GPDU18 – Proving we’re better together!
Dr Ayman Shenouda GPs Down Under There was plenty of discussion about collaboration at the recent GPDU18 inaugural conference on the Gold Coast. This was collegiality at its best and perhaps not surprising given we know that flat hierarchies are where innovation and collaboration will thrive the most. GPDU offers healthy debate which is open and inclusive with all members encouraged to moderate. There is very little censorship here provided you remain on topic – GP learning, peer support, and advocacy. Enabling an inclusive dialogue is why this Facebook community of over 5000 members exists and thrives. It provides the opportunity for real-time online discussion in a forum for GPs - one that is free from corporate vetting offering a rare open communication channel. Better collaboration If there was one clear connect from this conference it was that we need better collaboration. Collaboration creates value in communities. It is about sharing vulnerabilities and being open and being brave enough to distribute your power to many. For GPDU18, day one great debate certainly focused on a rather divisive topic: ‘The Three, Two, One Debate (how many colleges is too many?) which saw an overwhelming yes (79%) for a single united college. Panelists’ Drs Cameron Loy, Fiona McKinnon, and Liza Lack in this session provided either the for or against – one, two or three (college) - noting they didn’t get to choose which side they were on. They each worked through issues including what a college should be doing for their members and more broadly about their values. There was also a discussion during conference on tribalism and the stages of tribal culture led by Dr Edwin Kruys. Based on the work by Logan, King, and Wright in their bestseller Tribal Leadership which takes you through the five kinds of tribes that humans naturally form and the benefit of establishing triadic relationships. It was a timely and interesting reflection allowing us to turn our attention towards building the culture we want. You could sum up both sessions in three words - we’re better together! Building the culture, we want In building the culture we want, it is important to understand why tribes exist. This is really important as an understanding of tribalism is a key strategy for improving collaboration. And, certainly on both topics – one college and that of tribalism - I really don’t think these issues are necessarily separate. Collaboration begins with organisational culture and we are all seeking a more collaborative approach and there were plenty of lessons to take home here. While I doubt the vision for a single college will ever be realised, I think what we certainly do need is more coalition building. This is what GPDU does really well and why it works. It forms coalitions with those holding similar values, interests, and goals to combine expertise and resources for a common purpose. Primary care and collaboration In a past blog about the possibilities of having a united front in primary care and the need to find some common ground, we established that for collaboration to work then this relies on respect and trust. A lack of trust only stifles collaboration. We need to create a shared vision of the future and move towards it together. Have an agreed common goal and sign up for it. In a more recent blog, we discussed ways to position ourselves as leaders of primary care into the future and the idea of a College for Primary Care. Getting back to our value proposition to achieve integration as well as satisfy funders positioning ourselves together in the health system will be important. This is key to ensuring we make the shifts towards a health care system based on wellness rather than the treatment of illness. Collaborative healthcare leadership We need a focus on positioning ourselves together to advance primary care reform and to help orchestrate a collaborative culture. Formalising this structure more would create a work culture that values collaboration. It would help us to put in place the adaptive collaborative learning systems required for the future. For me, GPDU18 just proved that we’re better together and certainly the key themes that emerged particularly around collaboration reinforced a need for a stronger focus around this. Building trust and blurring traditional boundaries will help end tribalism and silos – it would help bring the ‘we’ (as in the primary care team) instead of ‘me’ (the GP) back into focus. Our sector needs to find a place for more inclusive reform and opportunities for collaboration through communities like GPDU. Working together towards a common agenda is the only way we will see the sector-wide change required. Improving health value in the healthcare system starts with us and it’s time to reconnect.
