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.[1] Key is the priority shift toward improved patient outcomes and value, not just volume of service.[2] 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.[3] 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.[4] 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.[5] 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.[6] 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.[7] 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. Conclusion 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. [1] 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 [2] 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 [3] 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 [4] 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/ [5] Australian Government Department of Health. Consultation Paper Redesigning the Practice Incentives Program. 2016. [6] 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/ [7] 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/
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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.[1] 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.[2] 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.[3] 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.[4] 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).[5] 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. [6] 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.[7] 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. Service integration 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.[8] 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.[9] 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. [1] 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 [2] 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/ [3] 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 [4] 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 [5] AIHW, op.cit. Profile of palliative care related hospitalisations. [6] 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. [7] Australian Institute of Health and Welfare 2014. Palliative care services in Australia 2014. Cat. no. HWI 128. Canberra: AIHW. [8] 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/ [9] 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 Changing our healthcare system starts in the consulting room 15 September 2017 Dr Ayman Shenouda Empowerment There’s been a lot of discussion around empowering the patient more in their treatment decisions. That we need to shift our focus toward a system that empowers and facilitates choice. But undermining a shared decision-making model – one which has room to provide for both clinical choice and patient choice – is our healthcare system. We have a system which is based on a disease-based model of care which leaves little room to take into account the context of the patient's illness. A system that can allow us to refocus on the patient-centered, personal and unique experience of “illness” must be prioritised.[1] Patient experience in the health system is so vitally important and has to be valued. For me, changing our healthcare system really starts in the consulting room. It’s that doctor-patient relationship that I really value. And this often goes unnoticed by our decision makers – but it is here where lasting change can be realised. Discussions in general practice are of great value for helping patients take charge of their own health. A more focussed effort here not only helps to improve health but will support quality reform measures which can reduce costs. Research shows us the benefits of a shared decision-making model approach. These include knowledge gain by patients, more confidence in decisions, and more active patient involvement. Studies have shown that, in many cases, informed patients elect for more conservative treatment options.[2] Preparing for the challenges ahead The health system cannot cope with what it is facing. Health care demand on the system is reaching crisis point with public spending at unsustainable levels. Empowering patients is most certainly part of the solution if we are ever going to meet rising demand with an ageing population. But to do this, empowerment needs to be met with a system that can facilitate choice. Recently I attended an event organised by the RACGP NSW Faculty delivered by an ICU Physician who led an impressive discussion around frailty. He spoke about the elderly intensive care unit (ICU) patient and poor outcomes. More specifically, the need to identify frail patients at high risk of poor outcomes and plan accordingly. We were brought across a study which investigated the effects of frailty on clinical outcomes of patients in an ICU. It used a frailty index (FI) which was derived from comprehensive geriatric assessment parameters. It found that the use of a FI could be used as a predictor for the evaluation of elderly patients’ clinical outcomes in ICUs.[3] Another study found frailty is common in patients admitted to ICU and is associated with worsened outcomes. It recommended that this vulnerable ICU population should act as the impetus for investigating and implementing appropriate care plans.