“I do know that when primary care doesn’t connect, collaborate and work together – patients see and feel that disconnection. And I have a feeling that those working in primary care see and feel it too.
Labor’s health spokeswoman Catherine King announced that her party will create a permanent health reform commission if it wins the federal election. I thought this sounds like a step in the right direction as long-term planning of health reform is much needed in Australia.
On the other hand, there have been many government committees, task forces, reviews and reports that haven’t made a dent in the primary care landscape.
If only we could put together some of the ideas coming from Australia’s health and consumer groups. These organisations, often working at the coal face of primary care, have an excellent understanding of the urgent needs and requirements.
I was pleased to see that some of this year’s pre-budget submissions by primary care organisations contain similar ideas. For example, the pre-budget submissions from AMA, ACRRM and RACGP all argue for funded telehealth services.
As expected, there is a strong push for adequate patient Medicare rebates and reduced patient out-of-pocket costs. The general practice profession also believes that spending more quality time with patients should be encouraged through better remuneration of longer consultations.
One of the main themes is improving care for people living with chronic and complex conditions. The Australian Medical Association is proposing a chronic disease quarterly care coordination payment to GPs to support team-based care.
The Pharmaceutical Society of Australia wants pharmacists in residential aged care facilities. The Consumers Health Forum argues for an Australian Co-Creating Health initiativeto support people with chronic conditions to actively manage their own health.
Rural doctors, RDAA and ACRRM, are asking for more junior doctor training places in rural and remote settings and a move to the rollout phase of the National Rural Generalist Pathway.
This is just a selection of some of the budget submissions. What struck me is that there is a lot of merit in many of the proposals. They are often not mutually exclusive.
Unfortunately, most budget submissions seem to end up in a large pile on the minister’s desk. Many great ideas never see the light of day, because there is no sector-driven vision or strategy.
Is this the best we can do? I believe it is time to work towards a shared vision for primary care. Why not start by looking at what the various organisations and groups have in common?
I always enjoy a good podcast. There is something appealing about listening to people’s stories via the cloud – and at a convenient time and place. I usually listen in the car on the way to work.
In 2014 I posted 6 great podcasts for primary care, one of the most visited articles on this blog. As podcasting seems to be more popular then ever and new podcasts for family doctors have been launched since my last post, it is time for an update (October 2018).
So here is my top 10. Since I’ve been involved with the BridgeBuilders podcast (shamelessly placed @ no.4) my respect for podcasters has grown even more; it takes many hours to edit one episode.
Click on the iTunes or SoundCloud logo to listen, and feel free to share your favourites in the comments section. Big thanks to all podcasters – keep going!
#1: The Good GP
The Good GP has been around since September 2016 and has grown into one of the most popular education podcast ‘for busy GPs’, hosted by Western Australian GPs Dr Tim Koh and Dr Sean Stevens, in collaboration with RACGP WA.
Guests are GPs or other specialists and a range of mainly medical topics is covered, for example: acute pain, allergies, immunisations, the future of general practice, euthanasia and the registrar -supervisor relationship.
This is another popular medical education podcast – hosted by Queensland GP and medical educator Dr Sam Manger.
Sam interviews guests covering a wide variety of topics including case studies and guideline reviews. The podcast is aimed general practitioners, family physicians, other specialists, allied health, nurses, registrars/residents, medical students and anybody interested in health, science and medicine.
Just a GP is a popular newcomer in 2018, run in collaboration with RACGP New South Wales. Hosts Dr Ashlea Broomfield, Dr Charlotte Hespe and Dr Rebekah Hoffman discuss leadership, quality in clinical practice, self care and wellbeing, difficult consultations, starting or running a private practice and GP research.
They explore the layered complexities with each other and other GPs with expertise in these areas. In each episode they share a favourite resource or clinical pearl.
Hosted by Dr Edwin Kruys, Dr Ashlea Broomfield and Dr Jaspreet Saini, the themes of the BridgeBuilders podcast are collaboration in healthcare, fragmentation, team care and working together to the benefit of our patients.
A wide variety of guests, including some of our healthcare and thought leaders from e.g. the RACGP, ACRRM, Consumers Health Forum (CHF) and the Pharmaceutical Society of Australia (PSA), give their view on trust, integrated care, quality care, leadership and what needs to happen to make Australian healthcare an even better connected place.
Broome GP & emergency doctor Casey Parker has been podcasting since 2012. He discusses topics related to emergency medicine and (procedural) general practice . In the Broomedocs journal club relevant research studies are critically appraised, often with guests.
