Change Pace Change Price

liftum foot

Lift um foot to change direction?

The Australian health care environment suffers from change fatigue and we are about to see the most massive dose yet experienced in primary care in Australia. I love change, opportunity and innovation. But I have learned that change has to be at a pace that is manageable and where the motivation is understood and embraced. The real problem on the ground is that change occurs at lots of levels – within the organisation, locally and at State and Commonwealth level. If you want to sink, guarantee failure, it is best to ensure that change takes place at all levels at once – oh and add multiple dimensions to really twist the knife.

This is my situation – from where I read the Federal Budget. I work in a GP Super Clinic, a non-profit, that is owned jointly by two universities and supplies 24/7 services to a rapidly growing local community with huge industrial development 30 Kms south of Darwin.  The service is evolving into a training and primary centre provider throughout the Top End of the NT. We have a few specialist general practitioners, 5 registrars, 9 medical students coming and going, our PGPPP doctors are no more, and our solid group of IMGs are now under the pump. We have contracts with the somewhat fluid NT Department of Health, who after the Federal budget changes will no doubt be reviewing our arrangements. We now have a relationship with a Hospital Network faced with delivering on budget (never happened before) and our Medicare Local. Both are just finding their feet, the NT Medicare Local recently emerging like a phoenix from a merge of Divisions which itself only lasted a couple of years. NT Medicare local is already a formidable alliance of interests that is aiming to support general practice better and working hard on closing the gap. They are working closely with NTGPE – our soon to be dissolved local training provider which has been a pillar of stability lasting over 10 years! NT Medicare Local is now being dissolved to form a new PHN whatever that means. OMG – does anyone in Canberra know what it is like out here?

I cannot imagine the cost in capital, social and human terms of this change. Add to that a $7 copayment which will cause problems with our local community, many of whom will not pay – no way. Is anybody happy? What is this for?

I know that this sort of upheaval is happening around the country in one form or another.  WentWest Medicare Local in Western Sydney has been a trail blazer in provision of integrated Medical Local services and GP Training – the result of considerable planning and negotiation. But when there is only political impulse and convulsion, how can we plan? Should we say enough is enough? Should we plea to the tax payers of Australia that these changes amount to massive waste?

The price of change at this pace is staggering. What should we do?

Who’s Training in Whose Training?

WP_20131128_16_12_56_ProI am not sure if everyone is aware of the potential professional crisis for specialist general practitioners if the Department of Health and Ageing decide who is providing training for general practice in 2016. That is the stated aim, presumably not with advice from experts in health care delivery.

The Department contributes public money to primary care and so can decide who has access to what rebates and other financial assistance. This is the case for all specialist training.  During the Howard government a shortage of trained specialist general practitioners developed due to a failed policy to limit health care spending by limiting numbers of doctors. The ensuing GP shortage in outer suburban, rural and remote areas led to the government opening the door for doctors to work in primary care without the qualifications from the RACGP or ACRRM.  These qualifications have been developed to distinguish specialist general practitioners; the FRACGP has never been granted without submitting for the Fellowship exam, or equivalent international qualification. If the value of the FRACGP is not recognised by the community, then value in training to achieve Fellowship is also depleted. This is the crux of the issue and has led to the profession being at a precipice.

We specialist general practitioners understand how to deliver evidence-based sustainable primary health care across the broad range of community settings found in Australia. It is our space, not one invented by governments. Innovations and responses in our profession are not determined in Canberra. We are proud professionals delivering high quality care despite the limits of Medicare. I have worked in the NT for over 20 years and understand the issues with workforce distribution; I am keen to work with anyone who wants to ensure that all Australians have adequate access to primary health care. However the proposed takeover of our training by the Department of Health is unacceptable.

Universities and other large providers will no doubt see this as an opportunity. We will see massive conflicts of interest paying dividends to various agencies to meet workforce needs, fill departmental coffers or bring money to other organisations. Our new registrars have been learning on dolls and out of textbooks for years, and it shows. They want to be able to do doctoring – not be doctors. We have more to do than ever to prepare our registrars for delivery of the services our patients’ need. We need to do better at it.

I have a 7 principle approach to success:

  • The College must determine if placements are suitable for learning specialist general practice
  • The College must determine if supervisors are suitable for training registrars seeking to become specialist general practitioners
  • Our Fellowship must be seen as the hallmark of quality primary care, the doctor with FRACGP as the go to professional to provide primary ongoing medical care and lead the primary care team
  • The College must robustly represent and support our Fellows, particularly our supervisors, and our Members who are working towards Fellowship
  • The College should work hard for all Members to gain Fellowship and all Fellows to improve their standard of practice
  • Doctors with Fellowship should be recognised and promoted as specialist general practitioners and be expected to deliver a higher standard of care
  • The College should be the custodian of knowledge relevant to our professional practice and pathways to providing new and improved services to our communities.

