Has Australian general practice moved one step closer to the British NHS?

In 2019, the Department of Health, via its practice incentive scheme, will not only start setting the key performance indicators of general practice but also further tighten its grip on practice data. It is not unlikely that the Department’s strategy will create the same issues the National Health Service is currently encountering: loss of patient-centeredness of care, unreasonable KPIs and low doctor morale.

The redesign of the Practice Incentive Program (PIP) has been in the cards for a while. The introduction of a new quality improvement (QI) payment system was deferred for 12 months in May 2018 because of concerns that it was not fit for purpose.

Central role of PHNs

If it goes ahead in May 2019, the impact of the new scheme will be significant. The big change will likely be that Primary Health Networks (PHNs) become exclusive “QI providers” for general practice. This means that they will extract, analyse and store practice data and present GPs with benchmark reports. Many PHNs have already started collecting data in anticipation of the changes.

To be eligible for quality improvement incentive payments, practices will have to demonstrate to PHNs that their performance is on par with the Department’s KPIs. Although analysis and benchmarking of clinical data are becoming increasingly important to improve patient care, there are many issues with the proposed PIP overhaul.

Initially, there was talk about more organisations becoming QI providers, such as the Royal Australian College of General Practitioners (RACGP) and the Improvement Foundation, but, according to Medical Observer, it looks like there will be no profession-led alternative to the PHN model and, as a result, practices will not be given a choice of QI providers.

General practice is at risk of gradually losing control over its quality improvement processes, which will no doubt leave many grassroots GPs dismayed.

Professional buy-in?

The main issue with the scheme is related to professional buy-in. The Department of Health has gone through the usual process of consulting the profession, but it has always been clear that the PIP redesign was going to occur regardless of the opinion of GP groups.

The Department may claim in its communications that the KPIs are supported by the various professional bodies, but the level of engagement, trust and satisfaction with the new QI system will be low for various reasons.

First, this is an example of a top-down government solution, largely designed by the Department of Health. As we have seen with the My Health Record and Health Care Homes, this approach usually creates just as many problems as it is trying to fix.

Similarly, there has been a lack of engagement with the e-health PIP (ePIP) scheme, which requires practices to upload shared health summaries to the My Health Record to remain eligible for incentive payments or ePIP. This may have given the Department a countable number of uploads, but there is no evidence to suggest that it has improved meaningful use of the My Health Record or quality of care in general practice.

Weak evidence

In the PIP redesign process, only payments to practices have survived. For example, the aged care incentive payment to GPs providing care to patients in residential aged care facilities will be scrapped. This incentive is worth $3000–$5000 per doctor. Many have argued that it is incomprehensible that funding benefitting aged care is removed at a time when residential aged care facilities need more support to provide the medical care required.

By stopping these service payments to individual doctors, the incentives will be one step further removed from those who are responsible for the actual quality improvement activities. Again, this does not inspire confidence in the Department’s new QI system.

Measuring performance against KPIs in combination with performance payments will almost certainly create new problems. Quality indicators used by governments around the world are often easy to measure isolated parameters that have limited valuefor complex systems such as general practice.

The evidence to support financial incentives is weak, and the British Quality and Outcomes Framework (QOF) pay-for-performance system has illustrated what can go wrong: QOF has not improved care but did result in the loss of the patient-centredness of care and has created a significant decrease in doctor morale.

No funding priority

The new QI PIP will be subsidised by a shift of funding from other PIP and SIP incentives — which has been labeled as “robbing Peter to pay Paul” by the Australian Medical Association. In 2016, $21 million were removed from the PIP budget to partially fund the Health Care Home trials. The last budget announcements made it clear that there will be no increase in PIP funding in the near future. The PIP scheme, introduced in the 1990s, has never been indexed.

The Department of Health has not yet provided clarity on what the PIP scheme will look like beyond May 2019. This lack of transparency about long term planning creates uncertainty for practices. Although the expectations will start off low, it is to be expected that the Department will adjust the KPIs upwards over time, wanting more for less.

One of the PIP eligibility criteria for practices is accreditation against the RACGP’s Standards for general practices, and it will be interesting to see if upcoming changes to the PIP scheme will affect the percentage of practices that take the effort to go through the accreditation process.

