21 October 2017
Dr Ayman Shenouda
Health Education Accreditation
No case for change
Australia enjoys an enviable reputation as a provider of high-quality medical education and training. We have built a strong reputation for excellence and quality through a system of Australian Medical Council (AMC) led accreditation standards. A system that upholds patient safety and quality of care through high-level and targeted policy whereby accreditation indicators can be applied consistently has been key to our success. Yet the recent consultation with the release of a discussion paper as part of a Government-commissioned review into the accreditation systems suggests we have a system in need of strong repair.
The key shift proposed in the draft report involves the formation of more centralised control through a new Health Education Accreditation Board with an equally strong remit.
These would include:
The need to pursue such significant change at this time has confused many from within the sector. The specialist medical colleges through the Council of Presidents of Medical Colleges (CPMC) released a response early in the consultation. The Australian Doctors Federation (ADF) and Australian Medical Association (AMA) followed with strong resistance to such significant change to a system which is working well. All seem to agree that the key shift proposed in this paper would see the AMC’s role weakened leading to a dilution of standards and patient care. It would most certainly see unnecessary controls imposed on the specialist medical colleges.
Alignment or more bureaucracy
Major reviews usually share some common factors and this one is certainly not unique. These include the need for strengthened systems to improve outcomes and in driving efficiencies. It is a need for streamlining and alignment that make their way into most of these discussions. This in turn almost always means more government control.
The Accreditation Systems Review report states a need for alignment but then offers additional layers of bureaucracy to achieve it. It recommends increased government control over health professional education and training through the removal of the independence of the regulator. There is also a proposal to give the health ombudsman jurisdiction over specialist colleges particularly in relation to decisions around International Medical Graduates (IMGs).
Making a case for change
These key shifts are being floated as policy solutions ‘to ensure that the educational programs provide a sustainable registered health profession workforce that is flexible and responsive to the changing health needs of the Australian community’.
It is difficult to see how a large bureaucracy will drive system efficiencies and why you would seek more alignment beyond what already exists for medical education through the AMC. Specialty-specific requirements aligned towards patient need are key to determining quality outcomes. This expertise resides from within the specialist colleges and the AMC and will not be found through a bureaucracy-led board without any clinical discipline authority.
The draft paper seeks to introduce changes which really just stem out of a Productivity Commission Review undertaken more a decade ago. Given this review is being led by the same independent reviewer that’s not all that surprising. But it’s clear that much has happened since 2005 which gives, even more, reason for those ideas that were rejected once to be rejected now.
The draft report outlines the case for ‘Reforming governance – the overarching model’ presenting 3 options with their option 3 being the preferred model. Interestingly, all the recommendations within the chapter steer us toward this preferred option or model. It also includes a diagram of the model which does very little to clarify the role of the AMC in this new preferred structure.
It’s clear the discussion omits the fact that the AMC has led some significant reforms to provide a quality framework which delivers an outcomes-focussed approach to accreditation. This may be unintended but it is most relevant to many parts of the governance discussion.
In the last three years, the AMC committed itself to national and international review, to build on its strengths and develop and implement a range of new activities. Revised standards for specialist program accreditation were rolled out after a two-year review and consultation effort. Progressing the evaluation and deployment of a new accreditation management system that sees a more streamlined accreditation processes.  None of these get a mention yet they have been implemented to achieve many of the very aims outlined in this discussion. The fact is that the AMC has already implemented outcomes-based standards and it is working towards a more streamlined system.
Delivering a more responsive health workforce
Building on the recent AMC-led reforms through encouraging more inter-professional team-based learning is now key. Alignment can certainly be achieved through a stronger multidisciplinary approach and there remain plenty of barriers in the training system limiting us here. The report makes some good points around this issue. Ensuring our health workforce is more responsive to emerging health and social care issues and priorities through encompassing a stronger team-based approach is precisely where we need to focus our efforts now .
Driving key workforce priorities through our accreditation system through some of those key enablers identified throughout the report should be pursued. These include more use of simulation-based education and training in the delivery of programs of study as well as making mandatory the inclusion of inter-professional education in all accreditation standards. This more team-based approach to learning is most important enabling service alignment and it would be good to see it formalised in some way.
