Everybody has an opinion about their GP

Do you know that situation – usually at a party – when someone tells you what they do for a living, and mention a cool sounding job description like ‘product innovation manager’ or ‘advertising account executive’? I always want to know: what does that mean and what do you actually do?

Well, people never ask me what I do when I say I’m a GP. Instead, they usually tell me what their GP does. Or did. Or said.

Everybody always knows what I do, and that’s not surprising because the Australian general practice statistics are mind-blowing: Over 134 million GP consultations take place each year. Every year almost 9 out of 10 Australians make at least one contact with a general practitioner.

Professor Max Kamien said in the latest BEACH study:

“Mothers, children, the elderly and those with chronic conditions, such as diabetes, asthma and hypertension, have many more contacts than that. As a result of these personal contacts everyone has a view about general practice. Ministers of Health have been known to base their views about general practice on their contact with their own GP.

I’m privileged to have a job that’s smack-bang in the middle of life. One could indeed argue that we’re specialists in life, as we deal with just about everything: mental health, paediatrics, cancer, skin disorders, respiratory problems, grief, heart failure, domestic violence, emergencies, pregnancy, end-of-life care, immunisations, screening… you name it.

The latests RACGP commercial tells the story of diversity – the diversity of GPs, their patients and their conditions. I love the commercial because it captures in 60 seconds the wide range of issues people bring to the consulting room of the family doctor.

So if you want to find out what really happens in my office, have a look at this video.

What health consumers want: interview with Leanne Wells

Generating consumer-led ideas to improve the health system – that’s what the Consumer Health Forum is all about, says new CEO Leanne Wells. Health consumerism around the world is changing, and Leanne sees a potential for big reforms in Australia. I asked her about a range of topics, including the Medicare rebate freeze, the RACGP draft vision for a sustainable health system, funding and the role of pharmacists.

“It is a terrific honour and challenge to be leading this organisation at a time of significant developments in the role of health consumerism globally,” she says. “I believe in a strong patient-clinician alliance.”

“Consumer leadership is as important as clinical leadership in developing modern health systems that reflect the importance of patient-centred care. We can achieve this by working together to influence policy settings, design and operation of health care.”

Consumer-led ideas

What health consumers want: intervie with Leanne Wells
Leanne Wells: “Integration has to be the name of the game given modern health care is about managing multi-morbidity and complexity.”

“Our members include a diverse range of consumer organisations as well as professional associations, researchers and individuals with an interest in health consumer affairs. Through our membership network, we reach millions of Australian consumers.”

“CHF is all about generating consumer-led ideas for a better health system. It is the pre-eminent national organisation advocating on behalf of health consumers on policy issues pertaining to Medicare, PBS and population health and on issues such as health system development, access to best available consumer-centred care and access to medications.

“CHF’s work has included research and national campaigns on rising out-of-pocket health costs and prescription medicine costs. We deal frequently with questions from media on issues such as health insurance and quality and safety in health care.”

“There is potential for significant changes in Australia’s health system, particularly in Commonwealth-financed areas such as Medicare, primary health care and mental health, at a time when there are moves to put focus on reforms to Commonwealth-State health funding issues. In all of these areas, consumer-generated ideas for a better system will be crucial to success.”

Medicare rebate freeze

“CHF has supported the RACGP and others in the campaign against the rebate freeze. Nothing should compromise good quality, comprehensive, co-ordinated patient care. I support the concept of the patient-centred healthcare home.”

“Some consumers have capacity to pay a co-payment and will do so if they feel they get value. Others simply won’t go to the doctor if they are not bulk billed – and often those who don’t go to the doctor due to cost barriers are those from lower socioeconomic circumstances which we know are associated with higher rates of complex, chronic conditions: the very conditions that need ongoing, co-ordinated care. The issue highlights the need for the MBS review and a rethink of the way we finance primary care. Both are long overdue.”

“General practices need the flexibility to be truly responsive to their patient populations

“CHF seeks funding that is determined by the right models of care, not the other way around. At the moment we’ve got a system that is largely based on fee-for-service financing to drive and, at times, limit models of care.”

“General practices need the flexibility to be truly responsive to their patient populations. The expansion of health insurance to primary practice, may offer benefits in terms of better integrated care for some. The overall impact however is likely to be negative, setting up a two-tiered health system at the primary care level where insured patients would be likely to get preferential treatment.”

“The RACGP’s draft consultation paper ‘Vision for a sustainable health system’ makes the case for an alternative blended payment model offering flexibility and autonomy to respond better to contemporary care needs. The paper would be stronger if it articulated a vision for general practice emphasising how that could be done.”