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Untapping resilience
Dr Ayman Shenouda Overcoming adversity When each of us experience hardship, it changes us - yet not all of us experience lasting harm as a result. Stress affects people differently with many factors influencing the strength of our stress response. Resilience is our capacity to overcome adversity and our resilience is shaped by our experiences – both good and bad. And it’s really only when you’re faced with extreme stress that your level of resilience can be determined. ‘You only know what you are made of when you are broken.’ This was the moving statement from a father who lost his unborn baby during the recent Grenfell Tower inquiry. It is said that we can all overcome adversity and choose to be resilient. But how can we increase emotional resilience and cultivate more resilience for ourselves and for others? Neuroplasticity and resilience Can neuroplasticity help us to understand resilience? Mindfulness sites are full of the promise of rewiring your brain through neurally inspired therapies to increase emotional resilience. Brain researchers reassure us that the brain can change and that brain reorganisation is not limited by age. That it is the brain’s plasticity that can help us to overcome adversity. Neuroplasticity is the brain’s ability to grow and change in response to experience. It is supported by chemical, by structural and by functional changes across the whole brain and together they support learning. Personalised learning What is it that limits and facilitates neuroplasticity? Dr Lara Boyd Neuroscientist and Physical Therapist at the University of British Columbia explains this well in her work which looks at what can be done to help patients recover from stroke. In looking at how we learn she states that the best driver of neuroplastic change in your brain is your behaviour. But that it needs practice and you have to do the work with increased difficulty leading to more learning and greater structural change. Our uniqueness holds the key Dr Boyd’s research has looked to therapies that prime or prepare the brain to learn – brain stimulation, exercise, and robotics. But she also states that a major limitation is that patterns of neuroplasticity are highly variable from person to person. It is this variability in studying the brain after stroke that she believes provides some valuable transferable lessons. Learnt neuroplasticity after stroke applies to everyone. It is these individual patterns and variabilities in change that allow us to develop new and effective interventions. It is partly personalised medicine with each individual requiring their own intervention. However, this concept is then broadened through embracing our uniqueness with personalised learning being key. This research shows that biomarkers are helpful to match specific therapies with individual patients. More specifically it is a combination of biomarkers that best predicts neuroplastic change and patterns of recovery after stroke. Applying this learning Dr Boyd’s advice is to study how and what you learn best. Repeat those behaviours that are healthy for your brain and break those that are not. In applying this learning, it is clear that resilience can be taught. But it requires supportive relationships and opportunities for personalised learning. Bringing this back to our own workplace, how can we harness the brain’s innate capacity to change? Not only in our patients and ourselves but applying this knowledge in equipping our trainees with strategies to cope in dealing with stress. Resilience in the workplace I think it is important to look at how can we inspire resilience in others. Working through what strategies work for the individual is important but so is providing a workplace free from harm, neglect, and disrespect. More emphasis on building positive work environments, coping strategies and the importance of self-care is needed. Training in neuroplasticity and how to exploit it should be part of our armoury. For our trainees, we need to think more about building their stress fitness and coaching and mentoring are helpful in developing this resilience. Trainees would benefit from a buddy and a mentor to improve resilience and this needs to be formalised in our training system. Funding for formalised training programs to improve resilience in our trainees should also be prioritised. Webinars in workplace wellbeing, resilience, mindfulness, cognitive reappraisal training should all be pursued. Thinking differently Resilient people are able to see things from others perspectives. They also tend to value others. Simply conversing in a compassionate way changes the brain. Coming back to neuroplasticity, if we repeat certain throughs or behaviours often enough the neural pathway can be created. Forming new connections and weakening those patterns that are not working for you being key. In mastering resilience, we know that much of it has to come down to the individual and effort. Fixing a self-critical neural network is doable but takes practice and training to chart new pathways. In untapping resilience by harnessing the brain’s innate capacity to change we must prioritise the tools proven to bring about these shifts. This is particularly important in supporting our trainees so that together we can inspire and create a more resilient workforce. [ends] Federal Budget 2018