The other really important area for workforce policy is the requirement that clinical placements occur in a variety of settings, geographical locations and communities, with a focus on emerging workforce priorities and service reforms. This is particularly important to rural and remote communities and together with current workforce planning mechanisms will help ensure we can address unmet need. It will help build a rural GP generalist workforce prioritising essential rural advanced skill areas, procedural and non-procedural, in response to service and skill deficits. If planned appropriately – in prioritising skill need – then these shifts will help to rebalance training it current acute setting focus. This will help to prioritise funding to ensure more community-based exposure strengthening these service solutions over time which will bring about those required service reforms.
After deciding stakeholders needed a little longer to absorb the long draft report, an extension was granted with submissions having just closed (16 October). It will be interesting to see how this discussion evolves before a final report is considered by COAG Health Minister at their next Ministerial Council meeting in November. I think on many aspects this review failed to make the case for major reforms to governance particularly in light of the changes already implemented from a medical training perspective by the AMC. The real opportunity here is to build capacity from within the current structure to align skills to workforce need towards a more integrated national training solution.
In prioritising what needs to be done it is important to realise that we have an accreditation system which is working well. There is good reason why the AMC is internationally recognised for its work. We have the highest possible standards of medical education, training and practice already in Australia. The specialist colleges are key to ensuring we keep it that way through the delivery of high-quality specialist training. They also play a vital role in providing national oversight and consistency to medical specialist training. More dialogue was most certainly warranted before presenting such significant shifts. I hope the discussion moving forward brings a more balanced perspective encompassing the many areas of reform already achieved to build on these areas in ensuring a future workforce responsive to need.
 CPMC. Media Release. Australian Medical Regulation Must Remain Independent. Council of Presidents of Medical Colleges 2017. Available at: https://cpmc.edu.au/media-release/australian-medical-regulation-must-remain-independent/
 AHMAC. Australia’s Health Workforce: strengthening the education foundation. Independent Review of Accreditation Systems within the National Registration and Accreditation Scheme for health professions.Draft Report September 2017. Australian Health Ministers’ Advisory Council 2017. Available at: http://www.coaghealthcouncil.gov.au/Portals/0/Accreditation%20Review%20Draft%20Report.pdf
 Productivity Commission 2005, Australia’s Health Workforce, Research Report, Canberra. Available at: http://www.pc.gov.au/inquiries/completed/health-workforce/report/healthworkforce.pdf
 AMC. Annual Report 2016. Australian Medical Council Limited. 2016. Available at: http://www.amc.org.au/files/656a1621bae0b8baaabca9e3ada8280a1dcbd38f_original.pdf
16 October 2017
Dr Ayman Shenouda
What really lies ahead?
While the impending changes from the Redesigning the Practice Incentives Program (PIP) still looms over us, among this deafening silence there’s concern around what lies ahead. It’s not so much the proposed changes to the PIP but more the underlying policy consequences in terms of broader payment reform and control over the profession.
The fee-for-service payment system remains the predominant commonwealth funding mechanism that assists patients to access primary care. The system is not well aligned to address chronic disease management and the complex health issues of our aging patient population. There is a need to find an optimal mix in addressing current need and future demand. We need funding mechanisms to tackle both complex chronic conditions and issues around disadvantage. Key is the priority shift toward improved patient outcomes and value, not just volume of service.
Key questions remain around what a value based primary health care system will look like. It will no doubt involve extensions of bureaucratic controls used to regulate professional practice with potential impacts on professional autonomy.
Health payment reform
The Government has not been shy in terms of its core focus on health payment reform in securing broader fiscal sustainability. However, in finding solutions, the policy jam seems well and truly fixed on finding savings from within one sector – from within primary care – despite it already being largely cost efficient.
Aspects of primary care payment reform alongside structural reforms are already being tested. The Health Care Homes’ voluntary trial, the Medicare Benefits Schedule (MBS) Review and to some extent the Primary Health Networks (PHNs) are key examples. These shifts have been occurring for some time and this latest redesign targeting PIP signals some further key changes.
The PIP redesign will see, even more, conditions imposed on general practice with an apparent shift toward imposing more funding controls through increased reporting. The policy lens again is on general practice where Medicare spending is value for money. Is this same focus being applied to the broader medical specialties? Driving prices down to regulate perceived skill based premiums might just bring some equity back into the discussion.
The QI measure
The key aim of the PIP is to support general practice activities in recognition of comprehensive, quality care. It provides a blended payment approach for general practices in addition to fee-for-service income. We know the most significant reform will be from the Quality Improvement (QI) measure which will require practices to collect full datasets alongside individualised targets for improvement.
