About twenty years ago when I was a GP registrar in the Netherlands, my day began with checking results and making phone calls to patients before the first patient arrived in the practice.
After I finished GP training I started working as a locum. I remember several practices that used electronic prescribing: the medication order was forwarded to the pharmacy, straight from the practice desktop software. No paper, handwritten signatures or printed barcodes required.
Much has been said about the extraordinary creativity and innovation the COVID-19 pandemic has generated and what this will mean for Australia’s healthcare system after the pandemic.
Looking at telehealth, it appears Australia is catching up with the Netherlands and other countries. The question is, will we be able to retain the innovations that came out of the COVID-19 disruption?
In the past months the wheels have stopped turning in many areas of non COVID-19 related healthcare. There is now a backlog of routine care which, according to Grattan Institute Health Program Director Stephen Duckett, creates an opportunity for a new way of doing things.
He recently argued that telehealth, earlier discharge for home-rehabilitation and private-public hospital partnerships could assist in waitlist management. When considering returning to business as usual, he said, the new post-pandemic normal should be nothing like the old.
This ambition is echoed by others, including Queensland Health’s Director-General, Dr John Wakefield, who wants to retain the efficiencies that have been created in the public health service. Rather than returning to business as usual, Dr Wakefield said in a recent message to all staff, we should be finding the new normal.
“This is not about getting back to business as usual.
“This is not about getting back to business as usual. In fact, we want to make sure that in recommencing services, we retain many of the amazing innovative ways of working that you have adopted since this pandemic arrived on our shores,” he wrote.
He mentioned in particular video calls for outpatient department consultations and primary care, shifting chronic disease care from hospital to community and primary care and keeping emergency departments for emergencies.
Although this is primarily about increasing access to secondary care, it could be good news for those who believe in the “right care, right place” principle. Appropriate funding and support of primary care is an essential element for the success of this strategy.
I believe there are four areas of change for general practice, some of which relate to routine care and others are applicable to crisis management:
E-health: this includes phone and video consultations, electronic prescribing, secure messaging and transfer of information such as images;
Connecting health services: our relationships and the way we work with other health providers including hospitals and state and federal governments;
Workspace and flow: the way we design the layout of our workplaces, such as separate entrances, waiting rooms, check-in/out areas, isolation rooms and outdoor/offsite clinics.
Policies and procedures: Crisis, disaster and pandemic plans and procedures.
Most would agree that telehealth offers advantages in a post-pandemic world, and there are medical, social, economic and environmental reasons to make this part of routine care – like it is in various other countries.
There is of course work to be done. Implementing video consultations is more than turning on a camera at both ends as we have seen in recent weeks. There are challenges with regards to for example software integration, billing and security.
Care provision via telehealth should mirror the fee-for-service consultation model. To ensure telehealth will become part of usual care after the pandemic, commercial telehealth-only business models should be discouraged.
There is not much point in doing a video consult if we have to use a fax machine to get a copy of a prescription to the pharmacy, followed by a mandatory transfer of the physical piece of paper containing a handwritten signature or barcode.
Electronic prescribing has benefits, such as accuracy, safety and convenience. We also need electronic transfer of referrals, imaging and other test requests, as well as a solution for patients to securely send for example pictures of skin lesions, without having to rely on regular email.
It is important to note that this should not be not be regarded as ‘just a wishlist’ but as a fundamental digital framework supporting safe patient care during the good and the bad times.
Collaboration after the pandemic
There is room for improvement of information exchange and coordination of care between general practice and state health services during times of crises. The role of GPs is often not formally integrated into emergency responses (as was also evident during the 2019-20 bushfires).
In recent months however, innovative collaborative arrangements have emerged across Australia, embedding general practice in the wider healthcare response to the pandemic, such as participation in emergency planning and emergency credentialing of GPs by public hospitals.
In my area, GPs with a Special Interest (GPSIs) working in the public hospital were given the option to work in a Queensland Health virtual fever clinic after outpatient clinics temporarily closed. Flexible, collaborative workforce models like this should be explored further to encourage integration between primary and secondary care.
Dr Duckett and Dr Wakefield mentioned the hospital-in-the-home and hospital-in-the-nursing home models for routine care, as they are deemed cheaper and appear to reduce mortality and readmission rates compared with in-hospital care.
Indeed, it looks like care can often be transferred at an earlier stage from hospital back to the community, improving hospital access for those who need it most. An important step will be to engage the primary care workforce in these models and create capacity and incentives for GPs to be able to look after people that have been discharged from hospital wards, outpatient departments and emergency departments.
Consistent clinical handover procedures in combination with easy-to-use, two-way secure electronic communication tools between public and private sectors are a key factor to success.
There will no doubt be numerous other changes in the way we organise our work in the next twelve months or so. It is encouraging to see that permanent changes are being considered in many organisations and at all levels.
It will be necessary however, to agree on the priorities of the new normal and invest wisely. This may be challenging during a time of recovery, but not impossible.
Will the GP surgery of the future have separate entrances and waiting areas?
Will it be partitioned and contain designated isolation areas to accommodate possible contagious and non-contagious visitors? Will reception staff be working behind Perspex screens or will the service counters keep patients at a distance of one-and-a-half metres?
Has the era of universal telehealth, where patients can interact with their GP or practice nurse from the comfort of their home, or anywhere else – facilitated by permanent Medicare item numbers, practice support payments and new affordable and trustworthy digital communication tools – finally commenced?
Will office and medical equipment be designed to enable more ‘no-touch’ interactions?
Will technology such as remote monitoring devices and health apps be able to provide us with the information we need when we cannot observe someone in-person?
And are we going to have to learn new skills, such as gathering data and making reliable assessments while the patient is not in the same room? Will GP training of the future place a greater focus on telemedicine skills? Will we meet, make decisions and deliver education more often via video conferencing?
Will doctors finally be able to issue paperless scripts and let patients pick up their medications without having to physically visit a medical centre? Are we going to demand more from our medical software systems, so it will perform these tasks for us, even under circumstances of high demand and from different devices and locations?
Is the way we keep stock of essential equipment and medications going to change? Do we want to be more aware of the strengths and weakness of supply chains? Will GP surgeries in the future be more prepared for pandemics and natural disasters?
Will the interaction with other parts of the health system change, facilitating for example, better electronic two-way communication and sharing of information with hospitals? Will our patients be able to access telehealth appointments with allied health or secondary and tertiary care facilities more often?
Will we be able to better align general practice and state health organisations during future natural disasters and pandemics? Is it possible that doctors, pharmacists, pathology providers and telehealth providers will pull together, putting aside personal or political gains?
A lot has been said about the impact of the coronavirus pandemic and how it has forced us to review, rethink and redesign almost everything we do.
The pandemic has exposed weaknesses and limitations of our healthcare system and, at the same time, stimulated creativity and innovation.
