Who's afraid of change?

The term most frequently uttered at this week's Australian General Practice Network conference had to be ‘change management’. In some sessions, barely a minute went by without the term working its way to the fore, especially in talks on why information technology has failed to deliver in the health sphere.
Perhaps I’m a tad defensive, but after a while it felt a bit like calls for ‘change management’ were code for ‘bringing those pesky, self-interested doctors into line’.
A presentation by UK IT chief, Richard Granger, was inspiring on one level; for details look at the Connecting for Health website. For instance, 98% of UK GPs are connected to the largest virtual private network in Europe, and all radiological images in two hospitals every week are being completely digitised, and therefore transmissible to other health providers at the touch of a key.
I wasn’t the only one in the audience who felt some speakers laid the blame for our poorly connected and incompatible system at GPs’ doors.
To quote one GP addressing an expert panel, which included a high-level federal government health advisor: ‘The problem’s not at our end, it’s at your end”.
Of course, it’s not about blame, and there’s no doubt a plethora of reasons we’re nowhere near as advanced as the UK.
But if I had to name one advance that would improve my ability to care for patients who have chronic and complex problems, it’s timely, legible, comprehensive discharge summaries. I simply want to know the results of all investigations performed and their interpretation by the treating specialist, the diagnosis, interventional treatments, what drugs were stopped and started and why.
I don’t have access to Health Connect, still being trialled in several locations, and perhaps this system will help solve this problem.
But by his own admission, even the talented and determined Mr Granger hasn’t managed to pull this one off in the UK.
So let’s stop blaming GPs. All those I know say if there’s a high-quality, connected information-sharing system that’s also secure, bring it on.

Personal or political or both?

Whether doctors carry a social responsibility to address health-related matters beyond the care of their individual patients was the subject of an article in this week’s JAMA.
In particular, the authors investigated doctors’ attitudes to community participation, political involvement and advocacy through professional organisations.
Reading the article, I was reminded of my first, and inauspicious, foray into the community with my doctor’s hat on – a P & C meeting many years ago when my first child was in kindergarten.
Having volunteered as vice-president, my first objective was a healthy canteen, and somewhat nervously I addressed the meeting of strangers, giving them the usual spiel about obesity, diet etc.
Maybe it was because the woman who ran the canteen was morbidly obese, or because I was a brash newcomer threatening the shaky power structure of the organisation, but my speech was met with icy glares all round.
Only the school vice-principal spoke.
“Look love, brown bread’s just white bread with colouring in it anyway”, he told the meeting.
Needless to say, this wasn’t a battle easily won. Neither were my children always enamoured by my public health efforts – they never quite forgave me for the introduction of the broad-brimmed hat at their primary school, although I suspect they were secretly impressed when my dogged determination to get a road narrowed and pedestrian crossing installed near the school paid off.
Whether in small issues such as these, or on a larger stage, we doctors can make a difference.
Over 90% of doctors in the JAMA study agree, and support physician involvement in wider health–related issues, while a new UK GMC document says doctors should ‘protect and promote’ individual and public health.
We welcome your suggestions on how here.

Health check raises 'usual GP' question

Recently a kind and patient person from my general practice division guided me through the murky and confusing waters of the simultaneously new, old and disappearing GP item numbers.
Apart from the countless nuts and bolts involved, a few issues deserve special mention.
Firstly, patients will rightly be the winners of the November 1 psychologists’ access to Medicare, but employee GPs registered with Better Outcomes and who took home their SIP payments will be among the losers.

Patients of this group of doctors - and I admit to a conflict of interest here, I’m one of them - already had free access to six to twelve psychologist sessions via ATAPS (Access to Allied Psychological Services) if a mental health assessment and plan had been completed. On top of the associated consultation fees, a $150 SIP was paid to the consulting doctor after the third visit under the scheme, which will wind up in April next year.
Overall, however, the move is a probably a good one for the mental health of the community. After all, why should access to a psychologist depend on how many hurdles your GP’s jumped?
Nonetheless, I was glad to learn that other SIPs, such as those for performing a pap smear for women not smeared for over four years, will remain in place, as I fail to see how an incentive payment can be an incentive for someone who doesn’t get the payment.
Equally interesting, or annoying depending on your point of view, is the arrangements surrounding the new 45- 49 health check.
A call to the hotline confirmed it’s a once in a lifetime check to be performed by your ‘usual GP”, defined as the GP you’ve seen most frequently over the previous two years.
But just as patients who pop into a medical centre with a sore toe on holidays end up unwitting recipients of care plans, now they’ll likely end up with the only rebatable health check of their lives by a doctor who’ll never see them again.
My question is this:
How is it that ACIR can identify ‘usual GPs’ when it comes to withdrawing PIP payments for practices who’ve slipped below an immunisation target, but when it comes to rewarding doctors for performing a preventative health check, it’s suddenly too hard?

