Issue 9 / 14 March 2016

A LEADING general practitioner has agreed with the findings of the latest Grattan Institute report into chronic disease in primary health care, but says if GPs and primary health networks (PHNs) had access to the same data they would be able to help their patients to better outcomes.

The Grattan report – Chronic failure in primary care – was released last week to criticism from both the Royal Australian College of GPs and the Australian Medical Association.

It concluded that: “Our primary care system is not working anywhere near as well as it should because the way we pay for and organise services goes against what we know works”.

“At best our primary care system provides only half the recommended care for many chronic conditions. Only a quarter of the nearly one million Australians diagnosed with type 2 diabetes get the monitoring and treatment recommended for their condition.

“The role of GPs is vital, but the focus must move away from fee-for-service payments for one-off visits. A broader payment for integrated treatment would help to focus care on patients and long-term outcomes … The evidence shows that a consistent, coordinated approach to specific diseases helps primary care more effectively prevent and manage chronic conditions,” the authors wrote.

Dr Linda Mann, a GP in the inner west of Sydney and a long-time advocate for health care reform, said the authors of the Grattan report, Stephen Duckett, Hal Swerissen and Jo Wright, were “very, very right”.

“GPs can’t do any better because of the way Medicare functions,” Dr Mann told MJA InSight.

“What are we supposed to do, when we are denied access to the resources that could help [our patients with chronic diseases]?”

Dr Mann cited the way Medicare deals with mental health care programs such as Access to Allied Psychological Services (ATAPS) as a case in point.

“The federal government has told us that [tools] like ATAPS are only to be used for short-term mental health problems – problems that are perceived as quickly treatable,” she said. “We’re not allowed to use those services for people with long-term problems.”

The availability of data and feedback was also an issue for GPs and PHNs, she said, pointing out that data available to the Grattan Institute via paid-for patient management systems like MedicalDirector, were not necessarily available to doctors on the frontline of care.

“We need data,” Dr Mann said. “We are currently denied data. We want to know who is doing things sensibly and who is doing them badly so we can help them.

“Immunisation programs are an example of how data-sharing works well – the data on who is being immunised, for what, and when, is gathered practice by practice so that the PHN can help those practices that are not doing well.

“Why can’t we do this for other [procedures]? Privacy [regulations].

“The PHN cannot determine who’s doing what. If they had the data we could do appropriate things [to improve care of chronic disease patients].”

Developing care plans for patients was one area where Dr Mann saw a need for reform. The ideal use of a care plan was to allow a patient with chronic diseases to access allied health services – to act as a “gatekeep”, she said.

“But they are also developed so the practice can make money, frankly,” she said. “Bulk-billing practices are bereft of cash and they will do anything, within the Medicare system, to try to [generate income].”

That included developing care plans for patients who were not necessarily in need of one, with perhaps 1 in 15 reflecting a genuine need, Dr Mann said.

“If the audits worked, the practices would be given feedback – but that’s a conversation neither the RACGP nor the AMA are willing to have, it seems.”

The chair of the RACGP’s Expert Committee on Quality Care, Dr Evan Ackermann, said he “fundamentally disagreed” with the Grattan Institute’s conclusion that primary care was “failing with chronic disease”.

“What information we do have suggests that we’re heading in the right direction.”

Dr Ackermann did agree that there needed to be a different way to manage chronic disease.

“Chronic diseases are complex, particularly among aged patients with multiple comorbidities,” he said. “GPs only have one tool to manage it.

“What is missing is a way to manage complex scenarios, and it’s true that we don’t do that well.”

Professor Stephen Duckett, co-author of the report and Director of the Grattan Institute’s Health Program, told MJA InSight that he was “unsurprised” by the initially negative responses to the report from the RACGP and the AMA.

“There are a number of ways of responding – they could deny the evidence, they could bury their heads in the sand, they could say they didn’t like the way we phrased it but yes, or they could say ‘yes you’re right, let’s get on with it’.

“I’ve seen it all.”


