Raising the Care Factor: Royal Commission into Aged Care Dr Ayman Shenouda There is hope that ensuring dignified support for people in aged care will be one step further with the announcement of a Royal Commission into Aged Care. I certainly welcome this royal commission and see it as a key step forward in ensuring our patients get the right care, support, and dignity they deserve. This not only provides hope for patients and their families but hope for those working in the sector and committed to providing consistent, quality care to their residents. What have we learnt? Most working in the sector would welcome the opportunity for real reform through a comprehensive consultation and review of this kind. The issue certainly qualifies for such a focus but it’s not like there haven’t been any policy questions posed in this space in recent years. The royal commission is just the latest in a very long line of inquiries in aged care. We’ve had years of review and countless recommendations with most now, it seems, awaiting web archive. It has been reported in recent days that there have been 20 federal inquiries by the Senate and others into aged care since 2009. Even the Aged Care Minister admitted to that only a few weeks out from this latest policy shift: "…after two years and maybe $200 million being spent on it, it will come back with the same set or a very similar set of recommendations, the governments will respond and put into place similar bodies". Let’s not forget the states who have also had a strong focus over many years and there’s plenty of positive state-driven change and too many to list here. The point is that we know there are systemic national challenges in aged care and through significant review, we now have the policy answers. Ensuring quality care This Royal Commission certainly places a stronger lens on the issues but the areas of reform are already clear and this might just keep us in a constant policy cycle of inaction. Having worked in aged care over many years it is as clear to me what needs to occur as it would be for most in the sector. I should add that some of these facilities provide excellent care and this should not be lost in what will likely be a very intense and confronting royal commission. One glaring omission from a more recent review - the Government’s Review of National Aged Care Quality Regulatory Processes – was a required focus on enabling a more collaborative patient-centred care model. This model is reliant on adequate remuneration and unless this is prioritised residents in aged care will have their medical care compromised. Ensuring a key role of general practice in aged care service provision is integral to the solution. The review failed to acknowledge the critical role of GPs in improving the quality of care in these facilities and I wrote about it at that time. It is these obvious service issues, central to ensuring quality, that continue to be ignored or held over for the next review. What are the priorities? A focus on quality has to look at ways to make improvements including through stronger staffing and appropriate skill mix levels. We need to focus on different models of nursing home care that can support general practitioner decisions. It’s a step-up approach to support interventions to reduce acute hospitalisations from nursing homes. Reducing unplanned admissions means we have to start dealing with those issues in the nursing home setting and with that requires appropriately funded infrastructure including adequate nurse support. It is clear we need very different models of care than those currently funded in order to provide the complex support for those vulnerable to acute and deteriorating illness. Currently, the role of the GP is clearly limited due to low rates of reimbursement through the MBS. Optimal models of care cannot work in an underfunded service environment. Integrated pharmacy is another clear requirement. Ensuring the holistic needs of patients with dementia requires much more focus and there has been good research around this. More broadly, the emphasis needs to be placed on individualised care in supporting those with complex care needs including negotiating priorities for those with multimorbidity. In meeting the complexities in medications, in rehabilitation and functionality combined with broader family decision-making requirements it really requires a good team. These teams should be supported by a financial model which can allocate time for multidisciplinary case conferences. Training and roles Training is a big part of it to ensure care workers are better equipped to cope with the demands of providing this very complex care. In a largely for-profit sector, to ensure patient-centred quality care, there is really no choice but to mandate staff ratios. The other related aspect to this and it’s good to see it coming through in the discussion early is around valuing roles. Starting with care workers or care assistants - we need to make this a career worth having to ensure we attract the right people and skill sets. They must be properly paid and qualified for what is a role which carries with it a lot of responsibility. Registered nurses and so integral to ensuring quality of care and also key to preventing adverse events among residents. But RNs who work for nursing homes also tend to earn less than those working for other major employers. In welcoming the Royal Commission, the RDAA called for better incentives to recruit more registered nurses into aged care facilities along with improving infrastructure. Future policy must ensure registered nurses are in place to lead the team and this requirement should extend to prioritising RN coverage at night. This structure is optimal and can then accommodate different levels of nurses and staffing and ensure quality patient care. New models of nursing-home care It really comes down to the value we place on our older Australians and I think there are some key lessons for us from other countries with strong policy in place. There are also excellent models of care within Australia but we need a funding system to prioritise support of their development. We also need to ensure we balance this discussion by highlighting the good work some nursing homes are already doing. These are my thoughts to the key requirements to reform and I would welcome your contributions to keep this discussion going.
