most products can export their data in machine readable formats such as XML. They can also import an XML-file produced by their own software from other practices. There needs to be agreement on a standard structure for the XML-data and this is what NZ and the UK have achieved. We should use their format and then enforce it.”
The process of posting paper records and manually entering data is inefficient. Patients First, the New Zealand not-for-profit organisation responsible for introducing GP2GP, states on its website: “This results in a significant safety risk each and every time a person changes their GP.”
Indeed, when doctors or staff enter data manually, there is the potential to make mistakes.
“Having this knowledge at their fingertips will lead to improved clinical decision-making
According to Patients First, there are many benefits:
“With GP2GP, general practitioners will have detailed knowledge of their new patient’s current medication, allergies, current problems and past medical history. Having this knowledge at their fingertips will lead to improved clinical decision-making so that the right care can be provided at the right place and at the right time thus reducing the risk to patient safety during the handover of care.”
Lastly, a benefit that has been claimed is a reduction in the number of duplicate tests.
“The major issue is developing an agreed set of standards for both the content and technical requirements for point to point transfer that can be implemented by any vendor,” says Dr Pinskier. “The RACGP Optimus project has made significant progress in relation to defining the content, however there is no national program to address and fund the technical transfer work.”
Some have argued that there is no business case for software vendors to develop GP2GP in Australia. In New Zealand and the UK the project received Government funding.
The reduction in workload may not be as substantial as we would like. GP Emma Dunning pointed out in New Zealand Doctor Magazine that doctors still need to review the imported data:
“Where I used to be demoralised by the huge pile of paper notes awaiting my attention, I am now demoralised by the stream of tasks on my taskbar, in red, saying ‘GP2GP notes imported, review’. My lightbulb may never be green again!”
A 2011 pilot study from the UK found that the record transfer system was valued, but that there were issues with the quality of the records, which required significant resources to rectify. The New Zealand version also experienced teething problems.
Urgent national priority
Nevertheless, the adoption rate in the UK is 62% (2013), and in New Zealand 93% (2014) with 30,000 transferred records per month.
“I think it is excellent and it saves a lot of time
GP Dr Richard Medlicott, who is a member of several e-health task forces in New Zealand, is content: “Personally I think it is excellent and it saves a lot of time. It’s even better since we increased the file limit from 5 MB to 20 MB. I can’t see any reason you wouldn’t use it.”
According to Dr Pinskier making our systems talk to each other has become an urgent matter: “To support efficient healthcare delivery and continuity of care, we need an agreed mechanism for the safe and efficient transfer of clinical information. One would argue that this is now an urgent national priority.”
It seems GP2GP could be a cost-efficient improvement in Australian healthcare, but the question will be: who pays?
Thanks to Dr David Guest for the topic suggestion.
You don’t see or hear doctors talk about themselves in public very often. Yet it happened last night – on Twitter.
Just when I thought I had seen it all, the Royal Australian College of General Practitioners organised its first twitter chat for GPs. The topic was ‘doctors treating doctors’.
It was a great example of effective social media use and a free, open access learning opportunity for social media savvy GPs. Doctors are usually not the best patients, nor are they always comfortable looking after colleagues. It was heartening to see that the RACGP and many doctors were willing to discuss these personal topics on Twitter.
The chat was unique for several reasons:
It took place on a public forum
Doctors openly discussing their own care doesn’t happen every day
It was the first twitter chat organised by the RACGP
Doctors could earn CPD points by participating
Twitter chats go at high-speed – especially when there are many participants. This can be a challenge, but the amount of valuable information shared within that one hour was amazing. I certainly learned a lot, and for me it was a reminder to book an annual check-up with my GP.
Thrilled to see this first live Twitter Ed event for Aussie GPs run by @RACGP. It’s been a long time coming! Peer to peer at its best.
Couldn’t agree more. You can check it all out under the Twitter hashtag #RACGPed.
Many thanks to the RACGP(WA), Dr Penny Wilson, Dr Hilton Koppe and Dr Sean Stevens for organising the first RACGP Twitter chat.
The numbers are telling: About 1,500 UK doctors move to Australia and New Zealand each year. This exodus is causing havoc in England. A GP-shortage creates high workloads and overstretched doctors, and a survey showed that over half of UK GPs plan to retire before the age of sixty. This stressful situation has prompted a coming home campaign to entice doctors to go back to the United Kingdom.