Dr Ayman Shenouda Budget expectations Expectations around this year’s Federal Budget were high. The Government certainly worked hard in its lead up trying to lower expectations promising an economically responsible and fair budget. We knew we would see an election budget here and with that, we expected a strong focus on some key areas important to the majority of Australians. Voters wanted to see a focus on cost of living pressures and improving the health system and these two items came out on top in earlier polling. A budget for a healthier Australia? So, what is the verdict - is this a budget for a healthier Australia? There were certainly strong gains in rural health, aged care, mental health and medical research. There are some really positive initiatives in this budget but at a time of record inequality, more wellness measures through formalising a preventative health strategy would have made this a great budget. This is required to help drive a strategy forward to really address some of those causes of ill health. Spending measures in countering the high numbers of our population who are overweight or obese, for example, are needed and it would have been good to see some strategy around this. We all know to get to the bottom of the causes of health disparities then the focus needs to be on those social determinants of health. The investment is beyond health and an overall policy approach to protect those factors which stretch a range of personal, social, economic and environmental factors. Primary prevention focus A strong and broad primary prevention focus is needed to counter those health risks factors and improve health outcomes for all Australians. This budget does pick up a number of these issues, including for women’s health and wellbeing and more broadly through its More Choices for a Longer Life Package. Mental Health funding of $338 million and priority on suicide prevention clearly goes a long way towards addressing the system gap around crisis support. The allocation for older Australians which includes $83 million for more services within the RACF, again addressing a significant gap, is a really positive step forward. While short on detail, the new primary care funding model for the Indigenous Australians’ Health Program is another key area which required focus. The increases for PBS and new funding for medical research, development of diagnostic tools and medical technologies, and clinical trials of new drugs all represent a significant health investment. The standout here in terms of addressing disparities and ensuring a primary prevention focus is the rural investment and the Government has certainly delivered here. Equity for rural Australians The key rural health workforce measures are provided through the $83.3 million new Stronger Rural Health Strategy which includes some solid measures to secure more GPs for rural Australia. This is a 10-year plan and a $550 million commitment which promises 3000 more doctors, 3000 nurses and hundreds of allied health professionals to our regions. The plan provides an unprecedented level of funding and commitment for rural Australia and its packed with measures that show the Government has listened on addressing rural health need. The workforce component will see integration through the entire training continuum as well as measures to support the existing rural workforce with an important focus on retention. Stronger targeting of rural bulk billing incentives and key focus on accessing rural services particularly for older Australians with $40 million towards rural aged care infrastructure another positive shift. For Aboriginal and Torres Strait Islander communities, there is a $105 million boost towards access to services which are culturally appropriate and closer to home. There is a new MBS item to deliver dialysis services to remote areas representing a $35 million investment. We have some great leadership here at the moment in our Rural Health Minister, Senator the Hon Bridget McKenzie and Commissioner Professor Paul Worley and it shows in the budget. Rural pathway package The rural workforce package is certainly comprehensive and a significant step forward in securing a stable rural workforce with a number of the key components to this strategy covered in earlier blogs. There is a priority placed on establishing a homegrown rural medical workforce with an important emphasis on skills. Many of the placement gaps that make it harder to remain in a rural area have been addressed. More intern placements in general practice and an additional 100 vocational training places are committed. The latter committed from 2021 as part of the National Rural Generalist Pathway. New training facilities to help rural students aspiring to become rural doctors study closer to home is also welcomed. The $95.4 million new Murray-Darling Medical Schools Network will help universities work together to support medical teaching in our regions. It’s also great to see that the new Workforce Incentive Program will extend to supporting general practices to employ more allied health workers. Strong IMG focus It’s great to see strong action to ensure we retain the rural workforce in this package of measures which extends to providing incentives for IMGs to progress towards Fellowship. Those working in rural areas know the huge contribution IMGs make and it is great to see the shift here towards IMG retention. These doctors play a vital role in rural and remote communities and they deserve some support. The rural strategy outlined in this budget invests in the next generation through domestic recruitment to rural areas but shows a commitment to the existing workforce through investment in skills and retention with an important focus on IMG retention. Aged Care In Aged Care, reduced waiting lists and incentives to stay in the home longer sees another important policy shift. Measures which keep older patients in their homes longer is welcomed policy with this initiative providing $1.6 billion for 14,000 new places for home-care recipients. This is a good start but not nearly enough with more than 100,000 people on the waiting list. However, the policy is certainly headed in the right direction towards an integrated care at home program. Some of these measures will restore some of the cuts to the aged care sector of recent years. But it is unclear if they will provide for the targeted supports needed to deliver the complex care required which needs more focus on enabling more GP-led care. A healthier future There are some major challenges in funding and delivery of healthcare in securing a healthier future and for this budget, we’re seeing shifts in the right direction. Health is so integral to our nation’s prosperity and the Government through its investment particularly in rural Australia shows that it understands the value of general practice and primary