The Health Care System In Australia and the Role of General Practice Winthrop Professor Geoff Riley Acting Dean Faculty of Medicine, Dentistry and Health Sciences The University of Western Australia
Email: [email protected] Starting points
China has the opportunity to develop the best aspects of western health systems.
Comparing Health Systems Expenditure and Indicators
Country Health % GDP Life Expectancy Infant Mortality (2009)/ rank (2012)/rank (Deaths/1000 live births) Australia 8.5/47 81.9/9 4.5/189
UK 9.3/41 80.1/30 4.56/188
Canada 10.9/22 81.4/12 4.85/181 US 16.2/2 78.5/51 6.0/173
China 4.6/148 74.8/96 15.6/110 The Australian Health System Tertiary Care − All Australians have the right to free treatment at public hospitals − Large city public (teaching) hospitals and Private hospitals − Salaried Specialist doctors and Tertiary services eg Liver transplant, Emergency services, Specialist outpatient clinics etc.
Secondary Care − Specialist doctors in Private practice. Mostly urban. Some rural − Some regular rural visiting but only larger rural towns
Primary Care Private General Practice / Generalist – Primary Care - Gatekeeping, Access / point of entry to system – Comprehensive service, Generalist, holistic – Local, community, accessible, contextual, coordination of care – Personal consultation-based (WHO model), Continuity of care
Funding the Health System
Medical Benefits Scheme (MBS – “Medicare”) Universal health care is provided to Australians through Medicare which funds free hospital treatment and subsidised medical treatment – but gap / co-payment of about 30% for all but the very poor in primary and secondary care. Public hospital care is free. IMedicare is funded through general tax revenue plus a tax levy for high income earners and an additional levy for high income earners who do not have private insurance. Private insurance available. Offers services earlier care (eg operations) or in better facilities, but the quality of the Medicine is the same. Plus other services eg Dentist
Pharmaceutical Benefits Scheme (PBS) Provides reliable, timely and affordable access for medications Australian Government through the PBS meets 84% of the total cost of all prescribed pharmaceuticals
Primary Care
• Definition − Community-based health care which is therefore available, accessible and affordable − Private and public providers − Public health and social determinants of health
• Professionals and programmes − General Practitioners and practice nurses − Community Nurse and rural and remote nurses − Allied health professionals in Private practice
Primary Care
Some examples of Primary Care Services
General Practice, General Dental practice, Specialised nursing services (domiciliary aged care, Child development, and immunisation clinics), local Pathology and Radiology services, Physiotherapy, Occupational therapy, Speech pathology, Pharmacy, Mental Health services, Youth Mental Health services, Drug and Alcohol services, Psychologists, Optometry, visiting specialist services, Aboriginal Medical Services, Health education and specialised education eg Diabetes care.
Related services – Medicare offices, disability support services, Child protection services, Population Health services, Dept of Community Health and Welfare, financial counselling services and so on. Primary Care Provides Access
Access is central to the performance of health care systems around the world and includes the opportunity to identify healthcare needs, to seek healthcare services, to reach, to obtain or use health care services, and to actually have a need for services fulfilled. We conceptualise five dimensions of accessibility: approachability; acceptability; availability; affordability; appropriateness and accommodation (flexibility). Levesque et al (2013) Comparing Primary Health Care Systems
Outpatients or Polyclinics
Models of Primary Care
The Non-medical models ‘Bypass’ Comparing Primary Health Care Systems
Country Provider Gatekeeping Payment Insurance IT
Australia GP Yes FFS Gov + Pat (Gap) Good
UK GP Yes Cap/Sal/Inc Gov (NHS) Good
Canada GP Incentives FFS/Cap Gov Good
US Family Pract/Int /O No FFS Pat (employer) Poor & G/Paed China GP No Sal? ? ?
Schoen, C, Osborn R, Doty MM, Squires D, Peugh J, Applebaum S. A Survey of Primary Care Physicians in Eleven Countries, 2009: Perspectives on Care, Costs and Experiences. Health Affairs (Millwood). 2009;28(6):w1171-83. Why is Primary Care an essential part of the Health System?