But some things will never change. To maximise the benefits of primary care, the long-term therapeutic doctor-patient relationship remains crucial. And, at some stage this will again involve shaking hands, even holding hands, as well as the necessary physical contact during examinations, tests and procedures.
There is of course a possibility that we revert back to business as usual when the pandemic is over. Medical conservatism would caution against rapid change or innovation unless the benefits are clear and supported by evidence.
Sometimes questions are just as important as the answers. It will be interesting to see how we come out of this crisis; who chooses to adapt and why – and who prefers to go back to the way we have always practised medicine.
As John F. Kennedy purportedly observed, in Chinese the word ‘crisis’ is composed of two characters – one represents danger, and the other represents opportunity. Nothing could be more applicable to the present coronavirus pandemic.
Trust is an essential ingredient of effective healthcare delivery. It’s important for interprofessional as well as inter-organisational collaboration.
A 2018 literature review concluded that collaboration leads to more job satisfaction, improved morale and a better working atmosphere. Unfortunately, health providers don’t always trust each other. The authors of the review found 5 sources of distrust:
Doubting the other’s motivation in providing care and the perceived benefit for him/her
Feeling threatened by the other’s involvement and being afraid of losing some territory
A difference in philosophies and scope of practice
Negative images of the profession
Lack of confidence in the other’s skills and lack of awareness of the other’s role in patient care.
Other ingredients of effective collaboration include adequate communication, respect, mutual acquaintanceship, equal power-distribution, shared goals, congruent philosophies and values, consensus, patient-centeredness and environmental factors.
The authors did not explore the level of importance of each factor but I am putting my money on trust as the secret ingredient. If we continue to distrust each other, collaboration will remain a challenge. The question is, how to change this?
“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.
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.
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.
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.
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.
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’.
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.
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.
A while back I came across a new tool for those who, like me, use Dr Google but are concerned about the quality of some of the available online health information.
The tool contains two checklists and has been designed for medical education resource producers, editors, end-users, and researchers. I’ll let the authors explain:
“Through a rigorous research process, a list of 151 quality indicators for blogs and podcasts was formed and subsequently refined to elicit the most important quality indicators. These indicators are presented as Quality Checklists to assist with quality appraisal of medical blogs and podcasts.”
The checklists have three domains: credibility, content and design, and cover topics such as avoiding bias and conflict of interest, providing clear information about the identity and qualifications of the author, and referring to sources. The checklists also focus on design and didactic value.
I believe they can be useful for patients to assess the quality of online health resources. For more information read about the 6 warning signs that will help you stay clear from quackery sites.
This tool has the potential to take many health blogs and podcasts to the next level. It is available at no cost and can be found here.
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.
Image sources: The Family Doctor in 1948, Nedhardy.com and The Times.
“G’day doc. I’m a little embarrassed to bring this up but…”
“No worries, you know you can be honest here. Let’s check your blood pressure first. It was a bit high last time.”
“Oh… ok. Not dangerously high I hope?”
“Well it was just above the benchmark, which is concerning. As you know I don’t get paid if I don’t look after your pressure. Let’s see… 140 over 90. Uh oh. I’m afraid we have to bump up your medications.”
“But doc, could it be stress? I wanted to tell you that…”
“Stress, stress… That’s all well and good but Medicare doesn’t care what the cause is. If it’s too high I miss out. And if I miss out you miss out, you know that don’t you? We also have to talk about your weight target. As I’ve told you before, if you don’t lose those extra pounds our practice cannot afford to look after you any longer.”
“Are you listening to me? John and I broke up last night. I’m a mess!”
“I’m sorry to say that there’s no incentive payment for counselling anymore. Please do me a favour and book in for your pap smear on the way out. Last time you were late and we missed the deadline for our quarterly Medicare bonuses. We don’t want that to happen again do we?”
The National Prescribing Service (NPS) has made an interesting list of 5 questions patients should ask their doctors. The aim is to be well informed about the benefits and potential harm before you undergo medical tests, treatments, and procedures.
I think the list is useful and I’d encourage people to ask these questions. At the same time I suspect I will not be able to answer all the questions. For example, I don’t know the costs of all available tests, and the exact risks of certain interventions is something I may have to look up.
I have been told NPS is planning to develop resources for doctors so they can better help their patients with these queries. This would indeed be helpful. But in the meantime, feel free to ask! I hope it will lead to less unnecessary interventions.
Here are the 5 questions to ask your doctor before you get any test, treatment, or procedure:
In the 2015 Budget the Federal Government has allocated significant funding to improve the electronic health record system for all Australians. The personally controlled e-health record gives patients a lot of control, but many healthcare providers are still concerned about the medicolegal risks embedded in the system.
I had the privilege to speak with Dr Steve Hambleton, former AMA president and Chair of the National E-Health Transition Authority (NEHTA), about some of the concerns voiced by doctors and consumers.
It appears there are various sticks and carrots in the pipeline to get more healthcare providers on board, but there is no sign that for example the heavy-handed PCEHR Participation Contract for providers will be changed.
The good news is that Dr Hambleton expects the current national infrastructure will help other providers and products – different to the PCEHR – to emerge in the near future.
Here is the transcript of our conversation:
Are you enjoying your role within NEHTA?
“I think I am now!”
I assume you are happy with the allocated funding of $485 million for e-health over 4 years in the latest budget?
“Yes absolutely. I think it does two things: It restarts the momentum of e-health in this country, and the Federal Government has now sent a signal to the State Governments and the e-health community saying: ‘we are serious about e-health and we want to get an outcome; we want to get some returns.’ If you think about it, we’ve really had no momentum since about September 2013.”
The budget indicated that NEHTA will cease to exist as suggested in the Royle report – what will your role be after the transition?
“I hope to be able to contribute in some way, but there are no announcements about it as yet. NEHTA can now complete its task of setting up the infrastructure and I guess the Australian Commission for E-Health, if it goes forward as proposed, can take it to the next step of more meaningful and better use of e-health.”
What is the difference between NEHTA and the proposed Australian Commission for E-Health?
“I think the main difference will be in the governance, not so much the strategic direction. We recommended in the Royle review to put users and people who can meaningful influence the direction of e-health on the governance board, so the influence is there at the highest level.”
According to the PCEHR Act 2012 the PCEHR has four purposes: to help overcome fragmentation of health information, improve the availability and quality of health information, reduce the occurrence of adverse medical events and the duplication of treatment, and to improve the coordination and quality of healthcare provided to consumers by different healthcare providers.
It appears however there are least 5 other purposes of the PCEHR spread out throughout the Act:
Law enforcement purposes
Health provider indemnity insurance cover purposes
Public health purposes
Other purposes authorised by law
Especially the last one seems a catch-all category. There seems to be a lack of information about what happens with our patients’ health information in the PCEHR. What are your thoughts on this?
“We should probably engage with the minister now to gain a better understanding of where they want to go with e-health, but if we simply mechanise what we’re doing with paper records we really can’t reach the benefits of electronic health. We have to analyse the data we’re creating and use that to improve care and understand outcomes.”