“The paper lacked consideration of aspects of integrated care and placed ‘general practice’ rather than ‘the patient’ at the centre of the health system. We would have liked the paper to place greater emphasis on the patient as partner and on the consumer benefits of team-based care as well as the other non-financial levers that can work in concert to bring about change and innovation in general practice.”

Consumers as partners

“A big challenge is for health care to be much more consumer-centred. That works best when there’s a team of professionals looking after the consumer, when there’s an open flow of information and discussion between them about the patient’s needs and how to meet them together rather than separately.”

“We want to see a patient-centred approach to providing care – not disease-centred or system-centred

“Above all else patients want professionals who see them as more than just the ‘vessel’ of a disease to be cured, or a problem to be solved. Patients want to be recognised for who they are: unique individuals with their own unique lives. We want to see a health workforce which takes a patient-centred approach to providing care – not disease-centred, not system-centred, but patient-centred.”

“The National Safety and Quality Health Service Standards have consumers as partners in care as its second standard – solid recognition that this value must become inherent to the culture and operation of health services. Primary Health Networks have a pivotal role in bringing this about.”

“Having worked with divisions of general practice and Medicare Locals since the 2000s, I remain a strong proponent of the place ‘meso’ structures like these have in the system. The Primary Health Networks have great promise as disruptive innovators in our system.”

“With their distinct boundaries, alignment with hospital networks, relationship with general practice and the knowledge they will grow about their local communities, they are well placed to work with patients and clinicians to lead service and system development and innovation.”

“But they can only do this if they have mandate, the support and participation of patients and clinicians and the financial flexibility to invest in new approaches and new models of care.”

Dysfunctional state-federal funding

“The CHF supports a single level of government taking responsibility for leadership in health policy. We are diverse country with distinct regional communities. I believe moving to a single level of government, with regional purchasers administering pooled funding, is a concept worth exploring further.”

“The only way we are going to integrate the system is by having policy set nationally, and service commissioning undertaken regionally by single entities. Integration has to be the name of the game given modern health care is about managing multi-morbidity and complexity. Removing the dysfunctional nature of state-federal funding would surely be an improvement on what we have now.”

Devaluation of general practice

“Patients need to be seen as partners in care – assets not deficits. I agree that general practice and its place in the health system has become devalued over time. It is a very efficient and effective setting in which to deliver care close to where consumers live and work.”

“I applaud the RACGP’s efforts to get general practice better recognised and valued

“I applaud the RACGP’s efforts to get general practice better recognised and valued. However, in the campaign video, the doctor is represented as the sage authority while the patients are represented as passive recipients of the doctor’s view of them and their lives.”

“The characterisation was at odds with all the evidence showing that approaches which encourage patient-centred and patient-engaged care produce better outcomes. This aspect of the doctor-patient relationship could have been better reflected.”

Pharmacists and General Practice

“CHF supports a stronger role for pharmacists in general practice in areas such as medication support. It would be in the patient’s interest for general practice to have non-dispensing pharmacists as part of the team available to advise on quality use of medicines, hopefully freeing up GPs to focus on time-consuming, complex cases requiring medical expertise.”

“Expanding the scope for dispensing pharmacists to provide medical advice in pharmacies would also be supported by CHF provided the role was strictly within the pharmacist’s qualifications, was coordinated with the patient’s GP or local GP and where necessary, the services performed in a private area. Both options are good ways to make better use of an existing valued workforce.”

Patients or consumers?

“There is a continuing debate on the patient-consumer dichotomy. We prefer the use of the word ‘consumer’ when talking in terms of the health system generally. In that context we think the word consumer more accurately expresses the non-dependent status of a citizen and customer of health services and products.”

“The word ‘patient’ is appropriate when referring to an individual under treatment of a clinician where the patient’s outcome is directly dependent on the clinician.”

Why doctors should work closer with patient organisations

Historically, campaigns against bad government health policies have been predominantly doctor-centric. And the usual government response is to divide doctors and patient organisations.

Many politicians have mastered playing the ‘greedy doctor’ card, which is an effective way of making doctors’ objections seem less trustworthy.

A while back, I interviewed the influential patient advocate Jen Morris for my blog. Ms Morris is a researcher in healthcare quality and safety at the University of Melbourne.

Patient–doctor alliance

We spoke about the untapped power of the patient–doctor alliance. She strongly feels that we can achieve so much more in Canberra if patients and doctors joined forces more often.

“At a strategic level, it’s a numbers game,” she said. “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.”

