Changes to delivery of Primary Health Care

Changes to Primary Health Care delivery
Once again the Federal Govt has excelled itself in red tape. what it is trying to achieve is a reduction in what is termed “avoidable hospital admissions”
I would suspect that they really have not looked at these cases but only went on anecdotal evidence. The idea was that GP’s do not really look after patients when it all gets too hard, but slough them off to the Hospital Even more so after hours. The reality is that there are more and more frail sick people with multiple problems for which there comes a time when the GP can no longer manage them in an ambulatory clinic situation. House calls are a part answer, but it is not cost effective.

So in an effort to manage the patients “better” it is proposed that they be more closely managed by a single clinic. Of course it will change nothing. The end point will still come and referral to a hospital will still happen to them. CMA / Team Care was tried and it has made no differerence. They were never followed up They just sit in the notes and never refer to them.

The question is how will the patients understand that the “package of care” is supposed to effect a measured change. It is just Fund Holding by stealth. But what happens when they present for as sore throat separate from this package. You charge!! So what is to stop getting the package and then charging still ?

Again what happens when the patients do not present for their supposed check ups / monitoring. Patients do not care about it all they just want instant health care for free. No responsibility for their actions. To properly manage this you need a database that keeps track of where each patient is up to and what is needed. But do we contact them when they are overdue? No I do not think so. When they come in for a consult (usually unrelated to chronic disease) then you need a quick reference that says that this and this needs to be done. Then do it eg you need cholesterol levels done….

What I as a locum need to do is to make sure that I have solid management plans for the various problems I will encounter. To apply them to various patients at the time of consult eg need BP check / need cholesterols

It is up to the clinics to advise how they want me to manage the new “packages of care” but I suspect that things have gone too far and we will just keep on consulting as we have always done because it will be too expensive to construct an alternative model of consultations using a database of exception reporting.

What then should be done is to just make sure we manage our patients to the best of our ability

Getting at the older doctors !!

Are older GP’s cognitively impaired?  In the Australian Doctor http://www.australiandoctor.com.au/articles/B8/0C05C2B8.asp? the question is raised whether or not older GP’s can practice safely.  It is stated that the public now needs to be protected from the older doctors who may be cognitively impaired.

Actually what has been reported is fact (the Victorian Medical Board) but it is disturbing to see the emphasis that is being put now on “lets see how we can start the process / discussion about older doctors so that they will have to leave by the time the new doctors arrive on the scene (2013).  It will take time to get public opinion settled in this way so that older doctors are viewed with suspicion.

No so long ago we were all encouraged to continue to practice and not retire.  Now it seems that Medicare does not want the extra doctors.  Why?  Because it will cost Mediacre more if they do not restrict supply.  It has been done before with bad outcome from the patients viewpoint but a saving in cost for Medicare.  They gambled on the fact that the resticted numbers of doctors will not push up the price.  Well this worked for the consult fee, but locums can demand much higher fees because of a lack of supply. It will not be long before the average metro practice will push up its fees in order to survive and the patients will have to pay.

Nicola Roxon has no new ideas after 12 months in the job

Why blog at all??  I think it is important to record my ideas, thoughts and comments as well my forecasts about General Practice.  In this way I can record where I think things are headed.  More importantly what actions I should take to align myself with what I see as the future.  I have done this all my professional life.  It is not second guessing.

But at the moment all I can discern are changes to registration which involves revalidation and comments on cognition tests for doctors. 

There are no changes to basic consulting patterns – no new ideas!!  So what is this telling us.

I believe that Nicola Roxon is just a public servant with a few new ideas but her kite flying evoked the wrong response.  She realises that if allied health is to do any Medicare paid work then there will be an additional cost.  there will be no cost savings.  Also GP’s will not back or support independant groups.  So they function alone and wear the medico-legal challenge.  It is no use thinking that the existing nurses working in doctors rooms will do any additional work.  Their sessions are always full.  There is no more room for any more nurses.

So what would be the result of any mandated changes..eg paid less for driving licenec medicals.  Doctors would still do them and the gap would be more.  Consult pattern will not change. 

Care plans have not altered patient outcomes.  They are done in addition to the normal consultation patterns.  I have written on this before.  So where does all this leave us.  With all this indecision it means that the AMA has got its act together and has formulated solid proposals and highlighted problems.  Now all Nicola can do is to play catch-up.  If she attempts to go against the AMA proposals then her plans will end up in a mess with patients having to pay more.