[4] Identifying patients at high risk of poor outcomes is key here. But the system cannot identify what frail means, nor does it empower GP decision making at the cold face. Applying the FI is one way to ensure we’re not placing patients where there is no real benefit. But the culture within hospitals makes it hard to implement this tool. Enabling end-of-life discussions particularly at a point when there is a crisis situation is also a barrier. Planning for end of life and putting in place an Advance Care Plan early is essential. GPs are very good at this. It should be undertaken as part of the Over-75 Health Check. and helps equip the patient, and their family, well for what lies ahead. It’s a good time to talk to the patient about prevention, maintaining functionality, minimising pain or complexity of disease as well as strategies to address them. It is also time to start the discussion around being frail and their expectations around that. High price for poor outcomes We know that more than 30 percent of patients admitted to intensive care units never make it out. Those that do rarely make it back to their own home. It costs around $4,000 per night in ICU . This spend can be better utilised if redirected to support patients in their own home. I know from my own elderly patients’ experience that it is often hard for the patient not to end up in ICU. The system makes it hard to facilitate this care in the community. And it’s hard to take on the system during a crisis. It takes a strong family who is across their loved one's wishes. Care in the community I recall consulting at my surgery in The Rock some years ago and receiving an urgent phone call. It was the daughter of my 82-year-old patient and she needed my help in preventing the transfer of her mother from Wagga Base to Sydney. She told me the specialist was transferring her and that the family did not want her to go through this and that her mum didn’t want this either. They understood that their mum was in a critical condition but wanted her close to home. I immediately made the call to the Specialist Respiratory Physician who explained she had a flouting clot in her pulmonary artery and needed an embolectomy and a filter in her IVC. The specialist had already discussed her case with the Cardiothoracic Surgeon in Sydney and organised the transfer. I explained that the family had called and that this was not what my patient, nor her family, wanted. I also explained that I was prepared to look after her in the community. Fortunately, the specialist at Wagga was comfortable provided she sign a discharge against medical advice. This patient lived for a further five years. She was able to attend her grandson’s wedding in Sydney two years before she died peacefully at her home with her family around her. A testament to her strength and also that of her family. They ensured she stayed in Wagga to receive care an appropriate level of care in the community. They insisted that she was not transferred to a Sydney hospital where she was likely to end up in ICU and never to come home. Making the system work How can we ensure that the system can default to enable care in the community, rather than automatically preference for tertiary care? While there exists a frailty tool there’s reluctance to use it. There’s plenty of GPs happy to care for their patients in the community if that’s their choice. But rarely will the patient’s GP be consulted at that critical stage. There is also limited funding to facilitate this care. A reality check is well-overdue in terms of outcomes particularly in dealing with the frail. We’re missing the point on where to focus care. This needs to be where there is the greater need and where the efficiencies can be found. And this is not on a system which is disease focussed and already crippled by expensive treatments. To prevent waste, more realistic expectations around outcomes can be achieved through person centred care enabling empowerment. One of the strengths of general practice is the unique relationship between patients and their GPs. Patient centred communication and shared decision making is the foundation on which our health system can be remodelled. Let’s prioritise it. [1] Green AR, Carrillo JE, Betancourt JR. Why the disease-based model of medicine fails our patients. Western Journal of Medicine. 2002;176(2):141-143. [2] Stacey D, Bennett C, Barry M, Col N, Eden K, Holmes-Rovner, M Llewellyn-Thomas, H Lyddiatt A, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database of Systematic Reviews. 2011;as well as(10):CD001431. [3] Kizilarslanoglu, M.C., Civelek, R., Kilic, M.K. et al. Is frailty a prognostic factor for critically ill elderly patients? Aging Clin Exp Res (2017) 29: 247. https://doi.org/10.1007/s40520-016-0557-y [4] Muscedere J, Waters B, Varambally A, et al. The impact of frailty on intensive care unit outcomes: a systematic review and meta-analysis. Intensive Care Medicine (2017). 43: 1105.https://doi.org/10.1007/s00134-017-4867-0 Health sector reform: towards a sustainable system. 8 September 2017 Dr Ayman Shenouda A decade of reform We’ve had a multitude of reforms over the past decade or so with much of it stemming from the National Health and Hospitals Reform Commission (NHHRC). A strengthened consumer voice and empowerment was perhaps the most important shift in the reform discussion at that time. A shift which held great promise in realising change through a more patient-centred approach and one which prioritised primary care and its role in achieving the required shifts. During the NHHRC years of review, significant structural reform was recommended including in terms of responsibility for primary health care services as well as a more transparent and equitable funding model for public hospitals. The latter has seen some sizeable shifts, particularly in the way we determine funding to public hospitals through the introduction of activity-based funding. We’ve seen other changes too in formalising shared policy commitment in the form of National Partnership Agreements to help set and agree upon priorities and measure progress across a range of areas. Structure reform requirements It’s clear that much has been done to improve the performance of Australia’s health system. But after years of review and with policy fatigue well and truly set in are we any closer to a framework which will secure the future sustainability of Australia’s health system? Key to realising patient-centred health policy lies in structural reform to promote more integrated care. Our past attempts haven’t brought us much closer to realising