The RACGP’s ‘You’ve been targeted’ campaign earlier this year against the co-pay plan was an example of what happens if patients stand united with GPs to protect primary care. The Consumers Health Forum of Australia (CHF) issued a joint press release with the RACGP and the Australasian College for Emergency Medicine to reject the co-payment scheme. The RACGP’s change.org online petition had obtained 44,800 signatures within a week.

Other organisations including the AMA followed suit. The broad approach seemed to have an impact, first in the media and eventually in the corridors of power, and GP co-payment and extended level A consultations were dropped.

More recently, the RACGP, the Royal Australasian College of Physicians, and the CHF partnered in a joint submission to the Federal Health Minister regarding the deregulation of pharmacy locations and ownership.

Concerns

Although these are great developments, there are also concerns. What if our goals are in opposition?

Take for example the PCEHR. Patient organisations want full control of the data, which makes it less useful as a clinical tool for doctors.

Understandably, there is scepticism from both sides. Patient organisations may be wary of working with powerful medical organisations setting the agenda. Patients may feel that doctors are not genuinely interested in their opinions. Doctors on the other hand may be concerned about increasing demands and consumerism.

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.”

So, the answer lies in building trusting relationships. GPs are good at this on an individual level. It is one of the strengths of general practice. We should be doing the same at an organisational level. Working closely with patient organisations will improve the mutual understanding of our values and beliefs.

According to Ms Morris, we should be looking for common ground. More often than we acknowledge, patients and doctors are really advocating for the same outcomes. But too often, she added, we don’t take the time to really analyse where the crux of disagreement actually lies. Morris: “(…) 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.”

‘Them and us’

Of course, the ‘them and us’ thinking also occurs between providers. This can be confusing for patients and third parties including government organisations. For that reason, I’m a great believer in the power of United General Practice Australia. It is made up of the main GP groups, including the colleges, the rural groups, the AMA, registrars and supervisors and the divisions network. These organisations have shown a desire to collaborate and put aside their differences.

A similar structural working relationship should be developed between doctors and patient organisations. This alliance should exist not just to respond to new developments, but also to proactively set out a future course and lobby governments accordingly. It would make primary care less vulnerable to the rapidly changing preferences and priorities of the government of the day.

It is good to see the willingness from both sides to work together, and I hope it is the beginning of a fruitful collaboration in years to come. We must harness the potential power of the patient–doctor alliance to protect what’s good and, where needed, improve the care for our patients.

This article was originally published in Australian Doctor Magazine.

The untapped power of the patient-doctor alliance

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?

Jen Morris
Jen Morris: “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.”

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.”

What really matters

Dying is an intense sad process, but there is another side to it as well: people often take the opportunity to reflect.

As a doctor I have the privilege to talk to people who are nearing the end of their lives. A while back I asked one of my wonderful 85-year old patients what had been most important in her life.

She didn’t need much time to think, and said: “That has to be my family, doctor, and the move from England to Australia with my husband.” Her loved ones, and the journey that changed her life – she couldn’t have been more concise.

I asked myself: what matters most? I found three inspiring life lessons.

#1: Achieving childhood dreams

Randy Pausch was a professor in computer science who died of pancreatic cancer. He became well-known after he gave a lecture titled The last lecture: Really achieving your childhood dreams. It went viral on YouTube.

In the video below Pausch gives another, shorter, inspiring speech to university students about how to live your life well by nourishing relationships with others and expressing passion. Pausch died 68 days after giving the speech.

#2: Don’t be afraid to fail, be afraid not to try

“If today were the last day of my life, would I want to do what I am about to do today?” Apparently Steve Jobs asked this question everyday, and it has become a guiding principle for many. Like Randy Pausch, Jobs was looking for passion: “There is no reason not to follow your heart,” he says in one of his famous speeches. Jobs reminds us that all negatives, like fear of embarrassment or failure, just fall away in the face of death.

#3: Begin with the end in mind

One way of following your heart is to begin with the end in mind. This principle is very similar to Steve Jobs’ philosophy, and it’s habit two of Covey’s famous 7 habits of highly effective people:

(It) is based on imagination – the ability to envision in your mind what you cannot at present see with your eyes. It is based on the principle that all things are created twice. There is a mental (first) creation, and a physical (second) creation. The physical creation follows the mental, just as a building follows a blueprint. If you don’t make a conscious effort to visualize who you are and what you want in life, then you empower other people and circumstances to shape you and your life by default.

A patient once told me that he and his wife took their four-wheel drive and caravan five times on a trip around Australia. I said I’d love to do the same one day but that five times was a hard act to follow. He looked at me and replied: “Aim for it.”

When I listen to my terminally ill and elderly patients, they remind me – like Pausch, Jobs and Covey – to keep on trying, have fun and be there for others.