 

The RACGP needs to advocate strongly for our Fellows (especially our Supervisors) and Members seeking Fellowship while working closely with ACRRM and GPRA to ensure that our profession and quality primary health care thrive.

It is our training and those training with us should feel that we are supporting them in their endeavour.

Copayment Shmopayment

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I must confess that I cannot see any benefit from the proposed Medicare copayment either as a price signal or a revenue saver. And I stress that I am loath to write off any approach to improving health care in Australia. It is difficult to think of a blunter, more chaos inducing instrument to apply to Medicare. How will it save money? Largely from committed general practices located in deprived areas – the more committed the higher the saving.

The most lucrative savings will arise from pressure on practices to accept the lower bulk billing rebate – this will save $7 per visit. Let’s face facts, GPs already do this for the majority of patients; in poorer areas GPs will have to continue to do so at a very high rate because many people will be unable to or will refuse to pay. What will we do for a 29 year old who has no income and new onset diabetes? How will we manage an infection in someone who drinks their weekly income on pay day, or a refugee who has no income. In many Aboriginal Health Clinics it will be devastating. Please imaging living in poor over crowed housing on the edge of a town or in a remote area without public transport or any other facilities, with high prices for all consumables and getting the same income as a person living in a well resourced urban area. In the NT discretionary spending may be little more than a single visit to the clinic. The $7 (plus test on costs) will be a care killer. The primary care ‘Closing the Gap’ initiative has provide free health care and has had a big impact where I work. The copayment will reverse these gains immediately. Government Ck-Ching, primary care Ck-Chang.

The safety net is a massive administrative issue – $70 a year limit for an individual ($490 for a family of 7). How on earth will this be managed? Such approaches may have worked while the money was reimbursed but this is a payment at the time of service, prior to service for many I suspect. Who will keep tabs on who has reached $70? What a nightmare. We have had Medicare fraud with sharing of Medicare cards for some time. This will certainly add to incentives to share cards, only presenting with cards that have reached the limit.

The Corporate Practices who are profit focused will be working on ways to generate the same income without adding disincentives to patients. Such practices appear to be the primary target of this copayment but I am equally sure they will be best placed to minimise the loss of income. We are likely to see a major escalation of SIP payments and payments for non-attendance items in response to this. Government will get their dollars back, but new leakage is likely to occur. Successful approaches will put pressure on surrounding practices to match them.

I am the first to admit that there is wastage in primary care and that we do more harm that we intend. I am very interested in spending Medicare dollars where it is likely to return greater benefit. I have already raised one such approach in a previous blog Saving Medicare. But I do not think that the proposed copayment will do anything but harm in many areas of this country. I would like to work with Government to come up with focused responses to the use of Medicare funds that are wasteful. Our College is the vehicle to do this and has developed the slogan #CoPayNoWay  using social media – the top tweets can be found here.

Watch out – Medicare Shmedicare.

Facing complexity

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The wonderful Jan Radford (you should follow her on twitter)  drew my attention to Garth et al’s excellent study on repeat prescription management in general practice. I enjoyed the approach, a  feel good experience. On reflection I think this paper is avoiding complexity and seeing it as a problem for the consumer. Is that fair?

Why do people take medications that are of marginal benefit or doing them harm? Why do so many patients attend and ask for their scripts without any concern for their health and the continuing relevance of these medicines?

My introduction to the study of repeat prescribing was Michael Balint’s excellent research work with a group of GPs entitled “Treatment or Diagnosis: research into repeat prescribing in general practice” published in the 1970s. Although this predates many pharmaceutical treatments for chronic disease, it raises critical issues with regard to human behaviour and receiving medications as a surrogate for care. These are perhaps more relevant today. What does taking the medication mean for that person? Did it start when their mother died, perhaps their child or spouse? Is it the one remaining legacy of a doctor that helped them a great deal and is missed terribly? Does it avoid conversation and inquiry and keep the doctor happy?

A friend told me how he turned up for a script for his epileptic medicine for years after he stopped taking it, just to keep the doctor happy – he was too scared to say he had stopped it. Many people are afraid to stop taking something that affects them negatively for fear of something worse – the wrath of relatives or doctor? The fear of withdrawal effects?

We are the source of repeat prescribing and if we expect people to be organised 99% of the time, then a few people will run short unexpectedly every day. Should we blame them? The amounts vary – 28 or 30 tablets for some things – 25 or 50 tablets for others – 5 or 2 repeats. How do they manage at all? Is the list of medications in their file an “all time list” or an up-to-date managed list. Do you actually know what they are taking?