The Health Report by Norman Swan and other ABC reporters features health topics such as ‘fishy fish oil’, insomnia, asthma, chiropractic controversies, the cranberry myth and lyme disease. Often several national and international guest discuss various topics in one episode.
The Best Science (BS) medicine podcast is a Canadian show which critically examines the evidence behind commons drug therapies. GP and associate professor Michael Allan and professor James McCormack present many myth busters and topics relevant to general practice, such as the treatment of back pain, osteoporosis and common cold.
Doctors have called on the Federal Government to delay the implementation of the Health Care Homes model from the current starting date of 1 July 2017 by at least three to six months. Here’s why.
United General Practice Australia, which comprises the leading general practice organisations RACGP, AMA, RDAA, GPSA, GPRA, ACRRM and AGPN, has serious concerns regarding capitated funding for chronic disease management and treatment. It may harm patients, and it may undermine GP-led care when funding runs out.
Additional time to plan for the Health Care Home model is required to get the nation’s healthcare system right and properly consider, design, and implement the supporting tools, information and adequate funding mechanisms.
The extended timeline would allow stakeholders time to ensure the instruments and tools being used are appropriate and validated by evidence.
Health Care Homes: the background
A Health Care Home (HCH) is not a place but a partnership between a patient, their GP and the primary care team. Health Care Homes are general practices and Aboriginal Community Controlled Health Services that coordinate the ongoing comprehensive care of patients with chronic and complex conditions.
As part of the 2016-17 Federal Budget, the Government announced the Healthier Medicare: Reform of the Primary Health Care System package. The core element of the package was the staged rollout of Health Care Homes in selected Primary Health Network regions starting in July 2017.
The Government has re-directed $21.3 million from the Practice Incentive Program and is redirecting a further $93 million in MBS funding to support the HCH trial.
HCHs have the potential to drive a fundamental shift in Australia’s health services toward patient-focused health care practices and are a modified version of the Patient-Centred Medical Home (the Medical Home).
The HCH aims to facilitate a partnership between individual patients, their preferred GP, and the extended healthcare team. The model should enable better-targeted and effective coordination of clinical resources to meet patients’ needs.
Patient-centred Medical Homes have been associated with increased access to appropriate care and decreased use of inappropriate services – particularly emergency departments – for patients with chronic and complex conditions.
The clinical team– which may include GPs, nurses, nurse practitioners, Aboriginal health workers, care coordinators, allied health professionals and other medical specialists – collectively provides care for patients.
The HCH aims to meet as many of the patient’s healthcare needs as possible and for collaborating with other health and community services.
In the current proposal Health Care Homes will receive monthly ‘bundled payments’ on a per patient basis, depending on each eligible patient’s level of complexity and need. The payments will be paid to the Health Care Homes, not GPs.
All general practice healthcare associated with the patient’s chronic conditions, previously funded through the MBS, will be funded through the bundled payment. Regular fee-for-service will remain for routine non-chronic disease-related care patients.
Funding for services provided by allied health professionals and specialists, as well as for diagnostic and imaging services are not included in HCH bundled payments and will continue to be funded through the MBS.
Stage one is limited to Medicare-eligible patients with two or more complex or chronic conditions. Patients that fall within three identified tiers will be eligible to enrol in a Health Care Home.
The Department of Health is developing a patient identification tool to be used by HCHs to identify eligible patients as per the tiers. The Department states that the tool will attribute a risk score to each patient, which will determine the level of care required and subsequently the value of quarterly bundled payments that HCH will receive.
Unfortunately details on the eligibility assessment tool have not yet been released, but will likely draw upon information the practice already has on the patient (for example previous hospital admissions, diagnosis, medications, clinical risks), as well as non-clinical information such as demographic and psychosocial factors.
The patient identification process will be the same across all stage-one HCHs, regardless of whether or not they are in rural and remote areas.
The Practice Incentives program (PIP), a key driver of quality care in general practice, is currently undergoing reform. The redesigned PIP program will reportedly introduce a quality improvement incentive to replace the clinical specific incentives in the current PIP and provide a ‘flexible and supportive structure to the HCH implementation’.
Stage one of the implementation is currently set to commence on 1 July 2017 and run for two years until 30 June 2019. It will involve approximately 65,000 patients and up to 200 general practices or Aboriginal Community Controlled Health Services.
Why doctors have expressed concerns
One of the key recommendations by the Primary Health Care Advisory group was to encourage patients to be engaged in their care (recommendation 3). Although the model was intended to be ‘patient-centred’, the patient somehow seems to have been lost in the discussion around the current model.
For example, it is not clear how the proposed model will encourage better coordination or comprehensiveness of care to improve the patient journey (recommendation 7).