The major challenge in GP work is to integrate any followup plan in  a normal 15 min consult.  If you attempt to move to a special number then you are monitored  (see what has happened with level C&D consults)

Another challenge is to ensure that we have concise investigation plans for various diseases easily available so we can initiate investigations before referrals.

Nicola is right!! (the Aust Minister of Health must be right)

Nicola is right!!
Her assessment that others can do the job that GP’s do and just as well as the GP is correct.  Sacrilege I know but when you look at what the average suburban GP does each day it is not really that difficult.  When the difficulty level rises then referrals are necessary.
For such a GP the average day is episodic care for people who have aches and pains, feelings of unwellness – all of whom need blood tests, x-rays and ultrasounds all of which will be negative.  Then there are the “check-ups”   BP’s, lipids arthritis etc. Not very complex skill level here needed.  Repeat pill scripts and cervical smears are usually the lot of the female practitioners.  Asthma now needs complex investigations while stable diabetes means more of the same. If changes then off to the diabetic specialist.
PLUS  the forms to complete ranging from Workcover, drivers licence and Centrelink. This is the average day.
There are no emergencies to worry about in the metropolitan area as much we try and fool ourselves to maintain some relevance.  The reality is that serious problems go by ambulance to the A+E dept.  Nursing home visits (if done) are also not complex as the nursing staff do most of the work.
In short if you dare to take on palliative care or manage some cardiac problem then you quick smart get reprimanded by the specialists in those areas.  This is the same for any problem you might have identified.  E.g. prolactinemia or PCOS …off to the specialists.
Why then have we become so dumbed down??
It is a combination of the need for short consults in order to make a decent  living and run a practice – plus the medico-legal implications of mal-management (especially in the metro area)  So we go on saying that only we as GP’s can do it.  Slowly but surely our diagnostic skill levels drop (we do not need them).  We just need a good network of specialists to whom we can refer/. 
We go through the charade of CDM + TCM plans because they generate money, but we know that in order to make a difference follow-up is needed but it can never be properly done.  So on we go as metropolitan GP’s.
As you can see Nicola is right .  it does need a highly trained person to do the job of a metro GP.
This is precisely why you will not get GP’s into rural areas where the skills required are enormous. But no more than used to be demanded of metro GP’s in past times.  We still cling to these outmoded images. Why shift to the country when we can make a living in the metro area without a lot of stress and the deprivations of country life.
All of this is very sad and depressing but this is the way that the govt and social pressures have shaped us.  Most of us keep seeing patients because we like that type of contact and this is why we get upset when Nicola wants us to tackle CDM by a coordinated team approach which means more paperwork and less patient contact.  If we want to be true medical professionals then we should do rural medicine or become a specialist.  This is probably the reason why there is a rise in GP sub-specialisation.
Change is coming. The tidal wave of chronic disease management is here.
So in summary
Until the govt educates the patients about their part in health management we will just keep on being metro GP’s without any high expectations of patient management but avoiding being responsible for the actions of other health professionals around us. It is time to move on when we wake up in the morning and believe what I have just written and believe that what we do will not make the slightest difference to any patient.

Are Care plans for patients worth it???

Care Plans
Recent discussions have confirmed what I have already written.  I did not mention that another negative is the duplication in entering information in the Plans and the Team Care plans..
I explored the reasons for not wanting to set them up and although I did not specifically mention it, one of the major negatives is the total artificiality of the whole exercise  You go through the exercise of creating a plan and then explaining it.  The patients even sign to say they agree.  But they just see it as a thing the doctor has to do.
They rarely reappear and trying to track for plan adherence is a nightmare.  So the question has to be asked if any plan helps to improve patient care over what is done now without any plans.
The patient appears and you look for what is the chronic disease or diseases they have and then see if they need any follow-up.  Then you arrange it.  It seems to work well but is dependant on the patient coming to see the doctor.  There is no pre-emptive care and this is what care Plans attempt to do.  The whole idea is to construct a planned management approach which should optimise care of any chronic disease.
Follow up could be still done by a receptionist who would do it the same as the ideal followup that should be done for test results / referrals / x-rays .  it would work.  You could say that the patient has been referred for podiatrist.  Have they gone (is there a letter) if not follow it up.  But very labour intensive 
A Professor Georgeff has evolved web based system.  But again it has to be done by staff.  The question is whether or not you are paying a wage just to see if patients look after themselves. Is it worth it??  At the moment no because we are paid for sickness and not patient wellness.  Plans and adherence will be looked at in another light if we are paid on wellness results.  Sounds good but then we focus on adherence and not the patient.