Data extraction

Finally, general practice is not only facing loss of control of quality improvement but is also about to miss out on an opportunity to become custodians of its clinical data. Although the QI PIP data will be extracted from GP practices, it will likely be managed and controlled by PHNs and other government agencies, such as the Australian Institute of Health and Welfare.

When the government defunded the Bettering the Evaluation and Care of Health (BEACH) study in 2016, general practice lost its most important longitudinal source of data. It doesn’t take much imagination to figure out what will happen with the QI PIP data when, in a future reform cycle, PHNs or other government agencies involved are subject to funding cuts or cease to exist altogether.

The Department of Health’s underlying thinking seems to be that the responsibility for quality and data should be taken away from the profession, even though the government’s own data governance practices don’t always inspire confidence.

Professional response

The department should have given professional organisations the responsibility to execute a mutually agreed strategy, acceptable to all parties, including custodianship of data for quality improvement purposes.

Our peak bodies are working hard behind the scenes to negotiate the best possible outcome. It is more important than ever for the profession to work through any differences and present a united front. The question remains, can we stem the tide of increasing departmental control or has general practice definitely moved one step closer to the NHS?

This article was originally published in MJA Insight.

Revalidation of doctors, or how to spot the bad apples

Wouldn’t it be great if we could spot the bad apples before we consume them? Or even better: before they become bad? In recent years medical regulators around the world have been exploring ways to identify doctors who are performing poorly.

In the UK all apples are tested once a year via a process called revalidation. But some have said it will not detect poor doctors; its main purpose is to gain patients’ trust. Others say it is meant to demonstrate what good apples look like. But one thing is for sure: Revalidation is labour-intensive and expensive.

“There is indeed an additional time cost,” said GP Dr Paresh Dawda in Australian Family Physican. “The appraisal meeting was usually 3 hours in length, and on average it took another 5 or 6 hours to collate the evidence and complete the forms, which is in keeping with an average of 9 hours found in the revalidation pilots.”

Then there are the training, time and wages of the appraisers, usually doctors too, the administrative staff, extra regulation, log books, documents, IT… Revalidation has become an enormous enterprise, costing £97M ($186M) a year, mainly because of added pressures on doctors’ time.

It seems logical that, before a country embarks on an operation like this, the problem it is trying to solve has been defined and the solution is effective.

So what’s the problem?

According to the Medical Board of Australia, evidence from Canada shows that 1.5% of doctors are not good enough. The Board has translated this figure to Australia, and thinks that over 1,350 doctors could be performing unsatisfactorily. Other research indicates that just 3% of doctors are the source of 49% of complaints.

“Where is the evidence that further regulation is needed?

Several safety mechanisms are already in place: At the moment Australian doctors must meet the Medical Board’s mandatory registration standards, including for recency of practice and continuing professional development. Doctors can be subjected to random compliance audits.

Although a majority of Australian doctors seems to support competence checks, there are serious questions about the UK-style revalidation process.

Revalidation screenshot
Screenshot: Example of questions UK doctors have to answer during the revalidation process.

AMA(WA)’s GP Dr Steve Wilson in this blog post: “Where is the evidence that further regulation is needed, which will be preventative and ultimately beneficial to the profession and the community?”

“Will it address those who fail to practise to agreed levels, and is that a sign of ‘impairment’ or more about personal style, lack of time, adequate remuneration, or lack of care, training, experience, sheer demand and workforce numbers?”

At a conference in 2013 Medical Board of Australia Chair, Dr Flynn admitted that ‘the problem that a revalidation-style system would help solve was not yet defined’.

But Dr Flynn questioned the current continuous professional education system: “Can you assure me that everyone who has done your CPD program is actually competent and practising at a reasonable standard? (…) My sense is that, for most CPD programs, they don’t do that, or at least, not to a high enough level of certainty.”

After meeting Dr Flynn in 2013, the RACGP stated in Australian Doctor magazine: “The meeting provided an opportunity for the college to discuss the strength of our current QI & CPD program, and the necessity of adding yet another mechanism to identify underperforming doctors, when processes are already in place – such as the medical boards, health quality and complaints boards and indemnity insurers.”