For a long time the RACGP and other professional groups have been actively offering to work with the Government on the development of an appropriate model, but the RACGP and other GP groups were not consulted in this case. The general practice representatives on the Government’s implementation committees are not representing their professional associations and furthermore have had to sign confidentiality agreements so therefore cannot discuss ideas and recommendations with peers or policy development staff.
The RACGP has called for a rigorous trial subject to academic and scientific evaluation, rather than rushing into a phased rollout. The HCH implementation evaluation methodology is still under development. Health policy needs to be evidence-based and the evidence should to be carefully developed – otherwise it will fail patients and the Australian health system.
A correctly designed trial will properly address the challenges facing Australia, strengthen access to the delivery of high-quality care and ensure patients have a stable and ongoing relationship with a general practice.
The proposed model capitates funding for chronic disease management and treatment in general practice. It may harm patients and undermines GP-led care when funding runs out.
This major reform, which is expected to save millions of dollars in hospital care, did not receive additional funding. GP groups are concerned that the federal Government’s Health Care Homes model is inadequately funded and will not improve health outcomes for millions of Australians living with chronic and complex conditions.
An example of concerns
HCHs will be required to have a service or care coordinator for enrolled patients. As funding allocated to the HCH is in fact reallocated funding from PIP and Medicare, there is no additional money available to support this role.
There is presently not enough information available for practices to make an informed business decision about their involvement with the HCH.
Information released by the Government does not provide details on any additional support for e.g. practices in rural and remote areas and no additional funding is being provided for these areas, where there are higher costs and complexity in providing chronic health care.
The original RACGP Medical Home vision includes incentives for practices and GPs to facilitate patient-centered care, for example a complexity loading to support the delivery of patient services in areas of community need.
The RACGP vision also recommends a comprehensiveness loading: GPs and general practices that provide a comprehensive range of services can respond to the needs of the community they serve. Enhancing the comprehensiveness of services provided in the primary health sector will reduce demand for more complex and expensive services in the secondary and tertiary health sectors.
The Department has indicated that payments made to a HCH are also intended to cover after-hours services where they are provided in the practice rooms. Some practices may achieve efficiencies by providing some care for enrolled patients over the phone or electronically.
Each practice will need to determine if the allocated funding in the proposed model is sufficient to provide the additional care required under the HCH model.
The Department has stated that successful HCH applicants will receive a one-off payment of $10,000. The RACGP believes that an appropriately funded HCH trial would require an average of $100,000 per practice per annum, in addition to current funding allocations for chronic disease management items and other MBS items.
As the funding of the HCH by the Federal Government is minimal, additional funding from State Governments and Private Health Funds may be necessary to make the model a success. The federal Government could assist by negotiating such payment levels as part of the HCH.
The RACGP is prepared and ready to work closely with the Federal Government on this major health reform – let’s not miss the opportunity to make Health Care Homes a success.
This article was originally posted on Croaky. Dr Edwin Kruys is vice-president of the Royal Australian College of General Practitioners (RACGP).
The information in this article is based on public material provided by the Department of Health. Whilst all efforts have been made to ensure the details are accurate, information regarding Health Care Homes is subject to change.
A general practice or Aboriginal Community Controlled Health Service applying to be a Health Care Home must be within one of the ten selected PHN regions and needs to:
be accredited and maintain accreditation, or be registered for accreditation, against the RACGP Standards for general practices;
participate in, or be prepared to participate in, the Practice Incentives Program (PIP) eHealth Incentive;
register and connect to the My Health Record system and contribute to their enrolled patients’ My Health Records;
participate in the stage one HCH training program;
use the patient identification tool to identify the eligible patient cohort in their practice or service, assess individual patient eligibility and stratify their care needs to one of three complexity tiers according to their level of risk;
ensure that all enrolled patients have a My Health Record;
contribute up to date clinically relevant information to their patients’ My Health Records;
develop, implement and regularly review each enrolled patient’s shared care plan;
provide care coordination for enrolled patients;
provide care for enrolled patients using a team-based approach;
ensure that all team members have roles that utilise their qualifications and allow them to work to their scope of practice;
provide enhanced access for enrolled patients through in-hours telephone support, email or video-conferencing, as well as access to after-hours care where clinically appropriate;
ensure that all enrolled patients are aware of what to do if they require access to after-hours care;
collect data for the evaluation of stage one and for internal quality improvement processes.
Last night’s undecided election results raise many questions – and doctors will say: we told you so.
Family doctors have made it very clear during the lead-up to the federal election that it’s crucial for governments to invest in primary care to keep Australians well and out of hospital.