this clear requirement, noting we are still implementing much of it as many reforms are ongoing. Information Technology provides certain opportunity here. The My Health Record (formerly PCEHR), as one key measure, is still being implemented and yet to deliver on its promise. As it transitions towards the planned opt-out phase mid-2018 there is still much hope that it will succeed. Organising primary care through a medical home model of care would also support integration and provide patients with continuous, accessible, high-quality and patient-centred care. Australian general practice encapsulates the medical home model[1], and a supported policy shift here, if funded appropriately, together with further incentives to promote integrated care across different care settings, would bring us closer to the level of reform required to address current and future demand. But fragmentation in health care structure exists largely due to the primary and secondary care divide. Each which is then further complicated by its own arrangements through compartmentalised funding streams. This, of course, leaves little to no room to integrate at least not to the level we need to. Complex governance structure It’s clear that system complexities brought about by a governance structure with responsibilities falling between the Commonwealth and the states and territories have not served the health consumer well. It’s hard to navigate and even harder for patients with complex or multiple illness or disease.[2] Bringing the responsibility for acute and primary care together at one level of government is one clear solution. Devolving primary care to the states and territories might just help provide the structures and incentives needed to promote integration.[3] A way forward might be in the form of a state-level trial to integrate local hospitals and health services with primary health networks piloting integrated models in one health service/local health district.[4] Integrated funding and management have been suggested before, many times in fact and it wasn’t that long ago that we had a serious discussion around it from former Prime Minister Rudd, although with a Commonwealth dominated role in mind. More recent discussions lead to a similar conclusion, that a move to a single or pooled source of government funding would help to eliminate bureaucratic cost shifting and duplication. This alongside more private sector contributions and alignment to outcomes. Integrated funding and management is one of five central policy levers available to reform Australia’s health system. The other four are around consumer empowerment and responsibility; wellness and prevention; optimised care pathways; and information-enabled health networks. [5] Making it better It is important to acknowledge that Australia has a strong system of healthcare. A high-quality universal healthcare system with coverage through Medicare to the main components of care extending across public hospitals, medical services and pharmaceuticals. The Commonwealth remains the dominant policy maker, which is due to the simple fact that it generates most of the funding. There is a complex division of roles and responsibilities across levels of government with the involvement of both public and private sectors.[6] The financial dependency of the states on the Commonwealth makes it harder for them to lead in this area. The required focus on outcomes likely to become a bit blurred when it is confined to funding limits and controls imposed by it. While there may exist a shared policy objective - whether that is to help people sustain and improve their health or improving quality or even equity in access - in attaining those measurable outcomes compromise is always tied to the narrow confines of what has been negotiated. It seems the way forward comes back to a question around who’s best positioned to lead? The current division of responsibilities and roles across levels of government impacts significantly. Devolution of responsibility and funding to one level should be tested to see if integrated funding translates to integrated delivery. If we can move beyond the control being where most of the funding is generated for one moment then we might get a little closer to fixing our fragmented system. This is where we remain stuck and unless tackled we will not move forward. [1] The Royal Australian College of General Practitioners. What is General Practice? Melbourne: RACGP; 2012. Available at www.racgp.org.au/becomingagp/what-is-a-gp/what-is-general-practice [2] Bartlett C, Butler S, Haines L. Reimaging Health Reform in Australia. Taking a systems approach to health and wellness. PwC; 2016 Australia. Available at: https://www.strategyand.pwc.com/reports/health-reform-australia [3] OECD Health Policy Overview. Health Policy in Australia. OECD; 2015. Available at: http://www.oecd.org/australia/Health-Policy-in-Australia-December-2015.pdf [4] PwC 2016, op. cit., p. 22. [5] PwC 2016, op. cit., p. 8. [6] The Commonwealth Fund. Health Care System and Health Policy in Australia. Available at: http://www.commonwealthfund.org/grants-and-fellowships/fellowships/australian-american-health-policy-fellowship/health-care-system-and-health-policy-in-australia Let’s not lose another rural obstetrics service 1 September 2017 Dr Ayman Shenouda Decline of rural obstetrics services It was disappointing to see yet another decision without due consultation to downgrade rural maternity services recently and this one was particularly close to home for me. Temora Hospital’s maternity services will be reduced with patients requiring maternity surgery under general anaesthetic moved to other district hospitals. Only a month earlier, in July, it was Emerald in Queensland that was in the spotlight due to a maternity service closure. But none of this is really new, is it? Nationally we’ve seen more than 50% of small rural maternity units closed since 1995.