The issue around who sets these targets is still a little unclear – self-selected or enforced. However, if the aim is to capture specifics of a practice’s patient population then I would suggest that the practice takes the lead here, not the bureaucracy. This in some way formalises a broader population health framework approach. This is positive but does a new QI measure involving data capture really provide the best way forward?
The rationale is around the use of data to measure and drive improvement. And certainly, no one is arguing that quality data on outcomes has not been lacking. Clearly, it has had its limitations and one would be around funding commitment to evaluation.
The long-term aim of the redesign is said to be around assisting practices to participate in quality improvement processes. Payments will be tiered to how this data has been used in terms of improvement measures. Those PIPs likely to be removed may well have already captured this detail. Data collection software storage adds a cost for practices but some already have these management systems in place, although not standardised.
There are two key issues here, the first around maintaining data integrity given practices will be required to upload quarterly electronic data to a third-party (probably PHNs) QI provider. The second is broader intent which sees a likely shift towards a pay-for-performance scheme.
Maintaining clinical autonomy
Data control is, in fact, a real issue here. Maintaining data integrity given practices will be required to upload quarterly electronic data to a third-party QI provider is one clear risk. Although utilising the PHNs as a vehicle for change could be beneficial it will require a partnership approach. They will need to further engage with GPs to establish the required trust and make sure they don’t encroach on clinical autonomy. Broader organisations who already do evaluation well and are trusted by the profession should also be brought in. Overall, GPs must remain free, within the parameters of evidence-based care, to make decisions that affect the clinical care they provide, rather than having these decisions imposed upon them.
There seems a move here towards a pay-for-performance scheme which in itself is problematic. Combined with an added data task resulting in more paperwork for GPs these requirements will risk taking our focus from patient care. Most practices have clinical risk management systems in place to analyse weak points and improve patient care. The PIP redesign consultation paper states that there is emerging evidence around a need for regionally-based change management to embed a quality improvement culture in general practice. This implies that GPs are inactive in this area when in fact the profession values and drives many of its own quality improvement measures.
There are already measures in place to support practices in undertaking QI activities. The RACGP QI&PD services offer a wealth of quality improvement tools and guides including clinical audit mechanisms. The College has developed a set of 14 clinical indicators to deal exclusively with the safety and quality of clinical care provided by Australian general practices.
Important unmeasurable factors
It is important to recognise that not everything can be measured. While clinical and organisational measures can be captured, there are other aspects of care important for healthcare quality which prove more problematic. Continuity of care and ease of access to care are unlikely to be captured in a neat format for the PIP QI measure. While attractive to funders pay-for-performance programs may not improve health outcomes or improve system quality. They have the potential to worsen overall care quality as focusing just on measurable outcomes takes us away from holistic general practice.
There is a much larger shift which needs to occur here and it won’t be achieved through a pay-for-performance system. In transforming health, we need to shift from reactive to proactive and predictive care. Early identification is the only way we can control rising chronic disease rates but our system relies on patient contact when they present with noticeable symptoms. Often this is just too late. We need a system which can take us across the spectrum of preventive care - from healthy to chronically ill -and priority measures for what falls between - for those at risk - to allow us to intervene early enough.
Finding the right mix for payment reform might involve encompassing bundled payments alongside some capitation. The latter being voluntary. The fee-for-service payment system should remain the primary source of funding for general practice services. While very tempting for Government, stable controllable costs should not dictate here. It is the patient that should remain the focus. More measures addressing out of pocket costs for GP services are needed.
The paradigm shift from a reactive sick care system towards a proactive and predictive healthcare model still seems a distant hope. While we’ve started the transition to restrain the demand for acute services through more focus on preventive care, finding that balance of funding for both acute and preventive care is not easy. This shift will bring about payment reform which can drive significant change for a more sustainable health care system and provide for a healthier future.
A preventive care PIP could have been brought in as part of this latest redesign as a way to boost funding and encourage new ways of working, yet that opportunity has not been pursued. Regardless, the new proposed PIP QI measure should only be undertaken initially as a trial. This could occur alongside the Healthcare Homes’ voluntary trial. The PIP measure needs to be contained to a sample location to truly test its capacity to deliver what it claims, rather than bring unnecessary disruption to practices through national release.