“For example, when a new drug is released into the community we want to know: does it actually deliver the same outcomes as when the drug trials were run? We need to make sure that the healthcare we are providing does make a difference and does get an outcome, so we do need to analyse the data. Whichever way we go, the performance of the system is going to face more transparency as time goes on, and I think the profession is beginning to understand that.”
“We need to analyse individually what we do in our practices; all the colleges are now saying: ‘as part of continuous professional development we want you to reflect on your activities within your practice and show us how you modify your activities to get a better outcome.’ That will apply to GPs, specialists, hospitals, and the systems need to be analysed as well. We can’t do that unless we have a common dataset and I think that’s what e-health gives us.”
We need more information about what the government will and won’t do with the data because the PCEHR act 2012 seems to allow for almost anything.
“I think that’s probably a question we should put to the minister. We need to hear what’s in their heads. I don’t have any knowledge about what’s in the government’s mind.”
The data is kept by the government for 130 years, is that right?
“My understanding is that’s correct yes.”
Do you think patients are aware of this?
“I can’t answer that question, I couldn’t tell you what patients are thinking but certainly from the day-to-day interaction with patients it’s surprising to see how many people think we’re already sharing information about them and use that to try and improve the situation.”
Even if healthcare organisations or practices cancel the PCEHR Participation Agreement, 7 of the 14 clauses contain paragraphs that survive termination, including liability. Although practices may have signed up to access the incentive payments, they may be concerned about the fact that the contract has clauses that, once signed, will be perpetually binding.It makes sense to adjust the contract to entice clinicians to participate, doesn’t it?
“My comment would be that we’re bound by good medical practice in any case, no matter what we do in relation to our patients. Decisions that we make are expected to be in their best interest. And putting my AMA-hat on, our interaction with e-health should be no different and shouldn’t require any different concept than when we are interacting with patients in other ways.”
“E-health is a different way of interacting and recording data and I guess that’s why we’re well-educated and insured and act in the patient’s best interest. If you look at good medical practice and say well that’s the guidance that we’re all subscribe to, than this should apply to any interaction including e-health.”
But 130 years seems like a long time.
“We’re expected to keep paper records for a period of time and every time I try to get information about this, you know, nobody will give you a clear answer when you can dispose of them. Theoretically it might be seven years since you last used them but if you talk to a medical defence organisation they say: ‘well if you keep them longer that would be good.'”
“I’ve got electronic health records in my practice dating back to 1995 and you wouldn’t think of destroying any of those. I think it’s one of those areas that you think: is this information permanent? I mean, in 130 years is it going to be in a form that’s usable? I guess it’s one of these things we don’t know the answer to.”
How do we get doctors to use the PCEHR?
“Doctors have been sitting back asking: ‘well why should I engage with e-health when it’s not certain if the government is actually going to support it?” There has been a lot of uncertainty. We now have a strong signal from the government that e-health has a future and that we have a national infrastructure that we’re going to use.”
“Then we need to say to doctors: ‘well what is the benefit here?’ The primary beneficiary is the patient. The information collected that they can manage will provide the next doctor they see with accurate and up-to-date information. Specialists and public hospitals can get quick access to the curated information.”
“The reality is it’s going to make our lives easier and make our search time shorter and provide us with rapid access to accurate information. Opt-out ofcourse means that when you look for a PCEHR there’s one there; if the patient has been in hospital there will be a discharge summary; if you want to upload something it’s not complicated and you don’t have to sign people up. It will be more efficient.”
The budget mentioned revised incentives, can you tell us more?
“Nothing specifically, but I have no doubt that the practice incentive payments program will look at incentivising doctors to use electronic health records. Their software has to be SNOMED compliant, they need to have secure messaging protocols and be able to send messages between doctors and patients and utilise the e-health infrastructure. I think that’s going to happen.”
A problem with practice incentive payments is that they go to practices, not to doctors who are interacting with the PCEHR.
“It depends on how practices have set themselves up but you’re quite right. The Royle review recommended that there should be a link between annual health assessments, care plans and utilisation of e-health. This would be a direct reward for doctors if they interact with the e-health infrastructure. The government has indicated that it is going to try and implement the major recommendations of the Royle review.”
GPs could interpret a link between care plans and e-health as the government forcing them to use the PCEHR, because if they wouldn’t their income drops.
“It is by no means a definite outcome. It is something the PCEHR review commission thought would be worthwhile. The Primary Health Care Advisory Group [of which Dr Hambleton is chair as well] will consult with senior members of the profession to see what they think. I think it is pretty clear that people with high needs and chronic diseases would benefit from better electronic communication.”
I agree that certain people with chronic diseases could benefit from e-health. Many GPs however are weighing up their own risks of participating against the benefits to their patients, and that’s where some of the concerns come from.
“Yes, I think we should all look at issues like that. I suppose we will be looking to our indemnity providers to give us some guidance. The AMA has put out a guide for the use of the PCEHR which gives pretty good guidance. But if e-health reduces the risks for our patients and improves the care to our patients everybody is going to support it; if it does the opposite then they won’t.”
“I just want to make one more point. We focus on the PCEHR, and I understand why, but so many people have called me out and said: ‘we’ve spent a billion dollars on the PCEHR!’ but actually we haven’t. The national infrastructure that underpins the PCEHR is really critical for a successful e-health strategy.”
“Think about the individual health identifier, the individual practitioner identifier, practice identifier, SNOMED CT, Australian medicines terminology, secure messaging protocols and also a national product catalogue plus a national health services directory.”
“All of this basic infrastructure is built and can be used by other providers, different to the PCEHR, and that’s the exciting future. I think other products will emerge, which of course doesn’t mean that we shouldn’t make the PCEHR easier to use. We should. We’ve got to make it easier.”
Tricky medicolegal cases
I asked Dr Hambleton to comment on a few real-life cases. In some instances the doctors involved contacted their indemnity insurers but unfortunately insurers were not always able to provide advice. In his comments Dr Hambleton refers to the ‘AMA guide to using the PCEHR’ which can be downloaded here.
A patient saw another doctor in the same practice who did not upload the latest information to the PCEHR, and the patient subsequently complained to their own GP.
“There is no compulsion to upload anything to the PCEHR. A patient can ask the doctor to upload something but the doctor is not required to do it. The doctor may say: ‘I’m not your nominated healthcare provider but you need to see your own doctor to get another shared health care summary uploaded’. These sort of things need to be talked about in practice protocols and discussed with the patient.”
There was a practice that accessed the PCEHR when the patient was not present, and the patient threatened to sue the practice.
“Patients do provide standing consent for access to their records by registered healthcare providers, so they can assist with their healthcare.”
“I think we have to talk to the AMA or the indemnity providers, but accessing the PCEHR for reasons other than the patient’s healthcare probably is not appropriate access.”
One patient demanded that the GP did not mention essential information available in the PCEHR for a report to an insurance company. The GP was unsure what to do.
