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Round-the-clock GP care needs right incentives

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The Federal Government has been urged to reinstate direct incentive payments to support general practices providing after-hours services.

The AMA has told Professor Claire Jackson, who is heading a Government-appointed review of after-hours primary health care, that recent reforms to the provision of after-hours services have been a failure and there should be a return to incentives and targeted funding to assist GPs in providing such a vital service for their patients.

Health Minister Peter Dutton has commissioned the review amid widespread dissatisfaction within the medical profession about the previous Labor Government’s decision to hand responsibility for contracting and coordinating after-hours GP services to Medicare Locals.

Chair of the AMA Council of General Practice Dr Brian Morton said recently that the botched handling of after-hours services by Medicare Locals had not only increased red tape and compliance costs, but had discouraged many GPs previously committed to providing after-hours care for their patients.

Presenting the AMA’s submission to Professor Jackson, AMA President Associate Professor Brian Owler said the review was an important opportunity to undo recent policy failures and develop ways to strengthen and support the role of GPs in providing round-the-clock care for their patients.

“Cutting the direct PIP payments to general practices was a big mistake,” A/Professor Owler said. “It created a clumsy new layer of bureaucracy with Medicare Locals responsible for channelling the funding to after-hours service providers.

“Australia cannot afford to repeat the failed Medicare Local experiment with after-hours incentives, otherwise we will go down the same track as the UK, where general practice has largely walked away from responsibility for after-hours care,” he said.

The Government, which is focussed on holding down health spending, has specifically excluded the adequacy of Medicare rebates for after-hours consultations from the review’s terms of reference – a serious limitation in the view of the AMA President, who lamented that “the MBS does not adequately reflect the skills, responsibility and costs associated with after-hours services, and there remains a very strong case for the relevant items to be better funded”.

Before the previous Labor Government handed responsibility for after-hours care to Medicare Locals, such services were supported by payments through the Practice Incentive Program (PIP), and the AMA believes the system should be reinstated – with possible modifications to fill service gaps and address current Government concerns about the arrangement under which practices were used to funnel payments to medical deputising services (MDS’s).

“The AMA believes that the previous PIP model supported the provision of after-hours coverage to most of the Australian population,” A/Professor Owler said. “PIP should be restored, appropriately funded, [and] targeted funding should be made available to address identified gaps in service.”

At a recent meeting, United General Practice Australia – which includes the AMA and six other peak GP groups – warned the Government that simply transferring responsibility for contracting and coordinating after-hours care from Medicare Locals to the primary health networks being set up to replace them could exacerbate existing problems with access.

“There [is] a real danger that, should the current or similar arrangement continue under PHNs, more general practices will decide there is too much red tape and funding uncertainty for them to continue to provide an after-hours service,” UGPA said.

A/Professor Owler said many GPs continued to personally provide after-hours care to their patients, but changes in the composition of the GP workforce and the increasingly poor financial return for providing such services meant many practices were making alternative arrangements.

He said practices were increasingly using MDS’s or collaborating with other practices to ensure their patients had access to after-hours services – raising issues about continuity of care and communications between practitioners about matters such as medical history and treatment.

In its submission, the AMA proposed a set of principles to address current concerns and which should form the basis of future after-hours arrangements.

These include a proper level of funding for those GPs and practices that provide genuine after-hours services (defined as between 6pm and 8am on weekdays, between 8am on Saturdays and 8am on Mondays and 24 hours from 8am on public holidays).

Where practices do not provide after-hours services, the AMA said they must have arrangements in place for the on-call GP, contracted MDS or collaborative partner to be alerted to the medical history and clinical needs of at-risk patients, known drug seekers or patients with threatening psychiatric conditions.

To support coordination of care, the report of after-hours treating doctors should be provided promptly to a patient’s usual GP.

To ensure after-hours services are complementary to, rather than competing with, existing providers, the AMA said they must focus on genuinely urgent cases and, where clinically appropriate, encourage patients to seek treatment during normal hours.

To protect quality of care, doctors providing after-hours services should be appropriately qualified, and MDS’s should be fully accredited by the Royal Australian College of General Practitioners.

A/Professor Owler said the review should consider the need for as higher rebate for after-hours services in rural and remote areas to reflect the higher cost of attracting and retaining staff and operating facilities.

He suggested that video consultations, where clinically appropriate, could be used more extensively to provide after-hours care in rural and remote areas, for patients in aged care, and other settings, but would need to be supported by appropriate funding.

But the AMA President warned that after-hours helplines were no substitute for the service offered by GPs.

“There is a paucity of independent evidence about their cost effectiveness, and good evidence that they are ineffective in managing demand for emergency department services,” he said.

Adrian Rollins

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