MBS Review: A stronger primary care system in sight?

Implementing healthcare reform in Australia is always an uphill battle. After a disappointing outcome of the much-anticipated Healthcare Homes program, some of the members of the Primary Health Care Advisory Group regrouped when they were appointed to the Medicare Benefits Schedule (MBS) Review Taskforce.

The recommendations by the taskforce to improve the MBS are refreshing in many ways. There is a move towards strengthening GP stewardship, voluntary patient enrolment, more non face-to-face care, a simpler careplan program and increased support for home visits – which seems sensible and is addressing the frustrations of many about the current Medicare system.

It appears there are a few things missing. For example, there is no recommendation to spend more time with our patients by committing to an increase in the schedule fee of longer consultations (item numbers 36 and 44). This would have been more useful for most patient encounters than a new one-hour plus item number.

I believe the residential aged-care item numbers will need more investment when the SIP incentive ceases to exist. There is mention of outcome-based payments which requires an explanation. The lack of detail about the dollar values makes it challenging to predict the impact on general practice and primary care.

In an ideal world the recommendations could result in an invigorated, modern, patient-centred health system. However, if history repeats itself, the result will be a simple cost-saving exercise, dressed up as clinician-led, evidence-based healthcare reform.

A typical case of make it or break it.

Promising breakthrough: dramatic miracle cure offers hope to victims

The problem with headlines about medical breakthroughs and miracle cures is that they never live up to the expectations. On the other hand, the breakthroughs happening every day in primary care do not attract much media attention.

Seventeen years ago medical journalist professor Schwitzer published the seven words you shouldn’t use in medical news: ‘promise’, ‘breakthrough’, ‘dramatic’, ‘miracle’, ‘cure’, ‘hope’ and ‘victim’. Has Schwitzer’s taboo list made an impact?

Words you shouldn't use in medical news
Source: Twitter

Not really. A quick Google search shows that the same words are still used to celebrate ‘heroic medicine’ – often surgical interventions, new drugs or medical technologies. Scientific progress and developments are important but not always easily translated to every day care for every day Australians. They are never ‘miracle cures’.

At the same time we are seeing an increase in spending on hospital treatments but little investment in keeping Australians healthy and out of hospital. Although the breakthroughs in primary care are not regarded as newsworthy, they are often life-changing.

Dramatic & miraculous examples

Here are some of the amazing health ‘breakthroughs’ that are happening every day in Australian communities:

The patient who, supported by her general practice team, feels so much better after getting control of her diabetes. The person with a mental health condition who, after many months of hard work, and treatment by his psychologist and GP, is able to do the groceries again without a panic attack.

The woman who died peacefully at home, according to her wishes with close family around and supported by her GP and the palliative care team. The obese man who has been able to lose weight as a result of determination and regular contact with his GP and allied health team.

The patients who were glad they came in for a blood pressure check or immunisation because the general practice team picked up a heart murmur or melanoma. The highly anxious child who returned to school with help from the multidisciplinary team – much to the relief of the parents.

Medical news: wrong headlines
News headlines: room for improvement?

 

The courageous person who opened up and told his GP or practice nurse what he has never shared with anyone else before – and made a start to change his life. The worried parents demanding antibiotics for their feverish baby, but eventually leaving the GP practice relieved and without a script because they know the infection is self-limiting.

The hospital admissions avoided through a phone call by the GP – with a concerned patient, allied health professional, aged care facility nurse or hospital doctor. The elderly, isolated and malnourished patient who improved and continued to live independently with support from community nurses and the general practice team.

The consultation around the plastic bag of medication boxes brought in by a patient after a visit to the hospital – an essential chat about which tablets to take and when, to make sure she gets better.

Promising breakthroughs

Professor Lesley Russell Wolpe wrote in Inside Story about the value of incremental care. She said: “Heroic medicine has its place, but treating it as the core of medicine means that the majority of government funding goes to hospitals, acute care and elective surgery, a situation that is reinforced by the political imperative to deliver visible returns in a short election cycle.”

She said: “Treating general practice as a speciality in its own right — along the lines of the current advertising campaign ‘I’m not just a GP. I’m your specialist in life’ run by the Royal Australian College of General Practitioners — would help. Ensuring that primary care has the resources to keep up with its central role in the healthcare system is also vital.”

In the years ahead more ‘dramatic breakthroughs’ will continue to come from primary care teams who, day in and day out, assist people with important health decisions and adjustments in their lives. It is time to change the headlines. It is time for decision-makers to increase their support for primary care.

As RACGP president Dr Bastian Seidel said in The Australian: “Our patients want health, they don’t necessarily want treatment”.

How should Primary Health Networks support GPs?

It appears the new  Primary Health Networks (PHNs) are here to for the long haul. There is an enormous opportunity for PHNs to add value where they support quality primary healthcare services to the community.

RACGP Queensland has developed a draft position statement identifying 4 concrete targets that should be aimed for in primary healthcare reform at a local level.

The targets are presented below. I believe that PHNs could play an important role in achieving these goals – in collaboration with GPs.

  1. PHNs are in an excellent position to assist healthcare providers and organisations to build effective relationships. PHNs should facilitate a shared health vision for their local area, exceeding disciplinary and organisational boundaries.
  2. PHNs should encourage continuity of care and make sure new models and initiatives do not further fragment our health system and/or adversely affect health outcomes.
  3. PHNs need to play an important role in facilitating better information exchange and communication between healthcare providers.
  4. PHNs should encourage the development of innovative models of care that introduce genuine integration between the various parts of the health system.

The family doctor – old-fashioned or the key to a healthy future? (Part 2)

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:

  1. Primary care increases access to health services for relatively deprived population groups
  2. The quality of clinical care by primary care physicians is at least similar to specialist care for specific common diseases
  3. The positive impact of primary care on prevention
  4. The beneficial impact of primary care on the early management of health problems
  5. The accumulated contribution of primary care characteristics to whole-of-person care
  6. The role of primary care in reducing unnecessary or inappropriate specialty care.
Barbara Starfield
Barbara Starfield: “(…) good primary care is associated with better health outcomes, lower costs, and greater equity in health.” Source: Wonca

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.

Conclusion

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.

The family doctor – old-fashioned or the key to a healthy future? (Part 1)

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:

  1. Informational continuity: The use of information on past events and personal circumstances to make current care appropriate for each individual
  2. Management continuity: A consistent and coherent approach to the management of a health condition that is responsive to a patient’s changing needs
  3. 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.

Is family medicine going out of fashion?