Poll

Can primary care do better treating patients with chronic disease?
  • Yes, but we're hamstrung by the system (77%, 81 Votes)
  • Maybe, but we've made good progress (15%, 16 Votes)
  • No, we're doing the best we can (8%, 8 Votes)

Total Voters: 105

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7 thoughts on “Grattan primary care report right, says GP

  1. Stan Doumani says:

    Absolute Rubbish! What next? US style managed care, British NHS style per capita payments? All that needs to happen is for the “system” to reward time spent so that we have time to provide the quality of care that is required. What the system needs more than anything is real competition but this can never happen when the government underwrites everything we do, and that is here to stay I’m afraid. Let’s not cede them any more control over us and what we do than we already have!

  2. Dr Louis Fenelon says:

    I think Dr Mann should consider she is speaking for a group of private practitioners who provide intermittant services to patients who choose (less and less often) to attend that particular practitioner for their own reasons, when they want to. Fee for service made sense and still makes sense for the services provided. GPs perform multiple clinical assessments and on-site investigations that diagnose and lead to effective management of chronic illness. Some even achieve a fee for service payment. Suggesting we fail to manage chronic health because we don’t prove ourselves by reporting to big brother enough is an insult to our profession. Fact is we are increasingly expected to report to a public health system which has increasingly diverted patients it fails to manage to us. Inundated by it it’s own bureacratic failings it has coerced General Practice into accepting the burden and now wanting to enforce it. The public system couldn’t fund it and yet expects GPs to pay for our “failings” by carrying that part of its can. Failings assessed by those incapable of providing primary care and in most cases, any direct patient care. I never was a fan of direct billing, but have offered it when I think it may assist patients pursue health care for their chronic issues. Again it is pretty unfair to site “rorting” of care plans by GPs, when patients galore value a GP that gives them 5 podiatry sessions a year on their diabetes care plan. While I agree it is ideal if integrated whole-of-person care can be provided (I work in such a facility), the other fact is the definition of that sort of care used to be called a public hospital. Don’t even start me on My Health, another harpoon in the side of GPs deserving better..

  3. Hester wilson says:

    The Grattan report is spot on.  We need to change the way general practice is funded and supported.  There is no way the current fee for service that rewards 5 minute medicine can actually improve patient care in chronic disease.  The way that Medicare has tinkered at the edges and done nothing to change the fundamental underlying problems of community general practice in Australia is evidenced by this. Patients with chronic illnesses are often complex with co morbidities that mean they need a wide range of supports to assist them to manage their health issues in the longer term. Dr Mann is right when she points to ATAPS being wrongly directed.  Another example is a system that makes the active multimodal management of chronic non malignant pain costly and inaccesible.  Easier to prescribe truck loads of opioids that while they may help a small number of patients cause significant harm to others and don’t improve their pain.  Where prevention isn’t funded and instead money goes on funding more exciting things.

    Dr Ackerman, where is your evidence that Australian general practice is managing chronic illness well, I’d love to see it. once again the RACGP comes across as an institution maintaining the status quo at any cost. This speaks of a profession with a large chip on its shoulder, a speciality in its infancy that isn’t prepared to question itself.  It seems that the leadership and advocacy so urgently required in the RACGP is sadly lacking. And I, for one, as a member of this organisation am sadly disappointed but not surprised.

    Let’s grow up, take this on the chin and look honestly at the changes our profession needs to make to improve outcomes for our patients.

  4. Dr Spencer Craft; RNZCGP says:

    I worked in Australia for 3.5 years initially in a Bulk Billing Clinic & then Skin Cancer Medicine. I am now back in New Zealand.

    Australia GP/patient ratio 700/1                                  NZ ratio 1400/1 [my old practice 2500/1]

    Bulk Bill GP/Nurse ratio 4/1                                        NZ ratio 1/1

    GP sees patient for every event                                 Many events handled by a Nurse

    No appointments/ long waits on day or bookings.      Acutes on the day, Booked within 1-2 days.