 AHHA. Bundled payments: Their role in Australian primary health care. Australian Healthcare & Hospitals Association. 2015. Available at: https://ahha.asn.au/sites/default/files/docs/policy-issue/bundled_payments_role_in_australian_primary_health_care_0.pdf
 PHCAG. Better Outcomes for People with Chronic and Complex Health Conditions through Primary Health Care. Discussion Paper. 2015 Available at: https://www.health.gov.au/internet/main/publishing.nsf/Content/76B2BDC12AE54540CA257F72001102B9/$File/Primary-Health-Care-Advisory-Group_Final-Report.pdf
 Duckett S. Opinion: Why it costs you so much to see a specialist — and what the Government should do about it. Grattan Institute. Published 14 August 2017. The Conversation Available at: http://www.abc.net.au/news/2017-08-14/why-it-costs-so-much-to-see-a-specialist-the-conversation/8803864
 RACGP. Standards for general practices (4th edition). Criterion 1.4.2 Clinical autonomy for general practitioners.Availableat:https://www.racgp.org.au/your-practice/standards/standards4thedition/practice-services/1-4/clinical-autonomy-for-general-practitioners/
 Australian Government Department of Health. Consultation Paper Redesigning the Practice Incentives Program. 2016.
 Wright M. Pay-for-performance programs. Do they improve the quality of primary care? AFP 2012;41:989-991. Available at: https://www.racgp.org.au/afp/2012/december/pay-for-performance-programs/
 MacIntosh E, Rajakulendran N, Khayat Z, Wise, N. MARS Blog: Transforming health: Shifting from reactive to proactive and predictive care. 2016. Available at: https://www.marsdd.com/news-and-insights/transforming-health-shifting-from-reactive-to-proactive-and-predictive-care/
6 October 2017
Dr Ayman Shenouda
A focus on palliative care
There was some great discussion generated from my recent blog on frailty and ICU outcomes. The importance of patient empowerment and preference towards care in the community resonated with many. Palliative care is an important extension to that discussion. This is an area, which we know is expanding with demand which is set to rise alongside disease rates and an ageing population. Despite a stronger national focus on palliative care, the patient’s preference for community care is not translating into policy.
Palliative care should improve the quality of life of patients with an active, progressive disease that has little or no prospect of a cure. More and more we’re seeing patients’ preference for palliative care in the home. We know that 70 percent of Australians would rather die at home than in hospital. Whatever the choice, the model of care must enable access to all patients facing a life-limiting illness. We know that those who would get the most benefit from palliative care often accessed it too late. There is still so much in this area that we need to fix. I think a good place to start is ensuring our patients’ preferences around dying at home.
Access and choice
In finding a way through the system to facilitate choice for more community-level care we are still a long way from enabling equitable access. Early access to palliative care services is an internationally recognised policy goal. However, it is clear that our shared policy goal is not being met in Australia when it comes to access and choice.
This highlights our first policy failure, which is around equity in access which of course stretches beyond just palliative care and can be persistent throughout life for some most in need.
Where you live and your socioeconomic status has some bearing on choice in terms of preference of setting in palliative care. AIHW 2014-15 data released early in the year showed that there is a higher proportion of palliative care-related hospitalisations (22.4%) in the lowest socioeconomic status areas. The rate of palliative care-related public hospitalisations was also highest for those living in these areas (30.9 per 10,000 population). Conversely, the rate of public palliative care-related hospitalisations was lowest for those living in the highest socioeconomic status areas (14.5 per 10,000).
Funding and policy context
Funding and policy context really matters here. This is because funding models clearly influence service provision and the development of palliative care services. Funding for palliative care involves a mixed system of public, private and charitable players. A mismatch between policy goals and palliative care funding mechanisms can compromise our shared aim in addressing need. 
This leads to the next policy failure which is around service planning and problematic due to care being split across levels of government.
Service planning relies on quality data and this is a key gap in palliative care. The sole Physician MBS item numbers map only a very small sample of service provision which really limits service planning, particularly in enabling patient choice to die at home.
This palliative medicine focus, while important, is limiting. It means that what is actually occurring at the community level in terms of GP-led palliative care is less likely to inform policy decisions. The undefined role of the general practitioner in palliative care across a range of settings is a contributing factor. While we are seeing more and more GPs with special clinical interests in palliative care meeting these needs in primary rather than secondary care, the system just doesn’t see them.
In the absence of item numbers, how can GP-led palliative care ever be fully measured? GPs play a critical role here. Chronic disease management and home visit item numbers are not sufficient in terms of planning for future demand or in capturing the complexity and non-clinical time involved in providing this care. The only available BEACH data shows that about 1 in 1,000 GP encounters in 2014-15 were palliative care-related, which equates to around 5 encounters per 1,000 population. This is most certainly an underestimate of the actual numbers given services delivered by GPs cannot be established from Medicare data.
