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

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.

GP Clincs – super or ordinary

GP Super Clinics
An unfortunate name but typical of this new govts media attention approach
I do not believe that these new Clinics will provide a caring health service as the Brisbane GP would like.  I do not believe that doctors employed in these clinics will do house / nursing home /hostel visits.  Why should they? they would loose money if they are away from the consulting intensity of life (because they will probably have to bulk bill)
As I have said before Clinics of the future will have large numbers of doctors (super clinics or not).  They wiull be able to attract doctors because of working conditions – pert of which are no house calls etc.  Smaller clinics will not be able to cope and they will have to look at the service levels they provide.  So you will end up with bigger clinics scattered around (both the new Super Clinicxs and the enhanced larger current clinics)

So what can be done about the too frail etc in order to provide good comprehensive community care.  This is the backdrop of the future of Primary Health Care in the community.  All the newer prononcements on targets etc mean that doctors will only be able to function in large groups.  There will not be many 1-2 doctor practices left and those that are left will have to be focussed on trying to survive and might not be financially able to do non consulting room jobs.  I do not think you can attract new GP’s to work in smaller GP units.

So I will accept your challenge and try to come up with a workable solution for these disadvantaged inyour community.  This is a group that will get bigger over time and not be able to visit the consulting “silos”.

So wait till next blog

On being concerned

This sounds strange but because I have now come out and say that we must look at alternate practice structures, then there is pressure on me to now come up with something.  BUT I have no formal model to use,  All I can do is to sense that we as GP’s have become grossly deskilled and that only by slowly groping forward can we hope to evolve a different paradigm in GP consulting.  This should result in better work satisfaction for GP’s, increased patient confidence and better “patient directed” health care where the patients accept more responsibility for their health outcomes.

This is not easy because I have got into ways of consulting that are comfortable but unsustainable as we are now finding out.