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Dr Ayman Shenouda
There remains a deep undercurrent of racism in this country but it is not mainstream Australian opinion driving it. The problem is that the public debate in and around migration is persistently led by a far-right minority. And actively challenging such intolerance is vital otherwise I think these low debates will come at a high price for us all. I really think all doctors must unite against racist attacks on IMGs. This is doing considerable damage and we need to challenge these views. Where’s the evidence? If you were looking for more evidence that the media is complicit in fueling racism it could be clearly seen on the front page of The Weekend Australian last weekend. Beneath a headline that read ‘Foreign doctors blow out Medicare’ sprawled the most unbalanced, uninformed piece which firmly targets International Medical Graduates (IMGs) as exploiters of Medicare. This article, whether deliberate or not, purely through a sole focus on IMGs infers that they alone are responsible for driving some very complex problems facing our health system. Issues around over servicing and professional standards are not confined to IMGs and we have effective non-discriminatory processes in place through various codes, guidelines, and policies to address these. Let’s unpack the bias Starting with over-servicing and alleged Medicare fraud we’re told about “a rampant increase in IMG Medicare billing”. The article, of course, fails to balance this with required comparators for Gross Billings for Australian Trained Doctors (ATDs). There is also policy in place which addresses such issues – the Professional Services Review - and this is not confined to IMGs. Some much-needed context around what might be driving such increases other than the inferred fraud would have helped balance it. Issues such as long hours and caseload, acuity and complexity of patient need, and broader need for the specific population and working to align resources to need all factor strongly. The predictable narrow migration narrative The article then forewarns a policy shakeup which will see the number of IMGs or ‘imported GPs’ slashed in coming years and then states a budget return for policy justification. This just adds to a growing trend which sees skilled migration used as political fodder. Skills lists really are a decision for government and if we don’t need them then don’t get them. I actually don’t disagree that we should place strict parameters around skilled migration policy to ensure we are targeting the skills most in need. But if we do need them then we need to support them and that is the key issue here. More on that later! Recent policy through the new Temporary Skill Shortage (TSS) visa now works through short and medium-term skill requirement. This is a good policy reform which also works to limit the pathway to permanent residency. Where’s the detail behind the analysis? The article alludes to some analysis that claims average billing of IMGs — across Medicare, the Pharmaceutical Benefits Scheme, and referrals — has tripled in three years. Let’s be clear here defining total cost as MBS + PBS + referrals in no way reflects a GPs actual income. We’re then told that removing IMGs would result in a forecast saving of $415.5 million. This, of course, assumes that most if not all the services provided by the IMG equated to over-servicing. The article claims this is based on a policy assumption that other doctors would not cover the equivalent Medicare services or subsidised drugs and only half as many referrals. This is a very big assumption and one that is impossible to verify against such diverse need. Now to provide a much-needed defense for IMGs. A reality check on the doctor shortage Statistics might show there is no doctor shortage in Australia but there certainly remains a maldistribution issue. Maldistribution persists in rural Australia and with increasing remoteness you can expect to see both workforce shortages and a higher burden of disease. This is despite efforts to increase supply through policy measures which see increasing numbers of Australian Trained Doctors (ATDs) and broader workforce supplementation measures through skilled migration. Some policy insights Benefits from increasing domestic supply will of course take time and we’ve made great progress with more students training in rural areas through the Rural Clinical Schools. What is not seen beneath the supply stats are the policy complexities in regard to addressing population need, ensuring the right workforce mix, health infrastructure deficits, and distance and geographic location. There are still too many one doctor towns in rural Australia in need of an urgent injection of basic medical facilities. Keeping services viable in these contexts is the story not told. And it is for all these reasons IMGs remain an integral part of our workforce. Rural Generalist Training Excessive specialisation means there are not enough generalists particularly in rural