[1] In this latest downgrade, we’re told Temora’s maternity services for low-risk pregnancies will continue but caesarean births and gynaecological surgery will now be relegated to Cootamundra and Young hospitals. This just shifts the costs in my view and is not a sustainable solution for this community and could see broader impacts on other services too if works are not prioritised and essential staff leave. Surely, part of the cost equation has to also look at the costs transferred to the patient as well as the skills lost and broader safety aspects of NOT having a locally accessible service? The NSW Health Minister Hon. Brad Hazzard MP says he was kept in the dark on the decision by the Murrumbidgee Local Health District (MLHD) and wants the service retained.[2] There is at least some hope for this community with the Minister making clear his views on the matter. But why do we need to get to this level in the first place? Local level planning and consultation should have occurred on such an important issue and well before it got to ministerial intervention level and preferably not debated through the media in this way. Impacts for the local workforce Putting aside the clear impacts of this decision - including higher risk birthing outcomes - for one moment. What now for the three obstetric providers who have been providing this service? One GP obstetrician in the town stated in the Harden Murrumburrah Express that she did not want to see Temora become a victim of bureaucracy.[3] We know that driving decisions to close or reduce rural maternity services is often around doctor shortages, safety concerns or funding constraints. This decision according to media reports comes down to physical infrastructure costs. The issue is the obstetrics theatre room was deemed unsafe for surgery following an audit by the Australian Council of Healthcare Services.[4] Rural patients need viable maternity and surgery services near to where they live. And doctors who invest in training to ensure a service for their community need some certainty around service continuity. They most certainly need to be involved in local service decision making which certainly seems not to have been the case in the Temora downgrade. A strong focus on policy This is a decision which seems contradictory to what we’ve seen from NSW HETI in terms of its rural generalist pathway. There has been an expansion of training positions this year with 40 positions being made available. It is also contrary to the focus nationally which has seen committed action over an eight-year period. There has been a strong policy focus in the form of a Maternity Services Review (2009), a National Maternity Service Plan (2010-2015) and the current development of a National Framework for Maternity Services. We’ve seen such a strong policy response in recent years and it’s important that local level planning decisions work within these broader nationally set priorities. Both the National Maternity Services Plan (2010-2015) and new National Framework for Maternity Services (2017), which is still being finalised, have set specific priorities to secure more equitable outcomes for rural patients including in the areas of access and workforce. Some great policy outcomes have resulted already including in terms of tools to inform planning and in areas of national data development. The Australian Rural Birthing Index (ARBI) was a key outcome of the Plan which has provided an important index to help in the planning for maternity services in rural locations.[5] The index can be downloaded here: http://ucrh.edu.au/wp-content/uploads/2015/07/ARBI_FINAL_PRINT.pdf . While the AIHW-led National Maternity Data Development Project aims to enhance maternity data collection and reporting in Australia. Both are important national planning tools which aim to utilise a population based planning approach as the basis for demand driven evidence-based decision making. Protecting rural services Despite such a strong policy focus and commitment, it is evident that we still need to improve maternity services in rural and remote communities. There is clearly state-level support for the development of rural GP procedural skills. However, this needs to also extend to rebuilding rural hospital infrastructure when required to ensure service continuity. Here in NSW, we have a policy commitment to develop workforce capacity by expanding rural generalists being potentially compromised by a local level decision driven by infrastructure costs which have led to the downsizing of maternity services. The critical role of procedural GPs – both GP obstetricians and GP anaesthetists – in providing maternity services in rural Australia is well understood. Decisions which see closures or a downgrade of services will have a direct impact on the long-term commitment of both current and future rural doctors. Let’s not lose another rural obstetrics service – operative obstetrics and gynaecological procedures are needed in Temora and funding should be found to upgrade the operating theatre. [1] Rural Doctors Association of Australia. Maternity services for rural Australia. Manuka: Rural Doctors Association of Australian, 2006. [2] The Daily Advertiser. Media Article: Minister ‘kept in the dark’. Published 22 August 2017. [3] Harden Murrumburrah Express. Media Article: Temora Hospital theatre closure could see expectant mothers transferred to Cootamundra or Young Hospital. Published 21 August 2017. Available at: http://www.hardenexpress.com.au/story/4870112/obstetrics-theatre-room-closing-at-temora-hospital/ [4] Ibid. [5] Longman J, Pilcher J, Morgan G, Rolfe M, Donoghue DA, Kildea S, Kruske S, Grzybowski S, Kornelsen J, Oats J, Barclay L. (2015) ARBI Toolkit: A resource for planning maternity services in rural and remote Australia. University Centre for Rural Health North Coast, Lismore. |
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