The dollars and sense of self-care

For some time, I’ve been grappling with the concept of ‘self-care’, a term slowly but surely creeping its way into the medical lexicon. This week the MJA fast-tracked an entire article on the topic, but I’m still not much the wiser.
Apparently ‘self-care’ is now one of four main approaches to chronic disease along with prevention, early detection and treatment, and integration and continuity of prevention and care. And government is behind the move to the tune of $515 million over five years starting this year, in addition to $36 million spent on something called the Australian Government Sharing Health Care Initiative.
The alleged theory behind self-care is that informed, empowered patients have a better quality of life, although the evidence appears weak. Of 15 meta-analyses listed in the MJA article, only six showed any effect, and an Expert Patients Program in the UK has also apparently enjoyed only limited success. Indeed much of the self-care literature appears to be devoted to investigating why the approach has failed in various environments.
Unfortunately, it seems GPs are largely carrying the can on this one – apparently they haven’t engaged sufficiently with the idea, nor endorsed it.
Most scary of all was the $250,000 allocated this financial year to an ‘education, training and support program targeted’ at GPs and others - I think I’ll take a rain check on attending this one.
No sensible or compassionate person would argue against informed, empowered patients, but they’re also convenient to governments because they’re cheaper than their less informed counterparts; a reduction in GP visits is a frequent outcome measure in the research literature.
I’ve even read of overseas proposals to ration health care to those who participate in self-care programs. Let’s hope there’s no such agenda here.

The Deregistration Board?

Naming organisations can be tricky. Is it better for example, to call an organisation to tackle incontinence “The Incontinence Foundation”, or “The Continence Foundation” - the former reflecting an individual’s actual condition, the latter an aim, or desired outcome?

Cancer-associated organisations share this dilemma, and there’ve been both ‘Anti-Cancer’ councils and Cancer councils over the years.

In the same vein, a colleague wants to rename his state medical board – the organisation tasked with registering doctors for practice – the Deregistration Board after a recent encounter.

His problems began with advice from Medicare his patients were no longer eligible for rebates because he wasn’t registered as a medical practitioner. This came as a shock, but it turned out he hadn’t received, and therefore hadn’t paid, his last registration bill. Not currently in private practice, the rebate issue wasn’t a big deal, but indemnity certainly was.

A frantic call to the NSW medical board met with a stony, bureaucratic response. Yes, the bill had bounced, marked “Not at this address”, but rather than put in a call or two to track down my colleague – a specialist in a discipline of dire shortage – the board simply advised Medicare to stop his patient rebates. End of story.

At 3pm on a Friday afternoon with a weekend of rural hospital work ahead of him, my friend was keen to sort this out with a credit card over the phone, but again no luck. We only register people before 2pm, he was told. Ring back next week.

Noting that the top message on the home page of the New South Wales Medical Board says the board 'has a statutory responsibility to protect the health and safety of the people of NSW', my colleague wondered whether the medical board was more interested in deregistering doctors than registering them.

As well as protecting patients from dangerous doctors, wouldn’t it be in everyone’s interests – doctors and patients alike – to support safe doctors and make registration easier rather than harder?

Comment here.

To test, or not to test, doctors.

If we're honest, most of us have at some stage of our careers known a doctor we'd prefer our family didn't see. Maybe it was the on-call surgeon on Friday nights in our intern year. Or the ageing neurology professor whose erratic behaviour attracted corridor whispers but strangely no complaints from his tertiary teaching hospital peers. Perhaps it was a general practice colleague who seemed too rushed to apply himself thoroughly to patients' presenting problems, preferring to fob patients off with a reassuring word.
The questions is, both here and internationally, how to make health care safer, and a recent report by the UK Chief Medical Officer, Sir Liam Donaldson, addressed this very question.
Revalidation, relicensure and recertification have become familiar words to UK doctors even predating the Shipman affair, and the CMO's report, although controversial in some repects, significantly advances the debate.
You can hear Sir Liam being grilled by UK doctors here, but the thrust of his argument is that underperforming doctors are inevitable and regular appraisal is needed in some form. Currently, a doctor is not assessed between the time of receiving their specialty qualification and retirement, whereas in the same time frame, an airline pilot would be assessed over 100 times, the report says.
So far, Australian doctors have had to jump hurdles, such as continuing medical education requirements and practice accreditation, but our clinical skills have escaped scrutiny.
I guess none of us enjoys being assessed, but on the other hand, the public surely deserve a guarantee of a safe and careful doctor, and some form of routine appraisal seems inevitable in the long run.
So long as those who don't quite make the grade receive remedial assistance rather than ridicule and blame, it's hard to run the line doctors should be allowed to practice for four or five decades with no checks in place.
Comment here.