What’s the Medical Board up to?

“We started a conversation about revalidation in Australia in 2012,” said Dr Joanna Flynn in last week’s media release, “as part of our commitment to making sure doctors in Australia maintain the skills to provide safe and ethical care to patients throughout their working lives.”

The board has asked the University of Plymouth to answer some questions on revalidation. At first glance this seems a sensible approach.

Dr Flynn: “We have commissioned this research to find out what is working well internationally, what is in place in comparable health care systems, and what principles the Board should consider in developing revalidation in Australia. (…) this research will help make sure that the decisions the Board makes in future about revalidation are effective, evidence-based and practical.”

The aim of the project is to:

  • establish the existing evidence base for the validity of revalidation or similar in countries comparable to Australia
  • identify best practice and any gaps in knowledge for revalidation processes
  • establish the validity evidence for revalidation’s effectiveness in supporting safe practice
  • develop a range of models for the Australian context for the Board to consider.

It seems to me the research questions are broad and several steps are taken at once. For example: ‘Establishing the evidence for revalidation’ and ‘developing a range of revalidation models’ are entirely separate processes.

It appears the Medical Board has already made up its mind. The research findings will be considered by the Board in the second half of 2015. I am certainly looking forward to the results and conclusions, as well details about cost and setup of the study.

The Camera revalidation research website of the University of Plymouth doesn’t give any answers away: “The research team is currently undertaking an ambitious programme of research involving three interlinking studies to explore and understand revalidation in all its complexity.”

Putting the cart before the horse

The question is of course: Is revalidation the right solution? Are there other options? One could argue that this should have been considered before spending tax dollars on an overseas research project.

Professor Breen, from the Department of Forensic Medicine at the Monash University in Melbourne, said in the Medical Journal of Australia: “There is little to support the idea of simply transposing the UK system to Australia. Despite some local failures of medical regulation and hospital governance, there has been no widespread loss of faith of the community either in its doctors or in the regulatory system.”

“Is there a problem with medical registration in Australia that needs attention, and, if so, what should be done to fix the problem?

“The Medical Board of Australia would be wiser to start afresh by asking and answering two questions — namely, is there a problem with medical registration in Australia that needs attention, and, if so, what should be done to fix the problem?

“The medical profession in the UK appears to have accepted revalidation, albeit reluctantly, as representing the price to be paid for maintaining the existence of the GMC and for regaining public trust after a series of regulatory failures.”

“It has been claimed that revalidation will not reliably detect poorly performing doctors, and many commentators have pointed out that revalidation would not have identified Dr Harold Shipman.”

Immediate past president of the AMA, GP Dr Steve Hambleton had second thoughts too. In MJA Insight he said: “We need to make sure we maintain our currency and continue to improve health outcomes, but in terms of value for money, making everybody go through a 5-yearly process of 360-degree evaluation is not needed in the Australian health system.”

Both Professor Breen and Dr Hambleton suggested there are better ways to deal with the bad apples. Database analysis could be one solution. Other options are targeted revalidation and a revamp of the existing CPD program and accreditation. Some have argued that the focus should be on the workplace, not just on health professionals.

Journalist Paul Smith from Australian Doctor magazine was, as usual, spot on when he wrote: “(Doctors) may argue that targeted revalidation has greater merit than what they may see as carpet-bombing the entire profession.”

Red-tape stress

“Recently I cried at work,” posted Dr Adrienne Garner on the BMA blog. “Why? Because the evening before I’d been notified that my appraisal, submitted after hours of work, had been unsubmitted by my appraiser as it was ‘not sufficient for revalidation.”

“I was gutted. My mind churned with a mixture of thoughts ranging from anger to fear, through frustration and disappointment. Sleep had been impossible.”

“Under revalidation appraisals became a form of policing the profession.

Many studies show that doctors are more likely to experience psychological distress and suicidal thoughts than the general community, and there is a high rate of burnout. Pastoral care and self-reflection are important. But when they are part of a policed regulatory framework, they become a stressor in itself – which defeats the purpose.