Another key issue is that palliative care services have many individual providers both public and private. It is clear we need to get better at ensuring a more seamless service transition for the patient and family. Service integration prioritising multidisciplinary care at the local level relies on flexibility to facilitate the integration of funding streams. In rural areas, this can be particularly challenging even when there is a strong commitment by local service providers.
Service integration at the primary care level remains a key policy failing and much more effort is required to provide the necessary supports to enable a more integrated system.
General practice is the gateway for patients to the broader health system. We need new expanded funding measures specifically designed to enable service integration for palliative care in the community. Efficiencies can be found in community-based care, yet there is a reluctance to put the system supports in place to make it happen.
The recent $8.3 million announced in the Federal Budget will help boost the role that the PHNs have in coordinating end-of-life care. It is understood that the funding will support the provision of a facilitator which may help take the pressure off GP practices who are fulfilling much of this role already for their patients. But much more needs to be done in the area of facilitating greater access to GP-led palliative care services. Building local capacity to address increasing and future demand will require a significantly larger investment than we’ve seen to date.
Capturing broader perspectives
We know that demand for palliative care in Australia will grow. This, in turn, requires an expansion of home and community care in meeting patient preference. An important policy perspective needs to be captured from those receiving care and their caregivers. This will help us work through further how we can improve services to support dying at home.
A final additional focus therefore needs to be on the patient and caregiver if we are going to get this policy right.
A qualitative study of patient and family caregiver experiences of Hospice at Home care provides insights. It states that we need to focus on additional supports for older people and those living alone, recognised as high risk of being unable to receive this type of support. More targeted supports for older caregivers who are at a higher risk of caregiver burden are also required. The policy goal here has to be around promoting their quality of life with an emphasis on training for the full care team in the ethos of palliative care to ensure holistic care.
Where to now?
We know that GP-led community palliative care needs to be prioritised in policy. Yet there remains plenty of barriers limiting service expansion to facilitate this care from within the community and across settings.
Ensuring our system is more responsive to patient choice is of course what needs to drive all policy decisions. We know in this case that it is often a preference for care outside of the hospital setting. But when our system automatically preferences to tertiary care, it makes it harder to facilitate that care. This is unless of course you have well established and integrated service links and a significant local community commitment to make it work.
There’s a pattern emerging here and it’s about prioritising patient-centred healthcare in primary care. Access enabling choice, service planning and data capture, integration prioritising GP-led care and encompassing the patient and caregiver perspectives would bring us closer to a more responsive palliative care service system.
 AIHW. Web Report. Palliative care services in Australia. Last updated 24 May 2017. Available at: https://www.aihw.gov.au/reports/palliative-care-services/palliative-care-services-in-australia/contents/palliative-care-in-general-practice
 Palliative Care Australia. National health statistics highlight inequitable access to palliative care. 24 May 2017. Available at: http://palliativecare.org.au/palliative-matters/national-health-statistics/
 Parliament of Victoria. Legislative Council Legal and Social Issues Committee. Inquiry into end of life choices Final Report. June 2016 PP No 174, Session 2014-16 (Document 1 of 2) ISBN 978 1 925458 38 1 (print version) 978 1 925458 39 8 (PDF version). Available at: https://www.parliament.vic.gov.au/lsic/article/2611
 Connor SR and Bermedo MCS. Global atlas of palliative care at the end of life (Worldwide palliative care alliance, World Health Organization), 2014, http://www.who.int/ nmh/Global_Atlas_of_Palliative_Care.pdf
 AIHW, op.cit. Profile of palliative care related hospitalisations.
 Groeneveld EI, Cassel JB, Bausewein C, et al. Funding models in palliative care: Lessons from international experience. McCaffrey N, Cassel JB, Coast J, eds. Palliative Medicine. 2017;31(4):296-305. doi:10.1177/0269216316689015.
 Australian Institute of Health and Welfare 2014. Palliative care services in Australia 2014. Cat. no. HWI 128. Canberra: AIHW.
 Palliative Care Australia. Budget offers new support to coordinate end-of-life care. 10 May 2017. Available at: http://palliativecare.org.au/palliative-matters/budget-phns/
 Jack B.A., Mitchell T.K., Cope L.C. & O'Brien M.R. (2016) Supporting older people with cancer and life-limiting conditions dying at home: a qualitative study of patient and family caregiver experiences of Hospice at Home care. Journal of Advanced Nursing 72(9), 2162–2172. doi: 10.1111/jan.12983