care. This budget will certainly improve the lives of the seven million people living in rural and remote Australia. The rural health measures will help to address disparities and important gains will be realised through this investment and this is a clear win for the sector. The mental health and aged care gains are also significant and it is great to see those more vulnerable Australians being prioritised. [ends] Dr Ayman Shenouda Proving our value Recent coverage around the failed Health Care Homes roll-out saw some unsettling truths coming through in the comments by the reform architect Dr Steve Hambleton. This is in the context of the continuing trend for value-based care models, Dr Hambleton’s comments highlight a need in general practice to strengthen our data capture capability to prove our value. What was said really cuts to the truth in terms of where our focus needs to be and how we ought to align or perhaps realign ourselves to better capture outcomes measurement. For those who missed it, here’s the quote: “What I will say to GPs is that unless we have the [patient outcome] data to take to the government that proves the value of the healthcare we are providing, they are going to keep investing in the bits of the health system where they do have the data, which is hospitals.” Dr Steve Hambleton[1] The case for Primary Care In delivering more effective, equitable, and efficient health services, it is clear that strong investment in primary care would see fewer disparities across populations. The value and need of strong primary health care systems are already well established. There is robust evidence to show that good primary care is associated with better health outcomes. [2] Primary care improves quality and reduces costs. But primary care integration and care management are made harder by a system that has at its core a prime focus on episodic acute care. System barriers The shift to value-based care is inevitable. However, creating savings in the healthcare system is as much about structures as it is about payment reform or data capture in driving that reform. In measuring value, the current system and structure makes this very challenging. In many ways, the Health Care Homes model provided that answer in terms of how to provide and organise care in the future while enabling measurement and the policy is still worth pursuing. The key requirement in embedding value-based care as a business model into general practice will require a shift in terms of enabling more team-based care to occur in order to remain viable. Value in healthcare Value in healthcare is measured around patient populations requiring different bundles care, these are defined patient groups with similar needs determined by combined efforts over the full cycle of care. [3] This confirms the focus needs to be on primary care or new models of primary care but we need a stronger team-based focus and more support structures to make this work. We need to leverage as much as we can from the current payment system to provide integration across settings. Much of this already falls to the general practice but enabling integration is hard and often non-remunerable work. Our value proposition The lack of networked or organisational architecture to support the level of data capture required to measure the quality of care and outcomes achieved through preventive primary care lets us down. If we are going to achieve the level of integration required, satisfy funders with data capture demonstrating value then I think part of the solution also lies in how we position ourselves in the health system. We already have the right strategy to fix healthcare and that solution lies in more investment in primary and preventive care through a Health Care Homes model. In establishing our value proposition, if we must face off as Dr Hambleton suggests against advanced data-capture systems like those used in hospitals to capture detail right down to the bandages, then clearly, we need to get organised. Transitioning challenges Capturing quality measures and measuring performance on a continuous basis will be complex and creating reliable structures will be key to our success. Part of that challenge is around data capture and standardising that process and in particular who’s holding the data. The strength of our primary care system is associated with improved population health outcomes and we know that enabling service integration is key in terms of realising these aims. The other challenge will be our capacity to leverage technology, integrate more and build up those required team structures. It’s clear there is still much to work through here. But what often gets missed is the need to enhance professional experience and I think it is here where we have some real opportunities. Time for a rethink? Right now, we should be thinking about what we can do to be more proactive in terms of redesigning what we can for ourselves. We’ve been a College of GPs for some time now and certainly, that structure has been integral to the world-class health system we have today through supporting Australian GPs to provide the best possible care. We need to ensure we have in place the adaptive collaborative learning systems required for the future. Is it now time to think about primary care as the future and not only GPs as the centre of that model? College for Primary Care The new models of primary care required in response to the healthcare system shifts towards value-based care will rely more and more on team-based care. In demonstrating value, we need to think about those finite costs capturing those bandages too but this also needs to be about developing the primary care team. There is a real opportunity to support all the individuals working in general practice and train the whole team to enable more integration. Collaborative healthcare leadership will be needed in shaping the future workforce to support new models of care. The existing College structure can help provide this leadership model to bring about the transformative change required. Taking a more proactive approach to designing the health system means less focus