Former Coventry GP Dr Gaurev Tewary, now working in Australia, posted on a social media platform: “I was an appraiser in the UK. My overall impression is this: Appraisals used to be fun and interesting and mainly pastoral. You did them to help people and I enjoyed supporting the profession. Under revalidation it became a form of policing the profession.”

About 5,000 doctors a year are considering to leave the UK, and many come to Australia. Bureaucracy is one of the reasons they emigrate. We must become better at dealing with bad apples, but healthcare is already a highly regulated industry and the last thing we need here in Australia is more regulation, red tape and stressed-out doctors.

I hope the Medical Board will work with the colleges and the AMA to explore better options.

Revalidation

UK doctors in Australia – Why they won’t be going home any time soon

The numbers are telling: About 1,500 UK doctors move to Australia and New Zealand each year. This exodus is causing havoc in England. A GP-shortage creates high workloads and overstretched doctors, and a survey showed that over half of UK GPs plan to retire before the age of sixty. This stressful situation has prompted a coming home campaign to entice doctors to go back to the United Kingdom.

Why are doctors leaving, and, will they move back to save the NHS?

Dr Nathalie Departe is a UK-trained GP working in Fremantle, Western Australia. “I moved to Australia in 2009 for a change of scenery. I had visited Australia before and loved it, so when my husband found himself in a career hiatus, we thought we would enjoy the sunshine for a few years.”

“Working in Australia was a breath of fresh air. Patients were pleased to see me, understanding if I ran late, and I was rewarded and not penalised if I spent time with a complex patient to sort out their management. Access to pathology and radiology services was prompt, rather than a standard 6-8 week wait for an ultrasound, and access to allied health services didn’t compare – good luck trying to see a clinical psychologist on the NHS.”

“Initially it was a bit odd to bill patients and not provide free care at the point of need, but I soon came to value the transparency of the transaction. The integration between private and public care makes private care accessible and affordable in Australia, rather than in the UK where private care has to be funded in full.”

Escaping the NHS

“In Australia I can arrange imaging quickly, receive the results the next day and organise appropriate and timely care

Dr Janaka Pieris moved to Brisbane in 2010 to ‘escape’ the NHS: “When I think back to my working life as a GP in South East London, I have two overriding memories: there was never enough time in the day to do the work asked of me, and there was no means of limiting my workload. NHS General Practice is a sink for everything no-one else will take responsibility for. Many GPs feel unable to decline these demands – many of which are not NHS work and therefore unfunded – and as a result, are drowning in work.”

“When a patient presents with painless obstructive jaundice in the UK, I have no option but to refer in to hospital, because I have no access to appropriate imaging, or I cannot get it done in a timely fashion. In Australia I can arrange the imaging quickly, receive the results the next day, discuss the case with a specialist and organise appropriate and timely care. It is much more satisfying from a professional perspective.”

Dr Tim Leeuwenburg made the move in 1999, immediately after his internship in the UK. He is now a GP at Kangaroo Island in South Australia. “I was married to an Aussie and always knew I’d be coming to Australia for love and a better lifestyle.”

“That was 15 years ago. Since then I’ve vicariously witnessed the demise of UK medicine – and am anxious that Australia doesn’t make the same mistakes: Other professions trying to do doctors’ work, capitation and performance payments, privatisation, walk-in clinics, phone advice lines, revalidation. They are all seemingly good ideas, but not evidence-based and all have served to emasculate the profession and increase the number of doctors seeking to retire, locum or emigrate from the cesspit that is the NHS. None of these measures have reduced costs or increased quality.”

“The myth of the ‘fat cat’ wealthy GP laughingly enjoying his round of golf whilst poor patients helplessly waited for his attentions was regularly portrayed in the media

Departe: “Despite working in a nice area and enjoying my job, I had a growing sense of unease with the way UK general practice was going. There seemed to be ever changing targets to qualify for practice payments with increased red tape and less time for consultations.”

“There was a general loss of respect for the role of a GP; it was not unusual for patients to demand medication, tests and home visits inappropriately, then to be outraged if you questioned the need for it. The myth of the ‘fat cat’ wealthy GP laughingly enjoying his round of golf whilst poor patients helplessly waited for his attentions was regularly portrayed in the media, and I felt that general practice was being devalued in the eyes of public and politicians alike.”