“That’s very clear. If you have to write a medicolegal report it would not be appropriate to access the PCEHR, as it’s the patient’s record. If you’re writing a medicolegal report doctors can only access their own records, unless the patient has given permission to access their PCEHR. Practices need to think about protocols that describe who accesses the PCEHR and why, and have systems in place to make sure this happens.”
Misleading, missing or incorrect information causes mistakes or harm. Many doctors are unsure how they can assess if information available in the PCEHR is reliable or not.
“I think this is a really important comment as well. You can’t assume that any information in the PCEHR is absolutely accurate. If you are using that information you often have the patient in front of you so when you are taking a history, check if the information is accurate or not. No information is ever going to be complete and we shouldn’t expect that the PCEHR contains complete information.”
“Patients have the right to say, for example, ‘please don’t upload the fact that I had a termination’. Patients should understand that we don’t have to use the PCEHR and if we do, it should be weighed up like any other object of information we get.”
By looking at the PCEHR billing information providers can find out where patients have been, eg other doctors, even if a patient has asked the other doctor not to upload anything to the PCEHR. Are we supposed to have access to this information?
“Well, supposed to and allowed to are two different things. When patients consent to the PCEHR use, they are basically providing standing consent for access to the information that’s there. They have given consent but they also need to understand what consent means.”
“Patients have a lot of control: You can shut it down to one doctor or you can shut it down to only the doctors you give the access code to, and patients can switch the controls on and off.”
Some doctors are concerned that information they upload may be deemed not 100% accurate, in which case they would be in breach of the PCEHR Participation Contract.
“We are trying to provide the best available data. We will be judged by the standard of what a colleague reasonably would have done in the same circumstances. The intention of a shared health summary is to provide the next practitioner with a guide to manage the patient. If you think about it: there is not much difference between uploading a health summary to the PCEHR and writing a referral to a colleague using that exact information.”
“It is part of good medical practice to continually review the information that’s there, and for example delete previously prescribed antibiotics from the current medication list, and look over the past medical history we’re providing to other doctors to see if it is still relevant and useful to the patient’s medical care. It is certainly true that if you upload reams of information you may confuse the next provider.”
Jail is not good for your health. Communicable diseases like hepatitis, HIV and tuberculosis are more prevalent. About forty percent of the prison population has mental health issues and to make matters worse, delivering good care in prisons is a challenge. It seems clear to me that we need to keep people out of jail as much as we can – but that’s not always happening.
Summer May Finlay is a Yorta Yorta woman. She considers herself privileged: “My mother was an Aboriginal woman and absolutely determined and driven to make sure that her children would get the best.”
Summer started her career as a youth worker and now has a master in public health. She works in Aboriginal health and is undertaking a PhD in Aboriginal health at the University of SA.
“I have the capacity and education to have a voice for those who don’t, and that’s one of the reasons I want to raise over-incarceration of Aboriginal and Torres Strait Islander people,” says Summer.
Although the majority of Aboriginal and Torres Strait Islander people do not come into contact with the law, they are over-represented in Australian prisons. This is concerning as we know there is a health and life-expectancy gap compared to the non-Indigenous population.
I spoke to Summer about over-incarceration and what should be done about it.
Why is over-incarceration happening?
“That’s a good question isn’t it,” says Summer. “There is a range of factors, such as the links between over-incarceration and low-education, poverty and dispossession. There are also historical issues including our western justice system, which in some cases may not take cultural issues into consideration. It’s complex and that’s the reason we want to look at a solution and not so much the problem.”
“Our western justice system may not take cultural issues into consideration
“There is an inherent, unconscious bias which I also call institutionalised racism. We know that the police system and the court system are looking to address this. For example, a lot of Aboriginal people are incarcerated for short periods of time because they don’t turn up to court. They may be in a remote setting or transient, but if the court refuses to take this into account, they may blame it on the individual.”
A potential health catastrophe
“Incarceration affects the ability to get or keep a job, which creates financial restraints and subsequently a range of health and mental health issues. It could be that people don’t have the money to manage their diabetes. The Hepatitis C prevalence is higher in jail so therefore people incarcerated are more likely to become infected.”
“Fifty percent of juveniles that are incarcerated are Aboriginal and we only make up three percent of the population. They are removed from an education setting, and put in a justice system. They experience many difficulties after they are released.”
“People don’t become hardened criminals overnight. It usually starts off with petty crimes and non-violent crimes. That should be diverted before they reach a point where they are incarcerated for serious crimes. People also go to jail for fines. There are community service options but they aren’t used enough as they’re not always available, for example in remote areas. Funding for these programs may be ad-hoc or insufficient, and sometimes it comes down to political will.”
Do the crime, do the time?
“We have an Australian mentality that if you do the crime you do the time. A criminal system is meant to be a deterrent but clearly it’s not working as such with some Aboriginal and Torres Strait Islander people. Seventy percent of people that are incarcerated have been in jail before. So the system has failed miserably.”
“We have tried the paternalistic approach for over 200 years now, so let’s try our approach for a change
“We know what the problem is, we know the statistics, but we need to be looking at what happens when someone is in jail and after their release. We should also be looking at some of the solutions within the community. Over-incarceration isn’t going to change overnight so we need long-term funding that transcends political terms.”
“One of the key things for me is that we need to have better informed conversations about Aboriginal over-incarceration. We need to be focusing on mobile and community, Aboriginal-driven solutions. If you don’t have a solution that is driven by the people who are involved in it, than quite frankly, it is never going to work. We have tried the paternalistic approach for over 200 years now, so let’s try our approach for a change.”
“Hope is the physician of each misery” ~ Irish proverb.
I understand the power of hope in life & death, but sometimes it comes at a cost. It is painful to see that some of my sickest cancer patients are paying large sums of money to practitioners in the wellness industry who claim they have found a miracle cure. Glamorous and healthy looking health gurus attract mass online followings by selling a dream. Many of these wellness warriors are modern-day snake oil salesmen. The suitcase filled with dubious cures has been replaced by commercial websites, Facebook pages and YouTube accounts.
Jessica Ainscough was a self-proclaimed wellness warrior. She self-administered daily coffee enemas and took vitamin supplements to beat cancer. She started chemotherapy, but eventually declined it, as well as other conventional treatments like surgery and radiation, which she called the ‘slash, poison and burn method’. Although many of her followers thought her alternative approach was successful, she lost her battle and sadly died at the age of thirty.
The fact that she tried complementary therapies in itself is not surprising, as many people in her situation would do the same. The problem is that Ainscough was very good at selling unproven products to cure cancer, for example by claiming the methods ‘starved cancer cells’.
Ainscough completed an online course at the Institute for Integrative Nutrition in New York, and according to the Australian newspaper, she said it had taught her how to organically attract ‘an amazing tribe’ of people who trusted her.
Via her blog she offered a ‘lifestyle transformation guide’ for just under $1000. She also sold cosmetics and other products. It appears her business model was profitable, as she wrote on her blog: “I earned six figures within a year of completing B-School and have doubled my income every year since.” Ainscough later denied claiming that she had cured herself.