But not only that, during the longest election campaign in Australia’s history, GPs around the country have had discussions with millions of patients about the future of their healthcare.
Looking at the outcome of the election night, it seems that voters have taken the message to the polling booths.
Wealth should not affect our health
The day after the federal election date was announced, the Royal Australian College of General Practitioners (RACGP) launched the You’ve been targeted campaign, warning people about the looming higher out-of-pocket costs, which have already become a reality.
The aim of the campaign was not to increase health corporate profits or fill doctors’ pockets, it wasn’t even a political campaign – it was all about the message that the Australian people must be able to visit their doctor when they need to.
Doctors called on a newly elected government to invest in quality and sustainable general practice to strengthen patient services.
“Our first and foremost responsibility is to our patients,” said RACGP President Dr Frank Jones, “and this is really the message from the College in the campaign, because this is about the fact that we cannot sustain quality general practice under the present Medicare freeze.”
Posters went up in GP surgeries, messages were printed at the bottom of prescriptions, TV ads were aired and there were 2340 syndicated media stories featuring the RACGP on national TV, print and radio, and in medical and consumer media outlets across all formats.
The Australian Medical Association (AMA) followed suit and threw its weight behind the issue, and shortly after many political parties made health a key focus during the election campaign. The policy shift by Labor to lift the Medicare freeze and fund chronic disease management by general practice teams was welcomed by many.
What should happen next?
Whatever the outcome of the election will be, the new government would do well to sit down with GP leaders and develop a long-term plan to strengthen primary care. The message is simple and supported by abundant evidence: strong primary care keeps people well and out of expensive hospitals. Investing in general practice patient care pays off!
Dr Frank Jones: “The RACGP is seeking progressive health reform and a genuine commitment to the future of our healthcare system from our political leaders and we are committed to discussing funding models for a sustainable and effective primary health care system.”
As GPs around the country are moving away from bulk billing, health minister Susan Ley has already indicated she is prepared to look at a medical home model. The proposed appointment of a National Rural Health Commissioner and commitment of the Coalition to pursue a National Rural Generalist Training Pathway is another positive sign.
However, the medical home is more than a hospital avoidance project. “In a patient-centred medical home, patients have a stable and ongoing relationship with a general practice that provides continuous and comprehensive care throughout all life stages,” said Dr Jones. “This model is the most cost-effective way to address the needs of patients, healthcare providers and funders.”
Part of the future plan should be the continuation of high quality primary care research and the introduction of non-face-to-face patient services such as video consultations to improve access to family doctors and to transform Australian primary healthcare to the digital age.
Pharmacies will be handed $1.26 billion for delivering healthcare services. Good for them. But meanwhile the government is not prepared to increase the Medicare rebates patients receive when they see a doctor.
As a result of the new health policies, visits to the doctor will become more expensive in the years to come, whereas pharmacies will be paid more to deal with health problems. With this move Health Minister Susan Ley seems to make a clear statement: Don’t go to your doctor, see the pharmacist instead.
A vague agreement
It could be me but I’m not entirely sure what the Health Minister will sign off on – it’s all still a bit vague:
The Pharmacy Guild says on its website: “The Government has committed to $50 million over the Agreement for a Pharmacy Trial Program to trial new and expanded community pharmacy programs which seek to improve clinical outcomes for consumers and extend the role of pharmacists in the delivery of healthcare services through community pharmacy.”
National President of the Pharmaceutical Society of Australia Grant Kardachi says: “PSA particularly welcomes the doubling in this agreement to $1.26 billion of funding for the provision of patient-focussed professional services.”
According to Australian Doctor magazine, “some $600 million will be spent on ‘new and expanded’ services, but there is no detail on what services this will cover.”
One thing is certain: Pharmacies are going to deliver more healthcare services – and at the same time the freeze on indexation of the Medicare rebates comes at a cost for patients.
Here re my questions:
Is Minister Ley’s decision helping to improve teamwork within primary care, or is it creating more confusion and frustration for patients and their doctors?
Can pharmacists and their assistants offer the same quality healthcare as doctors and practice nurses?
Can the person who is selling the drugs give independent health advice?
Why not spend part of the money on increasing the rebate patients get back from Medicare after visiting their doctor?
Why not spend part of the money on improving access to practice nurses and GPs?
Does this mean that doctors will miss opportunities to pick up on health problems, because patients will see the pharmacy assistant instead?
When the Pharmacy Guild talks about ‘evidence-based’ services, what do they mean? (given the fact that many community pharmacies also sell unproven remedies and products).