Dr Mark McCartney left the UK in 2013 because he was not happy with the working conditions in the NHS, but moved back to England after 12 months because of family circumstances. “There is a huge cultural difference in Australia, where there is a mixed health economy of private and state-subsidised services. The NHS is free at the point of access for patients, and service always struggles to meet the demand and prioritise appropriately. UK hospitals are dysfunctional places and the effects of this trickle into General Practice.”

“UK GPs are mostly paid on the basis of capitation payments depending on the number of patients registered, with additional payments for reaching clinical targets and a small amount of fee for service payments. There is now a shortage of GPs and we work in an environment of running faster and harder just to meet demands, without additional incentives or resources.”

“Australian GPs have the luxury of earning a high proportion of income from fee-for-service payments, including patient fees and Medicare payments. The more patients they see and the more services they provide, the more they earn. Clinical practice is also more interesting with rapid access to x-rays and scans. It is a professionally motivating environment to work in.”

Would you move back to the UK?

Dr Pieris is sceptical about the fully funded induction and returner scheme: “Firstly, it is manifestly insulting to suggest that doctors who have worked in similar systems, such as Australia, need retraining to work in UK general practice. I do more medicine in Australia than ever I did in the UK.”

“Secondly, if people are leaving because of a failed system, a sensible approach would be address those failings, not try to tempt people back into the same environment they left.”

“To return would require most GPs to undertake 6-12 months of supervised training, and to surrender to ridiculous bureaucratic imposts

Departe: “Why would I return to a role where I am restricted in my clinical practice by financial constraints, strangled by paperwork, stressed out by time pressures, undervalued by patients and politicians and where I would earn less money for more work and more stress?”

“To return would require most GPs to undertake 6-12 months of supervised training, and to surrender to ridiculous bureaucratic imposts,” says Leeuwenburg. “The reason doctors are leaving the NHS is because of unfettered demand from patient ‘wants’ not ‘needs’, and reduced income as a result of capitation. Why on earth would you go back?”

McCartney: “Very few GPs will return, unless they have personal or family reasons. UK GPs are retiring early, but this does not seem to be the case in Australia. There are also huge barriers to doctors wishing to move back to the UK in terms of medical registration and licensing to practice. The NHS is wasting resources trying to recruit in Australia and they look foolish because of that.”

Doctor’s advice

“My message for governments,” says Departe, “would be Stop undervaluing good general practice! Good general practice has been proven to provide better value for money and a more integrated care approach than secondary care. By all means, regulate general practice to maintain appropriate standards of care but then pay us accordingly and let us get on with being general practitioners.”

Leeuwenburg: “Listen to grassroots doctors, not NHS managers who have destroyed the NHS and are now sprucing their wares in Australia. Nor to academics who think things like capitation and revalidation are necessary. Our Australian system is marvelous and we should be proud. Sure, there is fat in the health system that could be trimmed, mostly in hospitals and specialists, but primary care is overall incredibly efficient and GPs do a great job.”

“The UK government needs to stop attacking GPs and listen to doctors and the BMA, who have been largely ignored for the last ten years

“Ofcourse there are some outliers, but there are many more who are hard working and ethical, doing the right thing for patients and Medicare. Alienate GPs and risk the collapse of a great primary care system. It will cost more if we surrender to the failed experiments of the UK or privatise us with private health funds.”

“The UK government needs to stop attacking GPs and listen to doctors and the BMA, who have been largely ignored for the last ten years,” says McCartney. “Doctors want to work in an effective service so that they can focus on caring for patients. Learn from Australia that good access to radiology for GPs can keep people away from hospital until they really need to be there.”

Pieris: “The UK Government should let us do our jobs. Trust us. Stop interfering. No-one is saying regulation and scrutiny are not required. However, GPs are not some malign enemy. Stop treating us as if we are.”

Recommended further reading: Doctors from overseas, about my experiences as as a Dutch doctors starting Australia.

Image source: www.queensland.com