Oncologist Dr Ranjana Srivastava is concerned about these health scams. “There is a legitimate role for a variety of complementary therapies such as yoga, meditation, mindfulness, a balanced diet and moderate exercise,” she says in this article. “The problem arises when the generic multivitamin tablet from the chemist morphs into weekly intravenous injections costing $1000 a shot. Or when the notion of cleansing the body of toxins is exploited with sham diets and enemas that land patients in the very hospitals they are determined to avoid.”
Yet, most people don’t seem to be bothered by the modern-day snake oil merchants. I suspect that is because their fantastic stories appeal to our yearning for inspiration and herbal cures. What’s more appealing than trying the same remedy that miraculously cured someone we know? Understandably many cancer patients are desperate, especially when conventional treatments have side effects or are not effective anymore. But it is desperation that makes people vulnerable to dishonest gurus and wellness warriors.
What upsets us most is when the wellness warriors lie about their own health problems – like Belle Gibson.
Gibson’s approach was very similar to Jessica Ainscough’s. She claimed to have cancer and promoted a range of alternative cures to treat cancer. Her wellness and nutrition app ‘The Whole Pantry’ was a best-seller. Unfortunately Gibson never had cancer, and journalists found out she failed to deliver on promised donations to charity.
“What enrages us all,” says psychiatrist Dr Helen Schulz in this blog post, “is those who don’t have any training in health, who deceive the public for overt secondary gain (financial) and delay others from getting help until it’s too late.”
In many ways doctors and other registered health professionals are the opposites of wellness warriors. By law we are restricted in the way we promote and advertise our services. We don’t sell personal health stories, we often have to bring bad news, we don’t always give our patients what they want, we can’t promise total cure, our treatments may have side effects and often we are unable to offer a cure at all.
No wonder lifestyle coaches and health gurus attract large tribes. But, if homeopathy, vitamins and coffee enemas would cure cancer and other maladies, I’d be the first to prescribe it.
3 simple tips
I’m not saying that the wellness industry as a whole is unreliable. I’m also not saying to stay away from complementary therapies. But Ainscough and Gibson are not the first and won’t be the last as the wellness industry is not regulated in the way mainstream medicine is.
To avoid disappointment, please remember:
Magic cures don’t exist
Think twice before you pay large sums
Talk to your specialist or GP before you make a decision.
“Health policy has proved, over the years, to be a bugbear for the Liberal Party. The Fraser Government had made numerous changes to its health policy, which had been both unsettling and politically damaging” ~ John Howard in Lazarus Rising
As they say, those who cannot remember the past are doomed to repeat it. Governments often make two mistakes when it comes to health policies:
It is driven by dollars instead of health outcomes
Advice from patients and health professionals is ignored
The current ‘health’ debate has, in reality, been a debate about the level of out-of-pocket expenses. The elephant in the room – more efficient funding – has been carefully avoided. We know there is too much waste and bureaucracy in the system – and many have argued the fee-for-service model is not ideal to manage chronic health problems.
If the Abbott Government is serious about tackling some of these issues, but wants to avoid the mistakes of the past, they should embrace the RACGP’s draft Vision for a sustainable health system. It is an opportunity to start a real healthcare debate.
The new model
As the draft document reiterates, health systems focusing on primary healthcare have lower use of hospitals and better health outcomes when compared to systems that focus on specialist care. It makes sense to fund a comprehensive range of services in primary care, based on local community needs.
The new vision proposes voluntary patient enrolment with a preferred practice to improve chronic care delivery and funding. It also recommends that current incentive payments are replaced by a payment system that facilitates the following five key activities:
Better integration of care
Supporting quality, safety and research
Team-based nursing care
Using IT and e-health to improve efficiency
Acute care and fee-for-service are still part of the package, but practices and GPs delivering ongoing comprehensive and complex care will be better rewarded in the new model. It will also assist practices and doctors looking after disadvantaged patient populations.
Much needed leadership
Earlier this year the RACGP invited members to comment on a first draft. Yesterday RACGP president Frank Jones presented the current version to Federal Health Minister Sussan Ley. It’s good to see the RACGP welcomes further feedback. Personally I am particularly interested in the response from patients and consumer organisations.
It seems the blended payment model reflects the increasing focus on chronic disease management, while still rewarding acute care. As always, the devil will be in the detail. But to be fair, this is a draft (and if you ask me, a good one).
By starting the discussion the RACGP is showing leadership. Let’s hope the Federal Health Minister is appreciative and brave enough to take on the challenge.
It had taken a year to organise the required paperwork to make the move from the Netherlands, and finally I was here, about to start my job in a remote hospital.
However, the manager on the other side of the desk had other ideas. She looked at me over her glasses and shook her head. I wasn’t allowed to work, she said, because my Medicare provider number would take another month to come through.
Of course, this was just the beginning. After a few years working in the bush, I was thrilled to qualify for a permanent Australian residence visa. But first I had to pass the international English language test — again.
“G’day mate, do you really need me to come to the big smoke?” I asked a clerk at some department over the phone. “I’m flat out looking after this mob in the back of Bourke. I passed that exam ages ago, before I came to the Lucky Country. Surely me Strine hasn’t got worse since I’ve been here. Crikey, the rellies back home reckon I have a dinky-di Aussie accent.”
Needless to say, I had to sit the English test again.
Red tape bugbears
This was a decade ago, but things haven’t got any better. The GPs Down Under (GPDU) Facebook group, a new, quickly growing online community of Australian GPs and registrars, listed their ‘red tape bugbears‘ earlier this month.
The amount of time and energy GPs waste filling out forms and jumping through bureaucratic hoops is gobsmacking.
One GP recently posted on the GPDU Facebook page: “For practices employing a new rural doctor, there are at least 14 different forms across Commonwealth and State jurisdictions. Some have to be completed online, some need to be scanned, some mailed — yes, with a stamp. And some faxed.”
Hospital bureaucracy is also a big bugbear for many GPs. For example, in Queensland the public hospitals have an extensive referral ‘criteria’ for each department. GP referrals that don’t tick their boxes – often checked by non-medical staff – are simply refused.
One orthopaedic outpatient department doesn’t accept a referral until GPs have faxed a completed three-page ‘hip and knee questionnaire’.
Other health professionals can also add to the GPs’ burden when they selectively take over parts of our job under the notion of helping to reduce our workload.
But it doesn’t always work out that way as one GP on the GPDU site recently highlighted when she told of how her local pharmacy happily manages her patients’ warfarin doses, but only as long as the INR is within a safe range.
“Apparently this service is more ‘convenient’ as well as lucrative for the pharmacist. Until the INR level is more than 2.5. Then, late Friday afternoon, the pharmacy demands I manage the warfarin dose. So then it’s suddenly my problem,” she posted.
Red tape is often a knee-jerk reaction to a problem and not usually the best solution.