• Access means more timely care – treatment before more severe problems develop • Fewer preventable emergency department visits and hospital admissions • Avoids unnecessary care – fewer tests, overtreatment, less cost • Better health outcomes – especially for the poor, immunisation, BP control, reduced mortality, and improved quality of life • More preventive services than those who lack this source of care • Increased trust with primary care physician and improved treatment compliance
Primary Care enhances the performance of health care systems. It is not the solution to every health-related problem, but few, if any, health related problems can be adequately addressed without it. Phillips, RL and Bazemore, AW 2010
A Better Health System A Health Care System which has General Practice in the Gatekeeping role
Common conditions and Acute illness chronic illness, acute illness
General Practitioner Ambulance
80%
Home Specialist Hospital
“Gatekeeping” means mandated referral by GP and no direct access to Specialists A Better Health System A Health Care System which has General Practice in the Gatekeeping role.
Primary Care – GP and Patient
Secondary Care – Private Specialist Tertiary Care – Hospital Specialist
“Gatekeeping” means mandated referral by GP and no direct access to Specialists
The Best Health System
A Health Care System which has General Practice at its core.
Tertiary Care – Hospital Specialist
Secondary Care – Private Specialist Primary Care – GP and Patient
General Practice in Primary Care
Primary Care requires high quality vocationally trained General Practitioners (GP) as it’s core to provide leadership and skilled clinical care
GPs provide local, accessible, affordable high quality health care and therefore health care security for local communities, including rural communities
Gatekeeping GPs are the coordinators of care and decide who needs to be referred for hospital / specialist services and who can be managed locally
This system is the most cost effective (it saves money) and provides the best health outcomes for patients
Summary
A primary health care system which includes gatekeeping GPs can be best understood as creating an orderly delivery system which by referral connects the correct patient to the correct specialist, thus maximising the most cost effective and efficient use of the Specialist / tertiary services.
This save money and produces better outcomes
BUT, the GPs have to be highly skilled and therefore highly trained to get these decision right. Accordingly China must develop high quality training for GPs and expect to pay them properly.
The Role of General Practice
The role of The General Practitioner in a health care system is no more or less important than the role of the Specialist. Each has a distinctive set of knowledge and skills. The General Practitioner is a just different kind of doctor, with a different function in the Health System. The system needs both types of doctor to function effectively.
Specialism Generalism The Characteristics of Generalism
• “Technical Generalism”, Broad knowledge base
• “Evidentiary Generalism” – Use of patients’ knowledge (epistemology) and worldview (ontology) – “meaning”, sociological and cultural awareness, contextual thinking, systems theory, psychological insight
• “Reflexive Generalism” – Intentional choosing of generalism, reflection, time, growth of understanding and objective self- awareness, “wisdom”
Heath and Sweeney 2006
So what does General Practice look like in Australia? A Typical Day in GP in Australia
Standard GPs treat all consultation stages of life 15 minutes
Long consultations 35—45 30-50 patients/day minutes
Less common and More common
Acute Medical Emergency Common conditions and chronic • Road trauma illness (including metal health). • Myocardial infarct And Multi-morbidity - Long term • Infants in respiratory distress management required. Presentations to General Practitioners in Australia National average %
Social Male genital system Female genital system Pregnancy & family planning Urology Endocrine & metabolic Skin Respiratory Psychological Neurological Musculoskeletal Circulatory Ear Eye Digestive Blood General & unspecified
0 2 4 6 8 10 12 14 16 18 20 The Nature of General Practice Care
Primary Gate keeping
Contextual Local Comprehensive Generalism Personal Consultation Continuing Care Long term Coordinated Not fragmented care Consultative style of Practice
"Spending time with patients listening to their story and their concerns actually saves money.”
“More listening means less referral for tests. The best investigation is the conversation – taking a history, and then examining the patient.” A General Practitioner
Undifferentiated Presentations
Primary: First point of contact. Gatekeeping. Point of entry to system. Undifferentiated presentations. Requires excellent diagnostic skills.
“A 48 yr old female says “Just a quick visit because my muscle therapist sent me to see you as I have a pain in the side of my chest and he thinks I have a broken rib”. History reveals no trauma and local examination reveals point tenderness on 6th rib laterally. (A RED FLAG for pathological fracture).”Have you noticed any breast lumps or changes in your breasts?” “ I’ve got an inverted nipple”
“Is it new or longstanding?” “About 6 months.” Breast examination revealed 8 cm mass, peau d’orange and axillary nodes. 15 minutes later an appointment confirmed for breast assessment centre in 3 days time.
