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Protocols will never replace a doctor

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A baby’s death, whenever or however it occurs, is a profound loss. This was evident from the recent media coverage of the coronal findings into the tragic death of a six-month-old infant from pneumococcal meningitis in 2010.

The Western Australian coroner was critical of the 24-hour telephone helpline healthdirect’s protocols after a nurse mistakenly diagnosed the meningitis as a stelhort-term ‘tummy virus’ that did not require review by a GP or presentation to a hospital emergency department.

The coroner found that the infant would have survived had she been taken to hospital, although the bacterial infection may have caused her significant harm.

At the release of the coroner’s report, my AMA colleague Dr David Mountain told the West Australian newspaper that “the tragic case showed there would eventually be a problem with a telephone service, no matter what protocols were in place, and it could not substitute for a trained clinician seeing a sick child or adult.”

I could not have said it better myself.

The plan to introduce the publicly funded National Health Call Centre Network (NHCCN) was announced by the Council of Australian Governments in 2006. A year later, under the name healthdirect Australia, it began the telephone nursing triage system healthdirect.

I recall thinking at the time that it was a misconceived attempt by governments to improve patient access to care on the cheap. It was, in effect, replacing doctors consulting patients face-to-face with nurses on the phone following computer-generated protocols.

These days, healthdirect Australia contracts to Medibank Health Solutions (MHS) to operate the helpline.

I have more than a passing interest in the effectiveness of telephone helplines – both as a practising GP and as a member of the Department of Health’s now-defunct After Hours Primary Care Technical Working Group (TWG). This working group advised the Federal Government on the introduction of the after hours GP Helpline, which patients access via healthdirect.

I still have doubts on the effectiveness of healthdirect, as well as the lack of transparency with the clinical recommendations made by nurses to callers and the GPs manning the after hours GP Helpline. We need to be confident that the medical advice provided is appropriate, and the patient is managed correctly.

Along with the AMA, the Rural Doctors’ Association of Australia and the Royal Australian College of General Practice were also members of the TWG. For some time we sought the agreement of the NHCCN and MHS to allow us visit a call centre in the after hours period to observe actual calls and how the helpline’s protocols and care guidelines were applied. Proper review and understanding of the service needs real life observation. This includes external auditing and accreditation.

Unfortunately, the response to our requests was disappointing. Commercial-in-confidence and privacy issues were used to keep us out of the call centres.

I found the resistance by the MHS to transparency of its processes disturbing. It prevented GPs from advising the TWG on how healthdirect detects the symptoms of simple and complex conditions.

One wonders how the service is being monitored if similar conditions are imposed on its audit and quality assurance processes. Further, experience shows that there are inherent dangers in self-auditing.

A computer-generated protocol will never be a substitute for a face-to-face consultation with a doctor.

We would have less need for these helplines if GP after hour consultations were better supported by the Government.

The AMA will continue to press for the re-instatement of the TWG to address problems with after hours care in this country.