    Free servce causes overuse.                                     Part charges encourages self reliance

    Medicare causes focus on income/billing                  Capitation encourages focus on good care to keep patients

    Subisidy follows patient encourages Addiction          Capitation with transfer of records limits Dr/Script shopping

    Original script packaging causes freq. GP visits        Pharmacy fee for packaging enables alignment of repeats.

    There are many other comparisions.

    Do not re-invent the wheel. Look at NZ, UK, USA,Austraila and work out the best bits to suit.

    Overhaul Medicare and make patients aware of the real cost. Focus doctors on care and not income.

     

     

     

  5. Paul Coughlan says:

    Given that the conclusions drawn about diabetic in the Grattan report are based on the percentage of patients having an annual SIP claim ,might I point out that the process of chasing the SIP moiety is hardly worth the quantum.

    Lack of a SIP clam does not equate to suboptimal care except in the verynarrow view of bean counters.

    Patient obstacles include not having their optometry check done before the cycle is up ,or presenting an acute issue or three in the EPC consultation timeframe (given that comorbidity is the norm not the exception in chronic disease management.

    It is also noteworthy that in 201 Medicare issued an edict against co-claiming items with EPC items ,necessitating yet another patent contact in order to claim SIP,(or just letting it  go.

    There is unlited potential for “incentives” to be designed wth built-in pitfalls ensuring savigs for Govt and futher opportunities to blame GPs for not hitting “targets”.

    For example

    In the UK ,vaccine refusers were counted as not done for GP payment purposes ,and total hysterectomy was the only exclusion for Pap targets.

    I for one cannot afford to base  a businiess model on perhaps being paid for professional time lready consumed.

     

     

     

     

     

  6. Roland Loeve says:

    Medicine is not immune to the perverse incentives that push service provision in many sectors. We may as individuals be ethically sound in our perspectives.When push comes to shove however, we can be influenced if income is threatened for doing things in our comfort zone. This also occurs if manipulators work out how to extract the absolute maximum from what oriiginally promised to be a good policy or preventative measure, but can be organised to become money for jam with no real purpose. We may let our standards slip, not because we are inherently unethical or uncaring, but because the work is so time consuming and fatigue leads to lack of oversight.

    The system needs overhauling, there is so much waste, inefficiency, poor communication between  health professionals, hospitals etc. I witness this every day, and it leads to mistakes, unnecesary patient morbidity,unmeasurable outcomes from costly processes and millions wasted.

    Lets by all means declare self interest- be paid a reasonable income commensurate with the role, training and responsibility. Let us also have a system that works for the community freer of incentives to do useless or inappropiate things than we have now. A purely fee for service system is not the whole solution, a coordinated system well planned and providing care in its truest meaning is required.

    In my working life I noted it was less than 5% of the workforce would involve themselves in working with  local organisations etc to make it work better, most sat back  busy as we all are, but piped up when comfort or income was threatened. Majority silently supported but left it to the5%. Lets just be honest and transparent about who the sytem works for.

  7. Dr Louis fenelon says:

    The Best and the Worst, I am sorry but what you said encapsulates what I hate most about general practice in 2016: meaningless comparisons!

    When someone compares the “failings” of general practice to our lack of involvement in programs and other crap that is not general practice, then I smell someone incapable of providing the care general practice patients deserve.  Someone who values process above people, including the real people who are GPs.  Someone who maybe was once a doctor “in their working life” and is now maybe a politician, or medical bureacrat?

    Exactly what “fair” income do you think we GPs deserve for our training and experience, if it doesn’t suit “the” values comrade?  

    All we ever try to do is help people.  Sadly it actually costs “public” money.  Pity that value is not held as high as more important ways to waste health expenditure on non-medicine – like guidelines, protocols and policy.  If you want GP’s to do real medicine, then respect the value of that direct patient care.  It deserves a value higher than the bureaucratic vomit that currently sets the standard for our quality of care, vomit which also allows non-doctors to demean the value of what real doctors do.

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