An estimated 25,000 patient consultations are lost every month while doctors are waiting for PBS Authority call centre operators to answer the phone. Meanwhile, our Medicare-funded sick certificate ceremony is estimated to cost the Australian economy $3 billion a year.
It’s time we did something about it.
Collaboration with other professions and organisations is more important than ever. If we help hospitals solve some of their outpatient department problems, our workflow will improve too. GPs need to negotiate innovative solutions that are mutually beneficial and acceptable. Building relationships, communicating and networking are the key to success.
We are in an ideal position to show leadership. This means we have to organise ourselves better, learn to be good followers, and support those who are trying to build bridges, including our peak organisations. No doubt we will occasionally have to compromise and, in some instances, lift our game.
I realise this is not easy in the current climate of cuts and freezes, but if we fail to do this, others will continue to take control of primary care. I love Australian general practice – it’s a great profession and the reason why I came to Australia. But we must protect what’s good and make it future-proof.
My call to action to colleagues, the colleges and the AMA is simple: please help and make things easier.
This article was originally published in Australian Doctor Magazine.
My first blog was a travel blog. Nancy and I were working and travelling around Australia and New Zealand and, like so many others, we blogged about our down-under experience. The audience: Family and friends. Number of daily visitors: 3-5.
In 2004 there was no Twitter, and LinkedIn and Facebook were the new kids on the block. Still, it was good fun. We were passionate about our travel adventures and we enjoyed uploading the pictures we took with our 4 megapixel Sony Cybershot.
Four years later we settled down in Western Australia and started a business. A blog became part of the new practice website.
In the early days the blog attracted 20-30 visitors per day, but after a while the number grew to 40-60. Connecting the blog to the practice social media accounts made a big difference. I learned a lot about content – what works and what doesn’t.
In 2013 we decided to move back to Queensland and I left the practice. I began to focus more on my Doctor’s bag blog (it’s good to see the Panaceum blog is still very much alive).
Keeping a blog going is hard work. There is no ‘easy way’ to do it. The competition is fierce and as there are many great bloggers out there, it’s not that simple to get noticed.
I really enjoy blogging – which helps of course. I am fortunate to work in an industry that’s a constant source of inspiration.
Slowly the visitors number started to climb to 80-100 per day.
But just as I thought my blog was taking off, writer’s block hit me hard. My creativity was gone. I didn’t blog for a while. The longer I didn’t post anything, the more attractive the thought of deleting my WordPress account.
English is not my first language and I often struggle to find the correct words. So, I argued, why not save myself the trouble and stop blogging altogether?
One evening I was reading an article about writer’s block. It was the break-through I needed. The author, Jeff Goins, simply said: “You overcome writer’s block by writing.” His message was short & sweet: It doesn’t matter what you write, as long as you get going.
That’s what I did and somehow it worked. Before I knew it, the inspiration was back and the blog ideas started flowing again.
The first time my daily visitors number reached 1K, I couldn’t believe it. I thought it was a one-off, just luck, but last month over 15,000 people visited Doctor’s bag.
Although I want people to read my posts, it has never been my goal to get more visitors – nor do I think the hit counter is a measure of success. I enjoy producing content that makes others think. If it leads to change – even in the smallest way – I’ve reached my goal.
There will always be people with more writing talent, better posts and more followers, so I try to keep Bill Gates’ words in mind:
“Don’t compare yourself with anyone in this world… if you do so, you are insulting yourself
But there is one thing that is more important than anything else…
The best tip
The one thing that determines success in blogging, and in many other ventures in life, is perseverance. It is important to follow your passion. If you enjoy writing, the best tip I can give you is: Don’t give up.
Everybody has a story to tell, so keep writing. You will get better at it and people will find your blog.
Picture from my first travel blog in 2004, dropped off at Lizard Island, North Queensland, with food, water, tent & map.
Traditionally campaigns against poorly thought-out Government policies have predominantly been doctor-centric, and the usual Government response is to divide consumer and medical organisations.
Jen Morris is a patient advocate and researcher in healthcare quality and safety at the University of Melbourne. She feels strongly that cooperation is required if we want to make more impact in Canberra.
This makes sense. It looks like the time is right for a novel approach – and it is much needed too, as the discussion about healthcare so far has been about dollars instead of quality. What are the benefits of a patient-doctor alliance and how do we overcome our differences?
The numbers game
“At a strategic level, it’s a numbers game,” says Jen Morris. “There are approximately 26,000 GPs in Australia, and about 82,000 registered medical practitioners. But there are over 23 million patients. That is an enormous bloc of voters and lobbyists to leave untapped.”
“When campaigns are too doctor-centric, that leaves this bloc ‘in play’ – sparking a spin and PR war between doctors and the government, vying for public support. But if doctors and patients can capitalise on common ground and present a united front from the outset, the weight of political force will rest with us.”
“More importantly, putting patients and their care at the centre of pro-healthcare campaigning recognises healthcare exists wholly for, and because of, patients. Sometimes, public debates amplify some of the worst features of traditional hierarchies in clinical healthcare. Authority figures argue over who knows what’s better for patients, and best represents their interests.”
“All the while, patients pushed to the sidelines quietly await a chance to speak for themselves. If we’re serious about changing the culture of paternalism in healthcare, and empowering patients, that change in approach needs to permeate right through from the consulting room to the campaign platform. ”
What if we disagree?
There may be topics where patients and health providers don’t agree, such as certain aspects about the PCEHR. This can really paralyse a project. How should we approach this?
Morris: “It is important to remember that disagreement doesn’t only pose an obstacle in ‘patients and providers’ scenarios. Neither patients nor providers are homogeneous groups, and we do well to remember that. It is worth asking how providers approach the problem when they disagree on an issue or project, and source lessons from that.”
“It’s worthwhile looking for points of common ground, and building upon those
“The possibility that some parties may disagree is not, for example, a reason to exclude likely dissenting practitioners from a committee of doctors. In the same way, it is not a reason to exclude patients from healthcare policy discussions. Moreover, the fact that patients and providers may not always agree is not a reason to close our minds to collaborating when we do.”
“We should approach such disagreement on policy and projects the way we should in any sector. That is, give relevant stakeholders of all perspectives a fair opportunity to be heard. And, where possible, try not to speak for others in lieu of them speaking for themselves first.”
“It’s worthwhile looking for points of common ground, and building upon those. More often than we acknowledge, patients and doctors are really advocating for the same outcomes. But too often we don’t take the time to really analyse where the crux of disagreement actually lies.”
“So it’s worth trying to identify when disagreement is about what the end goal should be, and when it’s about how we should best get there. That helps to clarify how the points of difference, and points to potential solutions.”
“In cases where viewpoints really do differ substantially, all parties should have the opportunity to make a case for their proposal, then let the policy and law makers evaluate those on their merits.”
Is there a will to cooperate?
Morris: “Because I don’t work for or represent a consumer organisation, I can’t speak for them with any authority. However, I will say that in my experience, there is reflexive and entrenched suspicion on both sides.”