Why are doctors leaving, and, will they move back to save the NHS?
Dr Nathalie Departe is a UK-trained GP working in Fremantle, Western Australia. “I moved to Australia in 2009 for a change of scenery. I had visited Australia before and loved it, so when my husband found himself in a career hiatus, we thought we would enjoy the sunshine for a few years.”
“Working in Australia was a breath of fresh air. Patients were pleased to see me, understanding if I ran late, and I was rewarded and not penalised if I spent time with a complex patient to sort out their management. Access to pathology and radiology services was prompt, rather than a standard 6-8 week wait for an ultrasound, and access to allied health services didn’t compare – good luck trying to see a clinical psychologist on the NHS.”
“Initially it was a bit odd to bill patients and not provide free care at the point of need, but I soon came to value the transparency of the transaction. The integration between private and public care makes private care accessible and affordable in Australia, rather than in the UK where private care has to be funded in full.”
Escaping the NHS
“In Australia I can arrange imaging quickly, receive the results the next day and organise appropriate and timely care
Dr Janaka Pieris moved to Brisbane in 2010 to ‘escape’ the NHS: “When I think back to my working life as a GP in South East London, I have two overriding memories: there was never enough time in the day to do the work asked of me, and there was no means of limiting my workload. NHS General Practice is a sink for everything no-one else will take responsibility for. Many GPs feel unable to decline these demands – many of which are not NHS work and therefore unfunded – and as a result, are drowning in work.”
“When a patient presents with painless obstructive jaundice in the UK, I have no option but to refer in to hospital, because I have no access to appropriate imaging, or I cannot get it done in a timely fashion. In Australia I can arrange the imaging quickly, receive the results the next day, discuss the case with a specialist and organise appropriate and timely care. It is much more satisfying from a professional perspective.”
Dr Tim Leeuwenburg made the move in 1999, immediately after his internship in the UK. He is now a GP at Kangaroo Island in South Australia. “I was married to an Aussie and always knew I’d be coming to Australia for love and a better lifestyle.”
“That was 15 years ago. Since then I’ve vicariously witnessed the demise of UK medicine – and am anxious that Australia doesn’t make the same mistakes: Other professions trying to do doctors’ work, capitation and performance payments, privatisation, walk-in clinics, phone advice lines, revalidation. They are all seemingly good ideas, but not evidence-based and all have served to emasculate the profession and increase the number of doctors seeking to retire, locum or emigrate from the cesspit that is the NHS. None of these measures have reduced costs or increased quality.”
“The myth of the ‘fat cat’ wealthy GP laughingly enjoying his round of golf whilst poor patients helplessly waited for his attentions was regularly portrayed in the media
Departe: “Despite working in a nice area and enjoying my job, I had a growing sense of unease with the way UK general practice was going. There seemed to be ever changing targets to qualify for practice payments with increased red tape and less time for consultations.”
“There was a general loss of respect for the role of a GP; it was not unusual for patients to demand medication, tests and home visits inappropriately, then to be outraged if you questioned the need for it. The myth of the ‘fat cat’ wealthy GP laughingly enjoying his round of golf whilst poor patients helplessly waited for his attentions was regularly portrayed in the media, and I felt that general practice was being devalued in the eyes of public and politicians alike.”
Dr Mark McCartney left the UK in 2013 because he was not happy with the working conditions in the NHS, but moved back to England after 12 months because of family circumstances. “There is a huge cultural difference in Australia, where there is a mixed health economy of private and state-subsidised services. The NHS is free at the point of access for patients, and service always struggles to meet the demand and prioritise appropriately. UK hospitals are dysfunctional places and the effects of this trickle into General Practice.”
“UK GPs are mostly paid on the basis of capitation payments depending on the number of patients registered, with additional payments for reaching clinical targets and a small amount of fee for service payments. There is now a shortage of GPs and we work in an environment of running faster and harder just to meet demands, without additional incentives or resources.”
“Australian GPs have the luxury of earning a high proportion of income from fee-for-service payments, including patient fees and Medicare payments. The more patients they see and the more services they provide, the more they earn. Clinical practice is also more interesting with rapid access to x-rays and scans. It is a professionally motivating environment to work in.”
Would you move back to the UK?