Australia. We’ve been working hard to address this through the National Rural Generalist Framework. This is key to ensuring a supportive pathway providing rural exposure in order to prepare trainees for work in a rural and remote setting. There is significant policy work currently being undertaken in this area led by the National Rural Health Commissioner. We need to facilitate some key shifts which turns a structure which currently sees most of the training being undertaken in the bigger tertiary hospital in the cities. We need to turn that on its head to provide more training in regional locations to encourage more domestic graduates to take up and retain postings in rural and remote areas. Currently, they are seconded for six months to a rural area but it’s just not going to be enough to give them the exposure they need to entice them to return. They spend most of their time training in cities and naturally build a life around that. We need to provide more opportunity for them to work in rural areas and experience the rewards. It is just about facilitating the training to connect these doctors to the communities that need them the most. It’s really quite simple and we’re now on the right path to make this happen. IMGs and their contribution IMGs are the lifeblood of rural towns. They are the backbone of our healthcare services in rural areas. You see without them many rural communities would be without a doctor. It is estimated that IMGs comprise approximately 40% of the medical workforce in Australia and 46% of general practitioners in rural and remote locations. IMGs saved this country from a disaster over the past 10-15 years and this type of reporting is just unhelpful. Let’s not forget that they are often recruited to work in some of the most difficult environments, with little support. IMG is also a broad definition If we are going to persist with a debate that sets IMGs up against ATDs then lets first clarify the definition. I don’t think it is well understood just how broad this term is. And it’s a term that sticks. IMG simply means that you have been trained overseas and while we’re on that point it also means that you’ve not cost the country a cent in your training. Many IMGs have been through the system, working in rural areas for many years and achieved Fellowship. These doctors are serving their communities delivering a very high standard of care. Legacy of forced distribution The legacy of a forced distribution policy – the 10-year Moratorium – is that the gains for our rural communities are only short term, as doctors seek to return to more populated areas. The policy may only provide intermittent gains, and ultimately fail to provide a stable workforce for the rural and remote areas in need. For it to work, it is reliant on a longer-term commitment from IMGs – a key consideration which currently lacks policy focus. For some practical policy solutions, here’s a link to a conference paper from the 14th National Rural Health Conference last year: Keeping them there: shifting our focus toward IMG retention, beyond moratorium obligations Shifting focus Now one final word on the debate we ought to be having. The discussion we need to be having is keeping doctors where we need them. For rural and remote communities, we need to shift the focus toward IMG retention, beyond moratorium obligations. But we also need to focus most on a policy which prioritises and secures domestic graduates for regional, rural and remote Australia. A strong investment in the National Rural Generalist Pathway will support this outcome. The reality is that we will also need to continue to rely on those IMGs currently working in regional, rural and remote Australia to help train our domestic workforce coming through. IMGs are vital in securing the next generation of rural GPs and this is a really important point that just gets lost in these divisive debates. The health effects of drought and our role in planning
Dr Ayman Shenouda Last week’s blog on GP-led strategies to reach out to drought-affected farmers has started some good discussion around the role of GPs and our broader public health role. What we are seeing is a significant drought particularly in the worst-affected parts of NSW where the current dry conditions have spread to most inland parts of the state. The recent media focus is a good thing to keep some philanthropic and government dollars flowing, but we really need a better preventative strategy to protect our farmers and our food resources from these extremes. What we are seeing is reactive policy which only demonstrates the ineffectiveness of our national drought management policies. While short-term drought-related health shocks can be more obvious, it is those longer term, more indirect health implications that are harder to measure and monitor. In helping our communities prepare for drought, GPs should have a leading public health role in developing drought-related public health vulnerability assessments. This involves working with the community and key partners