Opportunistic Care
Primary: First point of contact. Gatekeeping. Point of entry to system. Undifferentiated presentations. Opportunistic care. Requires excellent diagnostic skills.
New patient to practice, 62 year old male: “I’ve come in to get some pills for my gout - I’m on Indocid.” “OK , we better get some history and check your BP.” It emerged in the conversation that his father died at 70 from Abdominal Aortic Aneurysm. Examination revealed BP 170/110 and large AAA. It measured 6.5 cms on Ultrasound. He was referred and repaired within 3 weeks.
The Importance of Context Contextual: Local community based (not hospital). Doctor lives locally – they know about their patient’s lives. 35 year old woman comes in very anxious, urgent appointment, had routine gynae surgery 1 month ago. “I’m really worried something may have gone wrong with the surgery. My bowel motion was dark red with blood this morning.” “Have you had any change in bowels recently, or any other problems gynaecologically since the surgery?” “No, it was all going fine until this morning.” “Hang on a minute, I saw you having lunch in the same café as me yesterday, did you have that excellent roasted beetroot salad for lunch?” “Yes, as a matter of fact I did.” “Then I think we’ve both got the same reason for having dark red bowel actions this morning!” No need for colonoscopy or referral for investigation. Comprehensiveness of Care
Comprehensive: Generalism. Wholism. All ages, all genders, all conditions and all acuity. Mind and body (interaction between the physical and psychological). The ‘Emic’ perspective
“I saw a young mother the other day who had brought in her four-year-old son because his ear was hurting and he was sick and distressed. On examination he had otitis media, so I gave him the appropriate antibiotics. But his mother was disproportionately upset and when I explored this with her it emerged that she was concerned that I might have considered her a bad mother. I was able to reassure her that she was not responsible for her son's illness and I added that I had observed that she was doing a great job as a mother. Because I knew the family I knew that her own mother had been uncaring and negligent. This explained this young woman's need for reassurance and affirmation. Her son was cured and she was healed.”
Personalised Care
Personal: Personalised care. Consultative style. A doctor-patient relationship develops. The patient is known to the doctor and trust develops
“Last week when I was at swimming lessons with my son, I saw a 70 year old lady doing water aerobics. I recently diagnosed her with type 2 diabetes. I gave her a wave and overheard another water aerobics lady ask her, 'who's that' and then a reply of 'that's my doctor’. The ladies then watched the childrens' swimming lessons after their aerobics finished!”
Continuing care
Continuing Care: On-going care. Continuity of care of chronic illness and multi-morbidity. Long-term relationship. Lifetime care.
Yesterday I reviewed an 59 year old lady who has several problems typical of her age. She is on several medications but remains well. As she left she reminded me that I had been looking after her for 20 years since my father had died. He had also looked after her for 25 years in this same Practice. Together we had delivered all of her children and grandchildren.
A General Practitioner Coordination of care Coordinated Care: Avoids fragmentation and repetition. Knowledge of patient and the local context means that the GP is best placed to coordinate care.
A 68 year old Farmer who avoids the city. He has lung cancer, and is on a course of chemotherapy supervised by the visiting oncologist, but the treatment is failing. He presented recently with multiple sites of bone pain. I admitted him to hospital to get pain under control using paracetamol and 100 microgram per hour fentanyl patch plus opiate as necessary. Steroids were unhelpful but 5 mg of ketamine/hour was excellent. Monday morning discussion with oncologist - in view of short time left to live and his distaste for the city, to go for one day / dose of radiation and return next morning. Domiciliary care team co-opted to refill syringe driver each day plus home visits by myself will ensure he is pain free and so he and his wife do not feel abandoned. End of life care administered by a doctor he has known for past 18 years - myself. Low cost.
Other common management tasks A case example… “A mother brought in her sick child because of a small single lesion on his skin. I knew it was the A patient presented with recurrent beginning of chicken pox because in the last headache worried he had a tumour but his few days I had already seen five children from history was sufficient to diagnose migraine his class at school with chicken pox. without a scan. Money saved and ” A General Practitioner inconvenience avoided. Good outcome.
