Speech to the Australian Nursing Homes and Extended Care Association (ANHECA) Panel on Workforce Solutions - Adelaide Tuesday 26 October 2004 - AMA Vice President, Dr Mukesh Haikerwal
**Check Against Delivery
SOLVING THE GP CRISIS
Thank you for the invitation to be with you today.
In focusing on the human dimensions of our ageing society, one of our biggest challenges is to try to ensure that we have care and funding arrangements that will continue to work into the future.
Aged care is fundamentally a health care issue.
And a key component of that health care issue is older people having access to doctors when they need them.
It is hard to believe now, but just a few years ago there was no official recognition of the fact that Australia had a GP workforce shortage.
Here we are today talking about the GP crisis and we all accept and acknowledge that this crisis exists.
You cannot mention the term GP now in any general practice or government arena without everyone present murmuring sympathetically about the terrible shortage plaguing this nation.
Yet in 2001, the AMA had to commission Access Economics to survey the GP workforce and prove that this shortage really existed.
This work was a major turning point and has allowed us to provide clear evidence to back up what the AMA has been hearing for a long time - there are not enough GPs in Australia to care for our communities.
Having solid data has allowed us to heavily lobby Government and in a few short years, GP workforce issues have come to dominate the medico-political landscape.
We have just seen an election fought where one of the main battlegrounds was primary health, in particular how to ensure patients have access to a GP when they need one.
As a result of that, key issues affecting the availability and quality of health and aged care are now starting to be addressed seriously.
Much more needs to be done if we are to seriously address the issues that need to be addressed if our ageing society is to meet our needs for health and aged care services.
All health professionals who care for older Australians - GPs, geriatricians, nurses, other health professionals and carers committed to best health outcomes for seniors - face serious barriers and disincentives in providing health care to older people.
This is not just remuneration, though it certainly includes that.
Most often, residential facilities don't have adequate facilities for examination and treatment. They pretty much all have hairdressing salons, though. It's a matter of priorities.
Plug-in computer access to patient records would facilitate access to patient records for all visiting health professionals, would save duplication of records, and improve overall care.
More of that later!
On the remuneration side, doctors face inequitable fee structures that make working in aged care unattractive. GP participation in residential aged care facilities (RACF) has declined. Only 16% of GPs visit nursing homes on more than 50 occasions per year.
Nurses and other staff are also undervalued and are paid less than their colleagues who work in hospitals.
While the current political debate focuses on access to essential medical care, it's important to remember the very specific needs of our valuable older citizens who are among the community's sickest and frailest.
Red tape - especially the mountains of paperwork, I am sure you will agree, robs health professionals of time with their patients. Being slaves to the paper trail and treating the surveyors, not the patients, cannot be totally beneficial to the system. The many care needs of older people are complicated. It takes time, vigilance and patient contact to maintain a holistic approach to their wellbeing.
Social isolation is a reality for many older people.
There is no place for policies and practices that discriminate in terms of access to quality health care service at any age.
Politicians are being inundated with letters, phone calls and visits from their constituents who are suffering because they cannot find a GP.
The situation today is that Australia has a shortage of around 3,000 full time equivalent GPs.
The shortage is exacerbated by a falling participation rate in the workforce.
Many GPs are either choosing to work fewer hours, planning early retirement or finding alternative work.
The participation rate of General Practitioners in general practice is now about 64% and falling.
AMA figures indicate a current average working week of GPs of 50 hours but a preference to reduce working hours to an average of 36.
This is the type of working week we expect GPs to embrace in the future, as average working hours are falling.
A drop in average GP time of 2 hours per week is equivalent to the loss of about 1,000 GPs from the workforce.
There is now ample evidence that those regions with inadequate access to medical services experience poorer health.
These areas are characterised by long waiting times to see GPs and overworked doctors.
So what can we do about it?
The AMA has proposed the QAAC theory.
QAAC stands for quality, affordability, access and choice. These are what we must strive to deliver to all patients.
To achieve QAAC though requires a long-term approach to health care.
We want to get QAAC and ensure it exists for future generations.
Unfortunately political parties tend to offer simplistic solutions that only last for an electoral cycle.
We have in Australia the opportunity to provide affordable, universal health services to our population.
We can, with the mix of private health care, properly financed public hospitals, improved community care provision and appropriate public health measures, make our system once again the envy of the world.
Access to, and affordability of, quality medical services for all Australians must be the principal goal of our health system.
The goal can only be achieved with the restructure of the Medicare system.