In the ‘Blogging on Demand’ series you get to choose the topic. If you have a great idea you want the world to know about, send an email, contact me via social media or leave a comment below. Melissa Sweet suggested the topic of this post: ‘Social determinants of health’. She tweeted: “Interested in your take on SDOH & how they play out locally.” Thankfully, to make the task easier, Melissa suggested some background reading: 436 articles from the Croakey archives.
Note: ‘Social determinants of health’ are economic and social conditions that influence the health of people and communities.
“Doc, that’s not going to work.” The health worker was standing behind me. She had overheard my consultation with the elderly man. I thought I was doing a great job, as I had taken the time to explain what diabetes was all about – in layman’s terms – and how he should inject the insulin.
The indigenous health worker continued: “He lives mostly outside and keeps his medications under a tree.” I couldn’t believe what she had just said. When the penny dropped I realised she was, of course, right: the insulin wouldn’t last in the excessive heat of the Kimberley.
It was clear that I had no idea of my patients’ living circumstances. I felt like a fool.
The home visit
Another time, another place. I was doing a home visit in a Cape York indigenous community as part of a team consisting of two nurses, a social worker, a health worker, a police officer and a local government representative.
The verandah was covered with rubbish and furniture. It was hot inside. The room was empty, apart from a few mattresses. The concrete floor and walls were dirty. “How many people live here?” I asked. “Between 8-20, depending on when you visit,” said the social worker.
The patient was lying on a mattress – she clearly only had a short time to live. There was not much I could do apart from some small medication changes. Afterwards, we had a long chat on the verandah about fixing the air-conditioning and the tap, and making her last days as comfortable as possible.
All tip and no iceberg
The contribution of doctors and other health care professionals to our wellbeing is relatively small: Depending on what source you read, healthcare contributes for about 25 percent to our health. On the other hand, an estimated 50 percent of our health is determined by economic and social conditions (see image).
One of Australia’s leading researchers on the economic and social determinants of health is Professor of Public Health Fran Baum. “Typically,” she writes in this editorial, “responses to diseases and health problems are knee jerk and concerned with ameliorating immediate and visible concerns.”
Professor Baum calls this the ‘all tip and no iceberg’ approach. Instead of focussing on disease and unhealthy behaviours we should improve the conditions of everyday life.
To combat the chronic disease and obesity epidemic for example, we should not just be advising lifestyle changes and initiating medical treatment. These are tip-of-the-iceberg solutions.
Instead, says Baum, let’s look below the surface at things like urban planning, the availability of unhealthy food, our sedentary lifestyles at home and at work, and equal opportunities for all.
In my work the influence of economic and social factors is apparent. Some examples:
The 26-year old single mother who cannot afford medications for her children
The 38-year old machine operator who gained 10 kg of weight since he started a fly-in-fly-out job in a remote mining community
The 50-year old chief executive who makes 14-hour days in a high-pressure environment, and develops anxiety symptoms.
My role as a GP in these scenarios is modest. Ok, ‘all tip and no iceberg’ may be too harsh – apart from the fact that it sounds like ‘all icing and no cake’…
But Professor Baum has an important message: We must not close our eyes to what really makes us ill and, more importantly, change it.
Health Minister Tanya Plibersek said on ABC’s Q&A that Medicare Locals had developed as a ‘natural successor’ to divisions of general practice to assist primary care at the local level.
Although this sounds great, it seems that Medicare Locals are wasting tax dollars and are creating red tape. Medicare Locals are funded by the federal government and responsible for funding local health projects such as after hours care.
This week, Medicare Locals have been put on notice by the AMA because they are rolling out onerous contracts for GP after hours services. Although the after hours work is still done by doctors and nurses, the funding is now in the hands of Medicare Locals instead of the state health service.
It also appears that Medicare Locals are sending out new contracts to GP practices for PIP incentive payments (‘PIP’ is a bonus paid out to practices if certain targets are met). The contracts require GPs to produce lots of data e.g. quarterly reports, and contain many clauses that give full control to Medicare Locals but put all the risks, costs and responsibilities on health professionals.
It is expected that many GPs will not sign these contracts. This will have serious consequences for patient care.
If we do not stop Medicare Locals, doctors and practice managers will be wasting valuable time behind their computers generating reports, instead of helping patients. Medicare Locals should be supporting health professionals to improve patient-access to health care facilities.
A recent survey also brought to light that about fifty percent of Medicare Local staff is busy writing reports instead of providing or facilitating services to patients or clinicians.
Whichever party wins the next election, this needs to change. Medicare Locals, please make it easier for us to provide patient care – not harder!