Then we have the narcotic repeat prescriptions – perhaps 100,000 medical addicts who cannot be late or they feel sick. When will we doctors learn that narcotics do not work for chronic pain, in fact they clearly exacerbate the problem. And Endone should be banned (along with its long acting preparations). What are we doing to people? A pain clinic referral is unlikely to help as the return letters  only seems to justify the damage or at least ease the conscience of the GP.

Finally, we can insist on people waiting for an appointment if they urgently need a script but have been reviewed recently, as a punishment and monetary tactic. This enables the doctor to be seen and the fee to be subsidised or bulk billed.  Is this a reasonable use of public money and is there any measurable benefit?

Repeat prescribing is truly complicated, involving issues of compliance, funding, safety, quality and motivation. Difficulties cannot be seen solely as a problem patients bring on themselves.  The doctor’s statement “Your lack of organisation doesn’t constitute our emergency” could be reflected as “Your complexity, dependency inducement and chaos causes our emergency”. Whatever your point of view, repeat prescribing illustrates the complexity of modern general practice.

Engaging with Australia

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Grand Beauty

One challenge we have as specialist general practitioners is that our work is never done. There are thousands of special interest groups who vie for the attention of both general practitioners and our patients. Often the agendas are not transparent: a favourite concern of mine is the push for PSA testing by the Urological Society of Australia despite the lack of evidence of benefit. Faced with patients that seek an intervention they have seen or read about, we are overcome with the need to help and do good. Our education on topics is largely sourced and funded by those with financial interest in our behaviour. We often do not have the tools and information to unravel the evidence and be in a position to provide sound advice to our patients. Very few of our colleagues are equipped or brave enough to challenge these sources: a notable exception has been Prof. Chris del Mar getting the evidence together and going public on PSA testing. Do urologists get lead time bias?

I would like the RACGP to engage in a direct dialogue with the Australian community and investigate the needs felt in primary care and seek innovative and practical solutions that are commercially sustainable. It will be important to include peak bodies in this discourse, while seeking to understand their funding models and motivations. We need to learn how to deal with issues with more trust in our clinical know-how, less medications and fewer tests. Patients prefer such approaches when accompanied with understanding.

Enduring issues that arise in such discussion are the expressed need to have timely access to care when a person is sick and to maximise continuity. These pose difficulties for all of us; hence their appearance in surveys around the world. Meeting these needs can bring more satisfaction than many might think. I work in the large Palmerston GP Super Clinic providing 24/7 general practice and urgent care, covering a population out of hours of 25,000 or so. It amazes me that patients understand the pressures we are under and genuinely value the fact that we deal with emergencies – although it is only 30 minutes to the hospital. Working some shifts is necessary to provide comprehensive primary care just as it is in retail. Continuity means that we need to stay engaged, not referring at the drop of a hat. Generalists need to take responsibility for a broad range of presenting problems and work with patients to come up with solutions. Patient satisfaction is not the sole aim – it does not lead to better health. Getting these things right is a real challenge and requires resources and genuine investigation.

At the heart of our work is care; primary care, health care – what ever you call it. It works better if we care and we can only care together. That’s what our College is for.

Wherefore Good Fellows

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I am pleased with the attention our President of the RACGP is giving to the issue of prescribing Roaccutane.(isotretinoin). It is a serious drug that is used to treat a common condition. Liz Marles is advocating that the prescription should be made in general practice.

There are good reasons for this. First, at least in my experience, if I refer for this purpose to a dermatologist they invariably prescribe. Second, contraception and adherence is something we know about and is the main argument for specialist review. Third, NZ GPs have been doing well since being able to prescribe the drug in 2009.

I would argue that, where such regulator concerns exist, at least in the first instance, Fellows of the RACGP should be able to prescribe the medication as specialist general practitioners. This provides evidence to regulators and patients that the GP has reached a suitable standard to take such action and monitor progress. I understand there are good doctors working in general practice without Fellowship, some no doubt far better than I. However, when actions demand high standards of care it seems reasonable to initially back doctors who have put themselves through assessment by their peers to ensure they are suitable for independent practice.

I would go further and promote those specialist general practitioners, their training and commitment to standards. Does the general public understand what Fellowship means? Do politicians? Do they understand that no one has been grandfathered by the RACGP?

Does your practice draw attention to Fellowship and what this means to your patients? Do they have a right to know?

Saving Medicare

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Consider carefully

I personally worry at the waste in healthcare and how we can save on Medicare. Unless we do something we will have to start thinking about how to save Medicare itself. To give an example: prior to the arrival of bulk billing practices in Darwin a few years ago we had one radiology provider and a couple of pathology companies. We now have 4 radiology providers and a few extra pathology providers. These also bulk bill. So I can now order unlimited blood tests and radiology without cost to myself, the practice or the consumer (a more appropriate name in this setting). I can get an MRI in 15 minutes and almost any test apart from an ultrasound within the hour.