Wound Care Antenatal care Procedural General Practice Rural Health Care • Regional, District and Local Hospitals serviced by Salaried Doctors (Regional) or Private Practitioners (District / Local) • Most Rural doctors are resident General Practitioners. A few resident specialists. Some regular visiting specialists • The GPs are known as Extended Skill-set GPs. “An elite” • They all have extra skills in Emergency Medicine, Trauma, resuscitation and advanced life support. • Many also have another specialist skill as well such as Anaesthetics, Obstetrics, Paediatrics, Counselling and Mental Health, Aboriginal Health or surgery • They are supported by ‘generalist’ allied health practitioners and community nursing, aged care nurses, remote are nurses, Aboriginal Health Workers • They are also supported by The Royal Flying Doctor Service Vocationally Trained General Practitioners
Vocational training of General Practitioners prepares them for the specific role, and results in: – better medical practice – better history taking and examination – better communication and better clinical reasoning – reduced and better targeted investigation – reduced and better targeted referral to specialists, and – more frequent and better resolution of the majority of problems at the primary care level without the need for referral. Training in General Practice Auspicing Authority of GP Training
“Undergraduate” training and assessment – The University
“Prevocational” Training and Assessment – Hospitals and Postgraduate Medical Education Committee who designed the curriculum
“Vocational” Training and Assessment – The Royal Colleges “Undergraduate” Training
• Australia is moving almost exclusively to “Pre-med” Undergraduate Degree followed by a 4 year Graduate Programme
• Generalist education throughout university years which graduates a “generic” or “pluripotential” doctor
Pre-Vocational Training
• Prevocational is equivalent to Masters stage in China • One, two or 3 years before starting Vocational Training • Prevocational stage is managed and paid by the hospital • Prescribed National Curriculum is covered and logged • Remains Generalist training and not specific to any specialty • Terms in Internal Medicine, Surgery and emergency Medicine are compulsory in the Intern (first) year • Logbook focus on procedural skills Prerequisites for Vocational Training in General Practice
• Successful completion of Intern year (PGY1) at least
• Received “General Registration” at end of PGY1 • These are the mandatory minimal requirements, but any additional training terms may be later accredited by RPL to “Extended Skill Training” stage (see below) Structure of Vocational Training in General Practice 2 years training comprising: 3 x 6 month terms of Supervised General Practice in General Practices (Called “basic”, “advanced” and “subsequent”) 1 x 6 month term of “extended skills” training at hospital eg. O & G, Paediatrics, Anaesthetics, “Academic” Local Supervisor in the practice Intermittent release for workshops Logbook – oriented to procedures Project - a submitted report on an activity External ‘personalised’ mentoring and support throughout Vocational Training period Regular “External Clinical Teaching” visits (external visiting GP assessors sitting in on consultations for half a day)
GP Fellowship Examination
The Fellowship exam is under the auspices of The RACGP
After all training requirements have been met the candidate may attempt the • Written papers – AKT and KFP
The AKT must be passed before the candidate can proceed to the • OSCE
Fellowship awarded after all assessments done Clinical Supervision
Designated experienced and trained GP available in the practice for advice (Senior registrar may assist) and dedicated teaching, debriefing, mentoring, and support. Training in supervision for supervisors is provided. Separate consulting room but available to Trainee eg. Immediately, end of day, designated meeting times. Supervision ground rules – mandatory supervision include eg. Children under 6 weeks, repeat visits with no progress in diagnosis or treatment.
Organisational processes
“Education” is used to mean delivering content and ensuring teaching and learning is occurring appropriately
“Training” refers to the range of administrative processes that a “training provider”, (an organisation such as a ‘College’ of General Practice), needs to be engaged in to support the delivery of the Education exercise. Organisational processes
A College or training organisation also needs to: • Identify and accredit suitable GP practices • Identify and train and accredit supervisors and medical educators • Develop contracts with the practices and the GPs • Develop payment schedules for the Trainees • Help trainees with practical issues like relocation and if rural, to return to centres for workshops, other training, and examinations