to ensure coordinated preparedness and response efforts. Staying engaged through non-drought periods is essential. Here are some key steps that we could consider in undertaking drought planning and vulnerability assessments in our own communities. Step 1 Identify vulnerable populations It is clear that drought severity and the vulnerability of particular populations requires a more targeted and planned response. While the health effects of drought can be severe, the health disparities in diverse rural communities can make public health planning a challenge. This is why GPs need to have an active role in identifying those priority groups within our community. Most rural practices sustain themselves by being attentive to key changes within their communities and know how to work within constrained resources. We need to allocate a greater proportion of total health resources to drought impact mitigation and prevention. A key part of this is enabling planning and establishing a leadership role for GPs in decisions to develop appropriate models of health care for these at-risk groups. It is important to note that there is also a doctor drought in some regions too. The distribution of GPs to underserved areas requires similar planning together with ensuring the adequacy of health infrastructure for longer-term service viability. Step 2 Make disease projections We need more data around this but generally, populations face an increased risk of illness in the year they are exposed to drought. A formal role for GPs in addressing the data gaps to build more evidence around the causal links between health and the environment is needed to inform future policy nationally. More research dollars and faster research into what works at the local level to help us better understand the risks and health status of populations. This requires a sustained research effort and is part of a broader investment strategy and structured support towards disease prevention. Step 3 Planning for specific health effects Droughts have many consequences for health. Social impacts are quite obvious as drought contributes to debt burden and the psychological impacts run deep. Generally, we will see more air and water-borne diseases and infections, with effects on air quality including related respiratory illness. The worsening of chronic illnesses and mental health conditions through social impacts and compromised food and nutrition. The more immediate impacts of heat include increased risk of dehydration and heat stress. A community capacity-building program for drought response should be prioritised to both assess drought impacts and explore actions in response from a health perspective. We have a good understanding of what the health vulnerabilities are for our own communities in times of drought. Allocation of funds towards drought mitigation in relation to health is needed. Step 4 Establish intervention strategies Inadequate social impact indicators make this task harder but we need to think about building resilience to drought. In building resilience, implementing critical programs to protect the most vulnerable health populations in specific locations is important. Building the evidence base for population-level interventions will also help close the gap between research and practice. A national program to support communities to undertake drought-related public health vulnerability assessments is a good way to make this happen. GPs should have a leading role in supporting proactive mitigation and health planning measures in managing drought risk and health impacts for their communities. Healing in times of drought: GP-led strategies to reach out to drought-affected farmers
Dr Ayman Shenouda Those living in rural Australia don’t need to see a politician donning an Akubra to confirm just how bad this drought is. Rural communities know only too well what this almost constant climate of suffering looks like. How this hardship can impact on community morale and health and particularly for mental health. This is clearly seen at the practice level in our patients with notable increases in the rates of depression and anxiety and with more and more patients disclosing suicidal thoughts. The most devastating reality of drought is of course suicide which is in part a system failure and a shift in placing prevention at its heart will require a very different model to the one we have. Only this week a patient came to me and described just how close he had come to suicide: ‘I came very close this time. Opening my shed looking at the rifle - it was very tempting to finish it all.’ This was a farmer reaching out for support and with this key step, the healing journey can begin. The depression begins with a downturn in cash flow and in a multi-year drought, there is often no clear way forward for them. A key hurdle for us is in reaching out to those more adept at hiding the problem. Trust is a big part of it. In rural people, particularly men, this is sometimes very well hidden. They often try and hide the problem and all too often we find it is too late to help. We are missing a lot of patients – those who won’t come forward – and this is where our funding dollars are most needed right now. It is often the case that even when mental health services do exist within a community, farmers are unlikely to utilise these services. A solution is for the GP to get out to the community and this is precisely what we’ve been doing in Wagga and The Rock Communities It involves taking your practice to the patient and there’s currently no real funding tied to this. This effort relies on the goodwill of the GPs, nurses, other clinicians and allied health professionals. These are ground-up initiatives to help communities manage their health and mental health. And these are the strategies that we know work in rural communities. I’d like to share a couple of practical strategies we’ve undertaken to reach out to those harder to reach farming patients. The Pub Patient information nights The pub is a good place to start. We often do talks in the pub which will have a formal health topic for the evening inviting the community to join us in the discussion. We see two groups form here. The ones actively involved in the discussion and those sitting at the bar (but listening). It is the latter that is often the most critical to reach. But it can start the conversation and importantly their involvement in their own health and wellbeing as well as new strategies to cope. Field day pitstop The field day pitstop check-up clinic places us right in the thick of the action. This is where farmers gather to exchange ideas, trade their goods and importantly just get together. We usually set up a tent clinic with a couple of doctors and practice nurses providing health and lifestyle assessments. We cover emotional wellbeing and general health checks looking at BMI, blood pressure, respiratory testing, blood glucose and covering other risk factors including cholesterol screening. These tests are vital and will often get them into your clinic and under your care longer term. Sparking that vital conversation around mental health is a key objective here and we aim to provide links to rural helplines and connect through to outreach initiatives. Dr Ayman Shenouda Patient loyalty and trust It’s hard to pinpoint precisely what inspires long-term patient loyalty. Quality of care and trust must come into it. The ability to listen, having a caring presence and reliability would also factor highly. From my own experience, I think patient loyalty is mostly about trust. And it is timely and effective communication that builds that trust. Of course, for doctors, communication also involves giving the patient bad news. Listening actively and providing comfort being core communication skills. There are very few studies that have explored those factors seen to build and maintain a patient’s loyalty towards their GP or a practice. Some recent research in France provides some specific insights while a more recent study closer to home provides a new novel way to measure both GP and practice loyalty. The loyalty equation First, let’s look at a possible loyalty equation. A 2016 French study tested aspects of patient loyalty in the general practice context. This study found that loyalty was more complex than commonly assumed and is reliant on a few factors. It involves dimensions of trust, listening, quality of care, availability, and familiarity.[1] So, the loyalty equation from this study looks like this: Trust + Listening + Quality of Care + Availability + Familiarly = Patient Loyalty This is interesting enough but I think what makes this study really interesting is that the loyalty factor was seen as important enough to formalise it in policy. The efficiency factor to loyalty In France, the Caisse d’Assurance Maladie (public health insurance fund) recognises a coherence in maintaining the doctor-patient relationship in terms of efficiency and healthcare costs.[2] This has been formalised in law since 2004 and was part of broader reforms to health insurance which requires a ‘preferred doctor declaration’. The policy requires adult patients who want optimal coverage of their care by national health insurance to choose a preferred doctor - typically a general practitioner.[3] [4] What we see in France is the use of a single lever-regulation through what it calls its ‘gatekeeping’ reform. The carrot and stick approach of this effectively means that every adult must first choose a primary doctor, or médecin traitant, or risk higher healthcare fees and being reimbursed at a lower rate. The policy aim is to control both the demand and supply side of health care provision to improve care coordination and reduce utilisation of specialists’ services. The policy operates by encouraging patients to choose one GP and imposes financial sanctions if they don’t. This gives value to the relationship and makes the patient’s loyalty official.[5] One evaluation of this reform explored effect and found that specialist visits fell slightly while self-referred visits and the number of different GPs seen also declined.