I can’t imagine the actual increase in costs – is anyone imagining? I do see the result of confused patients with multiple positive obscure serological tests and a cascade of radiology – each new test suggested by the radiologist to rule out the sinister nature of some incidental finding on the previous view. Further tests require further brief visits while time heals almost all things. Dollars all round – nobody’s money.

This is not ideal and the opportunity cost of unnecessary attendances, laboratory tests and radiology investigations is probably massive in terms of non-health fields such as housing and other basic services. So why don’t we come up with some alternatives for consideration. A $7 co-payment  doesn’t seem to do the job at all and seems to have few advocates. Here is an idea of my own which has had as little thought as the co-payment but might help funds go where they do more good.

Any attendance resulting in issuing of a private medical certificate for a period off work of less than 7 days will not be billable to Medicare. This would apply at the time of the visit or at any point in the future (to avoid being able to issue the medical certificate at a later date in order to claim the fee) but would not apply to parent or carer certificates for children.

Would this reduce medicare claims? Would it reduce the time off work for minor illness? Could it work? Would it be open to gaming? Let me know what you think.

Technology for GPs

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Technology Wasteland?

I see general practice as a technology wasteland. The problem is that while many useful technologies exist, these are neither designed to work in nor priced for general practice. Since the electrical rhythm of the heart was first recorded at St Bartholomew’s hospital in 1872 and the subsequent development of the ECG machine, there has been little in the way of major technology uptake in general practice. There are some notable exceptions; the spirometer is used reasonably often while clinic-based blood sugar, INR and SO2 measurements are definitely very useful and very affordable. Yet while individual patients regularly invest in these laboratory technologies, many practices do not.

The obvious example of a technology suitable for general practice is the ultrasound. First, it is a visual tool and can be seen by the doctor and patient. Second, real time imaging is essential for interpretation. Third, it both requires and enables maintenance of anatomical knowledge which is itself useful for primary care doctors. Finally, it is a massive convenience for our patients if we can exclude an intrauterine death, see an intrauterine pregnancy, look for subcutaneous foreign bodies or drainable collections, do guided injections and the like.  It is so obvious that this will be a key technology for GPs – it is safe, not expensive and provides value for patients who can also see what is going on. We need to work with companies developing ultrasound equipment to get it right for our setting. This will not displace radiologists but extends a service and convenience for our patients.

I do not want to decide which technologies might be taken up by GPs. There are so many to choose from. I would like our College to support the adaption of useful technologies for use in general practice, assist those wanting to pioneer use and then be custodian for the knowledge and skills-base required to implement the technology successfully for the benefit of our patients. This might be a useful app on a smart phone or a complex integrated fibre optic camera to view places difficult to see! Only our imagination will limit the possibilities.

Let the dance begin. The RACGP is the rightful facilitator and custodian of these endeavours.

eHealth and Clinicians

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Hi Tech

You may know me from my work in eHealth. I have been interested in discovery around ways for clinicians to control and develop the content specification for eHealth. It was a key role of the Royal Australian College of General Practitioners (RACGP) in the days of paper to offer quality health records for use in general practice. Technology has offered a lot to our profession, particularly in managing work flow and the movement of documents. However at current levels of eHealth provision, we have lost the ability to store information in a recoverable (or query-enabled) form in a way that meets our clinical needs. This is not unexpected and many are content enough with current software to tolerate this situation. I am not. I established Ocean Informatics with 4 GP Colleagues in 1996, ws CEO from 2004 to 2012 and now chair the Board of this clinically oriented health informatics company.

 

My aims have been to:

  1. Ensure that data collection specifications are managed by clinicians for specific purposes – not software developers
  2. That standardisation of clinical information enables interoperability of care environments, supporting clinical care
  3. That the infrastructure of eHealth should have no concern as to the content of the health records
  4. That there should be one logical record for every person although the information may be distributed among many systems
  5. That the infrastructure should not determine the information flows

I was a founding Co-Chair of the International HL7 EHR Technical Committee, and Co-Chair of the Standards Australia Working Group as well as the Australian delegate to the European Union’s eHealth Standards Committe (CEN TC251). My work has led to the establishment of the openEHR Foundation of which I am Chair. This international group is still evolving – this open source specification is now used in a number of European countries and Brazil. The openEHR method provides the basis for NEHTA’s Clinical Knowledge Manager.

The solutions in eHealth must involve and support clinicians. Not involvement  in some glacial consultation process once per decade (if we are lucky) but in a vibrant living evolution of clinical data specifications. I believe that our College could be the curator of such an environment.