The AMA, and in fact all major GP groups, have called for the introduction of a fully funded and appropriately indexed attendance item structure that is geared for the 21st Century. This scheme provides for an adequate patient rebate for a now ubiquitous 15 minute consult. The BEACH study of the AIHW confirms the trend to the longer - 15 minutes on average- consultation. The benefits that flow fro this 7-tier general practice consultation are self-evident and intuitive. Indeed we have seen the number of General Practice services provided per anum actually drop. The revised schedule aims to provide a remuneration structure that values GP services, but at the same time enables the ongoing provision of high quality primary health care.
This will be particularly important as our population continues to age and remain in the community with increased disability and chronic and complex care needs.
This restructure would have an immediate impact on Australia's workforce shortage, improve care for the chronically ill and help make primary care more affordable for all Australians and particularly disadvantaged groups.
In terms of workforce the impact would be two-fold.
First of all it would allow GPs to provide the quality of care and length of consultation that they provides the best health outcomes for their patients.
This will significantly improve GP morale and in turn help retain GPs in the profession, encourage GPs to increase their hours and attract new GPs. Retention is key: this will improve the chances of this
The second is that this system would value the service provided by GPs. Access Economics' survey showed that addressing remuneration issues will have a significant impact on the GP workforce.
The restructure needs to be accompanied by a change to indexation of Medicare so that Medicare keeps pace with rising medical costs.
For example, between 1994-95 and 2001-02 general practice expenses rose by 6.3% a year.
During the same period Medicare patient rebates rose by less than 3% a year.
If this trend is allowed to continue you can clearly see that what a GP has to charge to stay in business will outstrip the patient rebate to the point where the rebate becomes even less relevant than it is today. Without indexation, we will end up right back where we started.
The Coalition's election commitment to increase the patient rebate to the MBS, while welcome recognition of the shortcomings of Medicare. It follows the trend of of increased funding to the patient rebate pool that occurs in the run up to an election. I repeat: the Patient rebate pool is enhanced,so that medical services are more affordable as gaps will fall to reflect rebates approaching the true cost of providing medical services. The increase of rebate from 85% of MBS (a 50% discount on the true cost of providing services) to 100% of CMBS is a significant increase as these incremental rises go, but if accepted as full payment, this still represents a 40% discount on the true cost of the service. Therefore, it is not the long-term answer we need or require.
This may address affordability for a while - although it is not indexed so could be quickly eroded - but it does not support quality care.
The AMA plans to continue to lobby for the introduction of the re-jigged 7-tier which the Attendance Item Review Working Group also is reviewing the schedule in relation to care in aged care homes.
This is the major change that would address the GP crisis, but there are so many other things that need to be done.
For example, there are GPs out there who cannot take a day off because there would be no doctor at their practice, or they are on call 24 hours a day because they are the only medical service in their town.
So we need to get more GPs practicing and practicing in areas of shortage. They need to have access to locum relief for R&R and CME /CPD.
The AMA has numerous suggestions as to how this could occur and I can't mention them all here, but what all of them have in common is that they are based on incentives.
The AMA supports the "carrot" not the "stick" method.
1) Implementation of a sabbatical system for rural and remote GPs whereby every few years they are granted fully paid study leave to allow them to pursue study and training to upgrade skills. Currently, rural doctors are disadvantaged because of isolation and inability to easily access latest developments in medicine; and
2) Establishment of a national program to encourage GPs to work in rural/remote areas for a portion of their career. This could be achieved through providing financial assistance to relocate after 5, 10 and 15 year periods of rural/remote service. Such grants would be matched by similar bonuses for those choosing to remain.
There is also a need to ensure we have training facilities and infrastructure in these areas.
Training numbers must be increased to take into account the growing trend within general practice for a better balance between work and home life. Training numbers will only be filled however once the career path regains its former attraction: its heading that way.
Flexible training opportunities and exposure to quality general practice and GP mentors early in a career are important.
The AMA is strongly opposed to the unfunded bonding of medical students. This scheme dreamt up as part of the Mark 1 Medicare revamp in late 2002 is a shocking insight into thinking and planning. In order to gain a medical school place 20% of students have to bond themselves to an area of need for 5 years after qualifying as a specialist.
International evidence has shown that bonding is not the most effective way of increasing GP numbers or encouraging doctors to practice in areas of need.
We have a recruitment program for Overseas Trained Doctors too. This should not be seen as a significant / major method of addressing our workforce shortage.