on payment reform and more interest in investing in the primary care team. [ends] [1] News Article. Health Care Homes roll out 'went wrong somewhere' says reform architect March 27, 2018. Australian Doctor. Available at: https://www.australiandoctor.com.au/news/health-care-homes-roll-out-went-wrong-somewhere-says-reform-architect [2] Starfield B. The future of primary care: refocusing the system. N Engl J Med 2008;359:2087-91. [3] Porter ME. Perspective. What Is Value in Health Care? December 23, 2010. N Engl J Med 2010; 363:2477-2481 DOI: 10.1056/NEJMp1011024 Available at: http://www.nejm.org/doi/full/10.1056/NEJMp1011024 to edit. Let’s fix the health deficit through a more equitable distribution Dr Ayman Shenouda Highlighting inequity The alarming population growth in our major cities is not surprising and highlights a lack of a national population planning approach for sustainable development. This issue has been in the news recently and these conversations for me always highlight inequity and missed opportunities. There is usually fallout in distributional terms for rural Australia which continue to be left behind. This is despite the fact that rural areas don’t even get a mention in the discussion. The lack of rural focus is the underlying problem here with no attention to the broader spatial dimensions which result in increasing inequities. This is a much bigger issue than the inconvenience of the long city commute to work. It’s about the fair distribution of impacts to bring about more equitable outcomes. Persistent disparities In prioritising health, we know a community’s economic health is closely tied to health outcomes. There are persistent inequities in Australia and particularly in our remote Aboriginal communities. Returning from the Solomon Island’s recently and talking to a colleague about the plight of the people in the Pacific, I was reminded that some remote communities in Australia are worse than Third World. To get to the bottom of the causes of health disparities you need to look to the social determinants of health. Invest in policies which protect those factors which stretch a range of personal, social, economic and environmental factors and you will get results. Rural health disparities The converse is, of course, true and this is why we have such marked health disparities in rural areas. There is an estimated health deficit of $2.1 billion in rural and remote Australia.[1] The impact in health terms is that rural Australians are living shorter lives and they have poorer health outcomes and higher rates of disease. The more remote you go, the worse it is. It is the compounding effect that impacts here - where we see high levels of socio-economic vulnerability combined with lack of access to services. In addressing these issues, health workforce distribution is of course key to enabling access but so is getting to the bottom of what’s driving the disadvantage. Causal factors We need to focus on the value of working across sectors to address those causal factors. It is those causal or upstream factors – social disadvantage, risk exposure and social inequities – that present the real opportunities for improving health and reducing health disparities.[2] These powerful determinants of health inequality are why we need to put the spatial dimension back into population planning. More collaborative planning is needed to address the unique needs of these communities. Rural health investments Part of the planning discussion needs to focus on the role that rural health investments have creating healthy and sustainable communities. There is a failure to recognise the comprehensive impact of health care funding as a driver for local economic development. [3] I know from my own experience that just bringing a health service to an area will help to sustain it. When I established my practice at The Rock the medical facility was being run out of a rented room in the CWA building. We worked hard to not only establish our practice but build the required broader health service around us. Through our sustained efforts the pharmacy soon followed, then a pathology service and now finally an aged care facility. The economics of poor health We know all too well the economic effects of poor health. An investment in rural health boosts these local economies. A fairer health budget spend would realise strong returns and a healthier future for 30 percent of our population. But, it is not just a rural issue as there are pockets of disadvantage elsewhere including in our cities and on the fringes and of course in regional centres as well. Whether in urban or rural areas, pockets of entrenched disadvantage will remain unless we start to align health and causal factors in national planning. Fixing the health deficit We need to fix the health deficit through a more equitable distribution. In planning for a healthier Australia, a much broader focus is required which targets and acts on those upstream determinants. It’s not just medical care alone that influences health with social factors known powerful determinants of health.[4] This is the formula for a healthy Australia. [ends] [1] NRHA Fact Sheet. The extent of the rural health deficit. National Rural Health Alliance. 2016. http://ruralhealth.org.au/sites/default/files/publications/fact-sheet-27-election2016-13-may-2016.pdf [2] Bharmal N, Pitkin Derose K, Felician M, Weden MM. Working Paper. Understanding the Upstream Social Determinants of Health. RAND Health. May 2015. https://www.rand.org/content/dam/rand/pubs/working_papers/WR1000/WR1096/RAND_WR1096.pdf [3] Russell L. The economics of delivering primary health care in rural and underserved areas—what works? Menzies Centre for Health Policy. University of Sydney. 14th National Rural Health Conference. http://www.ruralhealth.org.au/14nrhc/sites/default/files/Russell%2C%20Kesley%2C%20KN.pdf [4] Braveman P, Gottlieb L. The Social Determinants of Health: It’s Time to Consider the Causes of the Causes. Public Health Reports. 2014;129(Suppl 2):19-31. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3863696/ |
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