“If we find that the aims of doctors’ and patients’ organisations are so distinct as to be deemed incompatible, we should be re-evaluating those aims urgently
“Patient organisations are concerned about being seen to endorse a situation in which doctors’ organisations dominate and speak ‘on behalf of’ patients. Because such situations hark back to unhelpful, dictatorial hierarchies which have traditionally silenced the patient voice.”
“On the other hand, doctors’ organisations have expressed concern that patients do not understand the complexities of health policy and systems, the challenges faced by practitioners, and the broader potential consequences of proposals.”
“But in my experience, if and where these issues exist, it is in working together that parties learn from each about about how they can all do better. And the result is stronger organisations, and a more robust campaign.”
“It is healthy for organisations to remain vigilant about being faithful to their purpose and mandates. However, if we find that the aims of doctors and patient organisations are so distinct as to be deemed incompatible, we should be re-evaluating those aims urgently.”
“As a patient advocate, I would be delighted to have the opportunity to campaign alongside doctors and their organisations when appropriate. And indeed, on several issues I have done just that.”
“I have the privilege of working alongside many doctors in my role, who have taught me a great deal about the everyday realities of being a doctor. And I am a better advocate as a result. I hope that working with patients and advocate affords doctors similar insights.”
In healthcare we’re often confronted with poor quality software. Bugs and security issues are common, and the design is usually not intuitive. I spoke to Frank (not his real name), an insider in the health IT industry. Frank gives us an interesting look behind the scene and seven strategies for developing or implementing new software.
“Any industry can be a target for poor software,” says Frank, “but healthcare certainly has its fair share. Believe it or not, medical software is unregulated. Medical software that runs on a computer, mobile phone or tablet does not fit the definition of a medical device in section 41BD of the Therapeutic Goods Act 1989, as they were not intended by the manufacturer to be used for therapeutic purposes.”
“How many software developers have clinical employees? Do these employees have input into design or are they there to sell the dream?
“There is a serious gap between software design and the real-world application. Often software developers do not fully understand what is actually required by the healthcare industry to support the services that they provide.”
“Far too often, developers over-promise and under-deliver. What software can do often does not live up the expectations of the customer. How many software developers have clinical employees? Do these employees have input into design or are they there to sell the dream?”
Causes of poor quality
Some argue that developers should test their product better before it can be used in patient care. Is this an issue?
Frank: “Quality must be incorporated into the entire software development life cycle, from inception through implementation and this is not always happening.”
“A lot of the actual coding occurs overseas, in countries like India, where the employment costs are much lower. Code may be written cheaply and quickly overseas but it isn’t necessarily quality code.”
“Testing is often an after thought and done quickly due to time constraints
“Testing is often an afterthought and done quickly due to time constraints. The most crucial functionality usually gets tested but bugs can still slip though.”
“On the other hand, sometimes the client is not specific about their requirements. This could be a result of not engaging the organisation to understand what requirements need to be met. How often are clinical and other front line staff asked what they need before software arrives?”
Talking about client requirements: Let’s look at the Australian national E-health records database, the PCEHR. The Government wants to use the data and eventually save money (even though so far they have wasted millions of dollars on the project). Consumers want full control of the data, and doctors need a reliable, safe, secure and easy-to-use tool. Is it possible to develop a national product that ticks all these boxes?
Frank: “Highly unlikely. There are too many competing interests and egos with those that have been involved. In the early days, NEHTA was an interesting organisation to observe. It was obvious that they didn’t understand the complexity of system interoperability or consumer expectations on how information is to be shared and stored.”
“Fear, uncertainty, and doubt also play a part in the slow uptake of the PCEHR
“The reality is that software used in healthcare is effectively a closed shop, and it’s difficult for different systems to be integrated. Once you’ve bought a solution from one vendor, it’s incredibly difficult – but not impossible – to walk away from it.”
“Also in recent years, there has been a seismic shift in patient expectations overseas and we’re starting to see the rise of patient advocates and patient hackers. These are savvy people who aren’t going to sit back and be a passenger in their personal health journey.”
“Fear, uncertainty, and doubt play a part in the slow uptake of the PCEHR. Some providers don’t want patients to be able to access reports on the PCEHR, others are concerned that patients may choose to make some information not sharable or viewable which may compromise care. I think the truth lies somewhere in between.”
7 tips to avoid fiascos
I asked Frank what doctors, healthcare managers and business owners can do to avoid disappointments. Here’s his list of 7 tips:
Be as clear as possible about your expectations and needs. Make sure you discuss the features you’re looking for and categorise them: absolutely essential, must have, good to have, nice to have, can live without. Ask how many features the software developer can provide in your first 3 categories.
Make sure that the software vendor understands your requirements. Get them to provide their understanding in writing so that you can see that they’ve understood.
Does the organisation hold certification for both ISO 9001 (Quality Management Systems) and ISO 27001 (Information Security Management) across all business units?
Find out where the software is being developed and supported from.
What is the quality like? Is it secure?
Don’t pay anything to a software developer before you are sure what you’ve been given is fit for purpose and what you asked for.
What contingencies are in place if the software fails to deliver as promised?
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. New regulation should be put in place to safeguard compliance by all parties.
The Dutch healthcare system has received international praise. This year the Netherlands are again topping the chart of the Euro Health Consumer Index. What makes the system so good? To get some answers, I caught up with old friends from the Netherlands.
The country’s philosophy is to cut costs and stimulate quality by introducing regulated competition. The Dutch have attempted to create a system that ensures universal health care, offers transparency and choice for consumers, and avoids risk selection. GPs play a key role coordinating care and preventing unnecessary use of hospitals.
Dr Pieter van den Hombergh, GP trainer and a former senior policy adviser at the Dutch Association of General Practitioners (LHV), is full of praise:
“In 2006, the country switched to a regulated market-oriented healthcare system: Insurers got purchasing power and the Government withdrew from healthcare, but set strict regulations for insurers and providers.”
Dr Jettie Bont is a GP and former board member of the Dutch Association of General Practitioners. “The Dutch health system is accessible to anyone, rich or poor, old or young,” she says. “Patients don’t have to pay a co-payment or excess payment to see their GP and we’re making sure it stays this way.”
How does it work?
The 6 key elements of Dutch healthcare:
1. Health insurance funds are not allowed to deny coverage because of illness, age or gender. A risk-equalisation system compensates health funds for accepting high-risk individuals.
2. Healthcare covered by the compulsory basic health insurance package is the same for every insurance provider. Basic cover includes GPs, medical specialists, hospital care, basic dental care, most prescriptions, and ambulance. Additional insurance packages can be purchased.
3. All Dutch citizens and residents contribute via a flat-rate premium set by competing funds – in 2014 the average premium was €1120 ($1626) – and an income-dependent payroll tax contribution. The Government covers premiums up to the age of 18, and people who earn less than a specific amount are entitled to a tax credit.