It is the retention of Doctors within the system that is key to maintaining doctors in the system: make them want to stay and work.
Every practice in Australia should have access to the general practice nurse scheme.
An AMA survey found 13 per cent of GPs spend 11 hours or more completing paperwork, 20 per cent spend 10 hours, and 52 per cent spend between five and 10 hours.
Red Tape has a significant impact on reducing clinical time with patients.
It also impacts on poor morale through the unnecessary additional hours of unpaid time it consumes. GPs would prefer to spend time with patients.
So reducing red tape would help.
The AMA advocates phasing out of blended payment schemes, particularly disease specific items: these apply to Diabetes, asthma, mental illness, cervical smears not performed for 4 years. Other chronic and complex conditions don't have any incentives attached including Rheumatoid and other arthritis, renal disease and the scores of other significant and severe conditions.
While there is merit in highlighting certain diseases and illnesses, these programs fail the equity and fairness test.
Worse, they imply that GPs are not capable of caring for certain conditions unless there is a financial inducement to do so. Further it fragments care from the holistic model to the dissipated, segmented model.
There would be a double benefit in scrapping these programs with a significant reduction in the bureaucratic red tape that reduces the amount of time that doctors can spend with patients and directing savings to rebates and reducing out of pocket fees.
There must also be ease of access for people needing care between the sectors, including accident and emergency, other acute care in hospitals, sub-acute care, residential aged care, and community care.
We must work to overcome both access blocks and exit blocks for older people in moving between these different sectors.
There must be links between the sectors that cut across Commonwealth/State funding divides.
There must be access to specific services when and where needed by older people.
Above all, there must be access to appropriate care.
We know that at present, older people must often stay in hospital for far longer than they need to.
Why? Because appropriate care is not available for them, either in aged care homes, or in their own homes where appropriate community care support is lacking.
In a derogatory and demeaning way, hospitals, both public and private, often speak of older patients as "bed blockers".
This results when they remain in hospital when no bed is available at a residential aged care facility, or when they are well enough to be discharged, but not well enough to look after themselves within their own homes.
The demand for beds in aged care facilities is rapidly growing as the population in the over 65 age group is escalating.
In 1998, the number of people aged over 65 years was 2.3 million. This figure is projected to increase to 4 million in 2021 and to 5.7 million in 2041.
Aged care must be regarded as a continuum of care.
The tangled web of services that plague the delivery of aged care services in Australia must be untangled if Australia is to meet the care needs of older Australians into the future.
Integration of services and good communication are essential in aged care.
One episode of care might involve several distinct services. It's essential that overall care is coordinated.
Political, professional and institutional differences must be overcome if we are to provide seamless, flexible care for our older citizens.
The different government agencies responsible for 'their' silo of health care, whether it be, for example, acute health care, non-acute or sub-acute medical care, residential aged care, community-based care, or the Pharmaceutical Benefits Scheme, are too-often concerned only with 'their' bottom line, and not with how 'their' program impacts with the 'other' silos in influencing overall health outcomes for all Australians.
Australia needs to break down the silos on several levels, including political, professional, and institutional.
Together we, as decision and policy makers, have an opportunity to develop a model for seamless flexible care, if we think outside the current boundaries and work together.
There is a chronic underfunding of the whole aged care sector which affects the availability of beds, community care, respite care, and the provision of health and health-related services to older people.
Links with acute care are also a problem.
For example, thousands of Australians are trapped in the wrong environment for the type of care they need.
There are many people in hospital who no longer need acute care, but are unable to care for themselves at home and cannot access appropriate residential or community care.
Similarly there are people in nursing homes who should be in hospital, and people in the community who ought to be in either hospital to treat particular conditions, or in aged care homes.
This is a discussion for now. There are models that were introduced in the dying days of the election campaign. The review of the Australian Health Care agreements and the workings between different tiers of government and within governments now is something we can already do.
The numbers of Older Australians will increase: this is a testament to the great care and environment in which they livea success. This will bring with it the challenges of further fine tuning our care provision.
This is a discussion to be had with time, due consideration and enormous good will, intent and obviously, action.
Better psychogeriatric care
Dementia is becoming one of Australia's greatest public health challenges.
The Alzheimer's Australia 2003 paper The Dementia Epidemic (prepared by Access Economics) projected that well over half a millions Australians will have dementia by mid-century, 2.3 % of the population.
This compares to the 2002 figures of 162,000 Australians, or 0.8% of the population, with diagnosed dementia.