[6] In other words – policy success – but does a forced scheme generate patient loyalty? What can we learn from the French experiment? Forced schemes like this are never good policy. But while this scheme is perhaps set out to control access to specialists the positives will be seen over time through continuity of care. The French patient loyalty study actually found this to be true. That, by inciting patients to always consult the same doctor, the reform of the preferred doctor scheme reinforced that bond.[7] Patient loyalty in the Australian policy context has resulted through a stronger policy framework which enables choice. So, where are we at in terms of policy success against the loyalty factor? The Australian context The richness and potential of de-identified Medicare data were shown through a recent Australian study led by the Centre for Big Data Research in Health, UNSW, and published this month in the MJA. [8] This study is said to open up a new toolbox for exploring how patients use healthcare services. It’s the innovative approach using network analysis that makes this a standout. It uses network analysis of big data analysing millions of Medicare claims to gain insights into the organisation and characteristics of Australian general practice over a 20-year period. New ways to measure loyalty Providing a novel way to measure change in Australian general practice over two decades, the study shows that while there has been a move towards bigger GP practices, patient loyalty remains high. These results were found by looking at the claims to see when patients were visiting different doctors for their GP services. By applying a network analysis approach, it showed where doctors had many patients in common that they were likely to be sharing the care for these patients in the same practice. These were grouped as a provider-practice community or PPC which also provided new insights into patient loyalty. The results showed that patients’ loyalty to their usual GP and usual GP practice is high and has been stable over the last 20 years. Policy application The loyalty result is exciting combined with the innovative approach used in this study to find that the density of patient sharing within a PPC correlated with patient loyalty. The fact that patients see multiple GPs within a practice is also significant in terms of practice design and enabling more team-based GP care models. The further link made in this study in terms of supporting future program design in terms of where to target incentives for encouraging quality primary care is also good news for our practices. For good policy reach, program success relies in part on the patients’ choice of practice and this fact is now more keenly linked to that loyalty factor as a result of this study. Australian success story These results provide a really positive outlook on Australian general practice and our approach to healthcare policy in enabling equity in access. In contrast to the French policy experience whereby a forced scheme has formalised patient loyalty in a way, the Australian experience shows that patient loyalty and choice of practice comes through less forced means. It will be interesting to see what more can be explored through big data analytics and the network analysis approach used in this study to better understand our health system. References [1] Gérard L, François M, de Chefdebien M, Saint-Lary O, Jami A. The patient, the doctor, and the patient’s loyalty: A qualitative study in French general practice. Br J Gen Pract 10 October 2016; bjgpnov-2016-66-652-gerard-fl-p. DOI: https://doi.org/10.3399/bjgp16X687541 Available at http://bjgp.org/content/early/2016/10/10/bjgp16X687541#ref-9 [2] Ibid. [3] Law No. 2004-810 of 13 August 2004 concerning health insurance. Article 7. Published in JORF n°190 2004–08–17: 14598. [In French]. Legifrance Paris, 2015. [4] Le Fur P, Yilmaz E. (2008) Referral to specialist consultations in France in 2006 and changes since the 2004 Health Insurance reform. 2004 and 2006 Health, Health Care and Insurance surveys. Questions d’Économie de la Santé 134:http://www.irdes.fr/EspaceAnglais/Publications/IrdesPublications/QES134.pdf [5] Gerard 2016 Op. cit. [6] Dumontet M, Buchmueller T, Dourgnon P, Jusot F, Wittwer J. Original research article. Gatekeeping and the utilization of physician services in France: Evidence on the Médecin traitant reform. ScienceDirect Health Policy Volume121,Issue6,June2017,Pages675-682.Availableat: https://www.sciencedirect.com/science/article/pii/S016885101730115X [7] Gerard 2016 Op. cit. [8] Tran B, Straka P, O Falster M, Douglas KA, Britz T, Jorm LR. Research. Overcoming the data drought: exploring general practice in Australia by network analysis of big data. MJA 209 (2) j 16 July 2018. Pages 68-73. Available at: https://www.mja.com.au/journal/2018/209/2/overcoming-data-drought-exploring-general-practice-australia-network-analysis |
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