4. People are free to choose their insurance fund and have the option to change once a year. People are free to choose their GP, but must be registered with a nominated family doctor.
5. Doctor’s fees are set, there is no co-payment or excess payment for GP-care (except for travel vaccinations). Dutch GPs are paid via an annual lump sum per patient (capitation) as well as fee-for-service payments.
6. To help consumers, the Dutch Government collects and publishes price, quality and consumer satisfaction records of insurers and providers.
What are the strengths?
According to the authors of the latest Euro Health Consumer Index report, the Netherlands has the best healthcare system in Europe. The authors feel one of its strengths is consumer participation: “The Netherlands probably has the best and most structured arrangement for patient organisation participation in healthcare decision and policymaking in Europe.”
Other positives mentioned in the report are the availability of 24/7 GP care, and the fact that ‘financing agencies and healthcare amateurs such as politicians and bureaucrats’ are not directly responsible for operative healthcare decisions. The Dutch national health budget is €71.3 billion, of which €63.8 billion is funded by insurance premiums. Various levels of Government contribute €7.5 billion.
Van den Hombergh: “General Practice revenue has increased since 2006 and as a result GPs were able to invest in premises, staff and infrastructure, including ICT and communication equipment. Their personal income increased as well.”
“Along with the change to market-oriented financing the total budget for general practice rose from €1.92 billion in 2006 to €2.37 billion in 2010, an increase of 14%. In 2011 all insurers invested another 10%. Before 2006 the macro budget for general practice had been constant.”
“More group practices appeared; solo practices dropped between 2006 and 2012 from 46% to 39%. The availability of nurse practitioners for chronic disease management rose from a few percent to over 90%, managing diabetes, heart & lung disease and mental health. Diagnostic and therapeutic activities were incentivised: About €50 ($73) per service for minor surgery, spirometry, ECG, joint injections etc.”
Incentives and penalties
Until 2006 GPs received capitation payments for their public patients (about two-thirds of their patients), and fees per consultation for their private patients (about one-third), but this two-tiered system is now history.
“GPs are paid by insurers according to a mixed payment scheme: Partial capitation plus fee-for-service for basic care.
Van den Hombergh: “Regulated competition between healthcare providers and between health insurers was introduced for specialist care, but family medicine provided in general practices was exempted from this competition. GPs are now paid by insurers according to a mixed payment scheme: Partial capitation plus fee-for-service for basic care.”
“GPs receive ancillary payments, mainly on a fee-for-service basis, for additional or special services such as care for people with chronic diseases. They are compensated on an hourly basis for care during out-of-office-hours. The incentives were negotiated with the profession and were closely aligned to professional values, which limited the risk of perverse consequences.”
“In 2008, the Dutch Association of General Practitioners accepted new benchmarks on availability and accessibility. Insurers offered €4 ($5.81) for each patient when the KPIs were met. Practices should minimally be open six hours a day, five days a week and address emergency calls by a medically trained person within 30 seconds. The GP had to visit the emergency patients within 15 minutes. It was incentivised but also checked by the Dutch Health Care Inspection and failure to meet the standard was financially penalised: Practices with more than 2500 patients could miss out on over €10,000 ($14,514). In the end, only three practices did not meet the target.”
Bont: “A combination of capitation and fee-for-service in a 40/60 or 60/40 ratio incentivises effective and efficient care. A consultation should have a financial stimulus, but not too much, and at the same time the prerequisites should be there to deliver optimal care.”
“Mandatory patient registration works well and helps GPs to coordinate care. GPs are paid to do this via an annual registration fee per patient. We have our own quality assurance system and our own national general practice guidelines.”
What are the weaknesses?
Australian politicians claim that Australian health care is too costly (9.1% of GDP), but the Dutch system is even more expensive: 11.8% of GDP is spent on health (note that the US devote 16.9% to the health sector).
Dr Marith Rebel-Volp is a GP and Member of the Dutch House of Representatives. She says: “GP-care is cheap. The total health budget is €71.3 billion and General Practice costs only €2.67 billion. At the same time GPs are dealing with the majority of health problems and act as gate keepers to more expensive parts of the health system. However, long-term chronic care is expensive and one of the reasons the system is being criticised is its costs.”
“Insurers can set the benchmarks and, as collective bargaining by GPs is not allowed, this is a problem.
The Dutch Association of General Practitioners is concerned that health insurance funds are becoming too powerful, limiting choices of doctors and patients. A survey showed that most GPs are unable to negotiate or discuss their individual contracts with insurers.
Rebel-Volp shares this concern: “Although General Practice has a relative protected position within the healthcare system, there is friction between insurers and GPs. Insurers can set the benchmarks and, as collective bargaining by GPs is not allowed, this is a problem. GPs feel pressured to sign on the dotted line. Recently, a parliamentary motion was accepted which called for re-introducing collective bargaining – this is an interesting development.”
Bont: “Compared to many other countries Dutch GPs are in a strong position, but our workload has increased. Sometimes the expectations are unrealistic. For example, GPs will be required to manage people with serious mental health conditions like ADHD, and we have to hire mental health workers, but I don’t have the physical space to accommodate more staff in the practice.”
“Another result of the current system is the focus on KPIs. I often don’t have time to look at my patient during a consultation as we have to register so many details for the health funds.”
Private health funds require ongoing scrutiny by watchdogs. Last year the Dutch Healthcare Authority (NZa) had to intervene to make sure insurers offered the basic package to everyone without discrimination. The mission of the Healthcare Authority is to guard quality, efficiency, market transparency, freedom of choice, access to healthcare.
“The senate blocked proposed legislation changes which would have opened the door to risk-selection by insurers,” Rebel-Volp says. Although risk selection by insurers is not allowed by law for the basic health insurance package, this doesn’t apply to complementary packages. Insurers will try to push people to take out more expensive insurance products, for example by making it harder for certain patient groups to obtain the basic package online or directing people to the expensive packages on their websites.
Rebel-Volp: “Another issue is the level of the excess payment. This is high and many GPs feel patients are avoiding specialist care as a result. Currently the Health Minister has proposed a new plan in which a lower excess payment is an option if patients choose insurer-preferred, contracted specialist care.”
Vertical integration of care, where health insurers provide health services, is a topic of political debate in the Netherlands. Although it is cost-effective, risks are loss of quality, consumer choice and professional autonomy. Doctors and consumers often argue that insurers should not interfere in the patient-doctor relationship to avoid managed care situations as seen in the US. At the moment the Dutch Health Minister and the majority of the House of Representatives do not support vertical integration.
It is not surprising that the Netherlands is topping the international healthcare charts. Although their system is not perfect – and still a work in progress – the Dutch have solved some major issues such as access and equity. The Government has become the regulator and withdrew from the operational side of healthcare – this appears to have been very beneficial for the industry. On the flip side, the system is not cheap, private health funds need to be watched closely, and Dutch GPs have had to sacrifice at least some of their clinical autonomy.