It is now the second greatest cause of disability and this disability burden is higher than that of every other national health priority area.
Dementia is the third and fifth greatest contributor to Australia's total disease burden experienced by older women and men respectively.
This paper ‑ supported by leading academics in epidemiology and dementia care ‑ called for dementia to be a national health priority area.
The care of people with dementia should be part of the expected skills set in all aged care facilities and services.
Challenging behaviour as a result of dementia, psychiatric illness, developmental disability, or other causes such as head injury, require specialised staff and facilities to complement geriatric services.
There is no current national strategy for early identification of dementia ‑ important not only for treatment, but for counselling and support.
Early identification helps people with dementia who are aware of subtle cognitive changes by reducing their anxiety and stress.
It also gives them a clear opportunity for control over key decisions prior to the onset of more significant cognitive decline.
The AMA welcomes wholeheartedly the Government's election commitment to recognise dementia as a National Health Priority area, and to allocate susbstantial funds to address the dementia epidemic.
The launch last week of Carers' week highlighted the central needs of carersin this continuum of care, the need for respite and support and care for carers' own health.
Enhance and integrate training opportunities for aged care workers.
There is a need to foster and enhance education and training for all in the aged care workforce in residential aged care facilities, including the fostering of undergraduate and postgraduate education in geriatric health.
This would ideally involve better integration of training and education between educational institutions such as universities, and aged care facilities. The teaching nursing home concept is often floated. With a move to Private medical schools and the use of under-graduate and post-graduate teaching into the private sector, this scheme has legs!
It can be central in providing education and development opportunities for doctors as well as nurses and other aged care staff.
The National Aged Care Summit hosted in Melbourne on 11-12 February 2004 by the AMA in partnership with fellow members of the National Aged Care Alliance agreed that aged care is fundamentally a health care issue.
We stress the importance of improved integration between the health and aged care sector involving a cooperative, multidisciplinary approach involving GPs, geriatricians, other medical specialists, nurses, allied health professionals, and carers.
What are the key issues for governments?
Demand for aged care services is rapidly growing as the population ages. In 1998, the number of Australians aged over 65 years was 2.3 million.
This figure is projected to increase to 4 million in 2021 and to 5.7 million in 2041.
Those people aged eighty-five and over are projected to rise from about 1.3 per cent of the population to 2.1 per cent of the population by 2021.
The challenge for Government is to adopt public policies that will enable society to adapt to changing socio-demographic circumstances.
What are my key messages for this audience?
I have outlined the environment which we as GPs are working in. The challenge is to engage those GPs working in Aged care to remain. Later, we may encourage more...but how?
Observations:
Only 16 % of GPs attend ACH 50 times or more a year!
There are more older people in the community
There are more people with chronic and complex care provided in the community
There are more admissions to hospital and early discharges seen:
There are more chronic and complex care needs in ACH: a reflection of the older and sicker residents being admitted.
There are more people with dementia.
There are fewer GPs in the system and in Aged Care in particular.
A significant feature of this is less participation by GPs.
The challenge is how to engage them and bring them back into residential care.
Staff in Aged care homes are stretched, both in numbers and drowning in paperwork.
During the election campaign we launched our Aged care considerations at a facility in outer West Melbourne. The examination facilities seen there were an excellent model. These were incorporated into the design of the facility.
Computer plug in access is important to access patient information and to enhance management and prescription management. It can be the difference between hauling around a notebook PC or a tiny memory stick.
I would remind the audience that providing care in ACH is not a good business decision.
In that context, I would urge you to consider the Dr who decides to allocate time: make it worth it by reducing their barriers.
Make their processes clear and straight forward.
Challenges: there are many, but here are a few.
- Paper mountains need to be addressed.
- Keeping the few Doctors, nurses and other health provision in ACH in!
- Bringing newer Doctors into Aged care
- Engaging with the geriatricians and seeking their guidance is vital.
Solutions:
- Understand the dilemma
- Start the dialogue: we did at the beginning of the process around the introduction of the 'Aged care Panels' proposal in the Medicare Plus package.
- Good communication is central: who needs to be seen when you call the Dr in? Where are they? What changes are of concern? What needs to be done? Follow the changes through. Follow the patients up!
- Address the genuine concerns of those a Drs that visit your ACH. Don't push out the Drs who are visiting. There aren't many others who will follow.
I thank you for listening and to ANHECA for the opportunity to speak on this very important subject.
Thank you.
Professor Len Gray. Two Year Review of Aged Care Reforms, Canberra 2001 p1.