Dr Pieris is sceptical about the fully funded induction and returner scheme: “Firstly, it is manifestly insulting to suggest that doctors who have worked in similar systems, such as Australia, need retraining to work in UK general practice. I do more medicine in Australia than ever I did in the UK.”
“Secondly, if people are leaving because of a failed system, a sensible approach would be address those failings, not try to tempt people back into the same environment they left.”
“To return would require most GPs to undertake 6-12 months of supervised training, and to surrender to ridiculous bureaucratic imposts
Departe: “Why would I return to a role where I am restricted in my clinical practice by financial constraints, strangled by paperwork, stressed out by time pressures, undervalued by patients and politicians and where I would earn less money for more work and more stress?”
“To return would require most GPs to undertake 6-12 months of supervised training, and to surrender to ridiculous bureaucratic imposts,” says Leeuwenburg. “The reason doctors are leaving the NHS is because of unfettered demand from patient ‘wants’ not ‘needs’, and reduced income as a result of capitation. Why on earth would you go back?”
McCartney: “Very few GPs will return, unless they have personal or family reasons. UK GPs are retiring early, but this does not seem to be the case in Australia. There are also huge barriers to doctors wishing to move back to the UK in terms of medical registration and licensing to practice. The NHS is wasting resources trying to recruit in Australia and they look foolish because of that.”
“My message for governments,” says Departe, “would be Stop undervaluing good general practice! Good general practice has been proven to provide better value for money and a more integrated care approach than secondary care. By all means, regulate general practice to maintain appropriate standards of care but then pay us accordingly and let us get on with being general practitioners.”
Leeuwenburg: “Listen to grassroots doctors, not NHS managers who have destroyed the NHS and are now sprucing their wares in Australia. Nor to academics who think things like capitation and revalidation are necessary. Our Australian system is marvelous and we should be proud. Sure, there is fat in the health system that could be trimmed, mostly in hospitals and specialists, but primary care is overall incredibly efficient and GPs do a great job.”
“The UK government needs to stop attacking GPs and listen to doctors and the BMA, who have been largely ignored for the last ten years
“Ofcourse there are some outliers, but there are many more who are hard working and ethical, doing the right thing for patients and Medicare. Alienate GPs and risk the collapse of a great primary care system. It will cost more if we surrender to the failed experiments of the UK or privatise us with private health funds.”
“The UK government needs to stop attacking GPs and listen to doctors and the BMA, who have been largely ignored for the last ten years,” says McCartney. “Doctors want to work in an effective service so that they can focus on caring for patients. Learn from Australia that good access to radiology for GPs can keep people away from hospital until they really need to be there.”
Pieris: “The UK Government should let us do our jobs. Trust us. Stop interfering. No-one is saying regulation and scrutiny are not required. However, GPs are not some malign enemy. Stop treating us as if we are.”
Recommended further reading: Doctors from overseas, about my experiences as as a Dutch doctors starting Australia.
Private health insurers are gearing up to enter the general practice market. But it appears their plan is a copy of the dreaded US-style ‘managed care’ approach.
It’s best to keep health funds at arm’s length or else they will decide what care can, and can’t be given – instead of the patient and the healthcare provider. Therefore, I suggest that six conditions must be met before private health insurers can engage with general practice:
#1: Universal access
Every Australian should have equal access to a GP, independent of insurance status.
#2: Freedom of choice
People should have the option to choose their GP and private specialists; this cannot be dictated by health funds. Patients together with their doctors are best at deciding which tests and treatments are appropriate, not third parties like insurance companies.
Patients should always be given the option to choose and change health funds and insurance products.
Health funds must provide a straightforward package covering GP and/or basic private hospital care – as well as more comprehensive packages. Exclusions should be kept to a minimum. Health funds should make patients aware of exclusions and any other limitations before they buy a product.
To assist consumers choosing the best health insurance that suits their circumstances, an independent Government website should monitor, compare and publicise all available insurance packages.
#4: Professional autonomy
GPs and practice staff need support to be able to provide good care; this also means they should not be overloaded with red-tape, reporting requirements and KPIs. For the same reason health funds should not cause delays in treatment. GPs have the right to set fees to ensure practice viability.
#5: Evidence-based care
Only proven, appropriate, and cost-effective care should be covered.
#6: Stakeholder involvement
Health consumer organisations and the medical profession need to be engaged, as this will likely lead to better outcomes.
Finally, new regulation should be put in place to safeguard compliance by all parties.