Less is more

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

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

To refer or not to refer?

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

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

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

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

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

Issues with online referral services

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

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

Never just about a script

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

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

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

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

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

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

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

High value care

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

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

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

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

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

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

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

Health Care Homes

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

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

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

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

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

Pay-for-performance

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

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

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

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

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

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

Slow down

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

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

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

Government health spending
Source: AIHW

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

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

4 take-home messages

I have four take-home messages for you today:

#1: Take the good, leave the bad

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

#2: Slow down

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

#3: Convenience ≠ high value

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

#4: Keep people well in the community

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

Take home messages

Bizarre research article about parental confidence in GPs gets a mention in ABC’s Media Watch

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…

Bizarre research article about parental confidence in GPs gets a mention in ABC’s Media Watch
Media Watch sets the record straight: Most parents have confidence in their family GP. Source: Media Watch

The background

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.

#trustaGP

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.

View ABC’s Media Watch here.

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

High confidence in GPs

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

This is of course good news.

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

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

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

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

 

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

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

More bizarre conclusions

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

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

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

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

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

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

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

Not helpful

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

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

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