Wednesday, October 31, 2012

Ministerial Speech To RACGP Last Week. It Will Be Interesting To See What Comes Of All This.

Here is the text of the speech. I have marked the e-Health Component in italics.
Speech - Royal Australian College of General Practitioners Conference GP12: Leading Primary Care - Gold Coast Convention and Exhibition Centre - Broadbeach, Queensland, 25 October 2012
Federal Health Minister - Tanya Plibersek.
Thank you for inviting me to be with you here today.
I’d like to begin by acknowledging the traditional custodians of the land on which we meet, the Kombumerri People, and pay my respects to their Elders past and present.
I would also like to recognise:
    • Dr Elizabeth Marles, the RACGP’s brand new President;
    • Professor Claire Jackson, immediate past President of the RACGP;
    • Dr Zena Burgess, the CEO of the RACGP; and
    • today’s keynote speaker, Professor Clare Gerada, Chair of the Royal College of General Practitioners in the United Kingdom.


I’m delighted to be able to acknowledge international delegates from an impressive 16 countries. Welcome to Australia and the beautiful Gold Coast.
Your presence underscores the importance of the Royal College and the high esteem in which this conference is held.
Primary care and GPs: the heart of our health system
For most Australians, visiting a GP is their first, and often their main contact with our health system.
And you’re a popular bunch – with GPs always amongst the handful of professions at the top of our ‘most trusted professions’ lists.
But I know that trust is hard-earned.
Earned through the caring relationships you develop with your patients, and in your practices, each and every day.
And it’s those relationships that mean GPs are the ones best placed to make decisions with their patients, based on their unique circumstances and needs.
Today I’d like to talk about what I think are three key roles for government in the primary healthcare system.
Firstly, about how we can support local decision making, especially by GPs.
Secondly, about collecting, analysing and reporting honest, transparent information about our performance in primary healthcare.
And thirdly, about using that information to help guide investment and drive continuous improvement across the system.
Supporting local decision making in primary care
The international evidence tells us, loud and clear, that health systems with strong primary healthcare are more efficient, have lower rates of hospitalisation, fewer health inequalities and better health outcomes.
The World Health Report in 2008 found that where countries at the same level of economic development are compared, those that were organised around the tenets of primary healthcare produced better health outcomes for the same investment.
We have also seen how care coordination in the primary healthcare sector has been demonstrated to have a significant impact on reducing avoidable hospitalisations.
A randomised control trial conducted by GP Partners in north Brisbane provided clear evidence that a model including dedicated care coordinators, and GP-led care planning leads to lower service utilisation and better health outcomes for patients. The randomised control trial was carried out over three years and involved more than 3000 participants, 179 GPs from 108 practices, as well as 16 care coordinators. The evaluation showed that after 12 months the intervention participants had better general health, and enjoyed a higher quality of life compared to the control group. And after 18 months of care coordination, the intervention participants accounted for an incredible 25% less hospital admissions than the control group.
And another nationally representative study from the United States showed that patients who had a family GP, rather than a paediatrician or sub-specialist, as their regular doctor had:
    • a lower annual cost of care;
    • made fewer visits;
    • had 25% fewer prescriptions;
    • and reported less difficulty in accessing care…
...even after controlling for case-mix, and demographic characteristics.
As a Government we are taking this evidence seriously.
We are shifting the centre of gravity in the Australian system away from acute care in hospitals to primary care.
And as you’d all be aware that’s what we’ve be doing through the establishment of Medicare Locals...
...and more flexible funding and decision-making arrangements to allow GPs and their colleagues to better respond to local needs.
But now Medicare Locals have been established, what we are looking at is what other responsibilities we might sensibly think about devolving to a community level, including to GPs.
At the end of the day, our goal is to have more decisions made locally by GPs, rather than by bureaucrats in Canberra.
The potential of patient-centred medical homes, and better integrated team-care arrangements are some of things already on my list for further exploration.
But I’ll be talking to the RACGP about their vision for how that could look. And I’m very excited by potential of things like eHealth to help realise that vision.
I’ve been working closely with the RACGP on eHealth and I am confident it will help empower you, as GPs, to make even better decisions for your patients…
...decisions based on more comprehensive, more integrated information than ever before.
The statistics tell me that in any week, one in three Australian GPs see a patient for whom they have no current information. And more than one in five GPs face this situation every day.
That really serves to reinforce how central GPs will be to the system – which is why today I am pleased to announce the Government will invest around $2.55 million for the RACGP to lead some new work to assist general practice engage with the Personally Controlled Electronic Health Record.
The College will develop an eHealth syllabus and education modules for use by the Australian General Practice Training Program. And that will be done in collaboration with the Australian College of Rural and Remote Medicine – with the final program earning Continuing Professional Development points for GPs with either College.
This will help ensure GPs can access professional training in eHealth so care can be confidently delivered in a shared electronic environment.
As well, the College will manage a program of GP to GP support – again in collaboration with the College of Rural and Remote Medicine.
The program will employ around 30 GPs with expertise in the PCEHR to speak to their colleagues in around 200 locations across Australia.
The program will engage GPs on the clinical utility of the PCEHR and help prepare general practice for e-readiness and PCEHR compliance. Of course, this will complement the practical support offered to GPs by practice liaison officers under the Medicare Locals eHealth readiness program.
As the PCEHR rolls out, we will be keeping a close eye on the impact it has on the primary healthcare system, as well as the system as a whole.
But to help us better understand impacts like these we need honest and transparent information about our performance.
Honest and transparent information about our performance in primary healthcare
I’m sure everyone here is well acquainted with the health performance information agenda being progressed through the council of health ministers.
And you’d know we have established the National Health Performance Authority to help manage that work.
But today I wanted to touch on some of the things the Authority will be looking at across the primary care system.
Initially the focus will be on information about local health systems – so we can better understand the relationship between hospitals and primary care systems in local communities.
People often tell me they feel a little 'in the dark' about primary care, particularly in terms of understanding its success in keeping patients out of the acute system.
So what the Performance Authority will do is pull together comparable data to paint us a more accurate picture of how we’re doing – to help us explain variation in health outcomes across different communities by exploring the link between primary care and things like avoidable admissions, and length of stays in hospitals.
This is the kind of information that should be valuable for discussions between GPs, Medicare Locals and hospitals.
It will inform your work to ensure that patients get the right care in the right location.
In terms of nationally consistent information on local communities, the Authority will present information in such a way that communities can meaningfully compare experiences with healthcare. The Authority is already working with the Australian Bureau of Statistics to create ‘comparable communities’ so that Medicare Local regions can compare their results with other regions in Australia that face similar social, economic and geographic issues.
And most importantly for everyone here today, the Authority’s first report will include information on use and experiences with primary healthcare – and GPs in particular.
Using information to drive continuous improvement across the primary healthcare system
But all the information in the world is for nought if as a government you don’t look at it, analyse it, and act on it.
The examples I touched on earlier really highlight the power information has to describe how the primary care system is doing, and to identify the things that really work.
For Government, it helps to guide our investment towards what the evidence shows to work, and away from the things that don’t.
It will mean we can make even better use of every precious health dollar.
For instance, research has suggested that in Australian general practice only about half of patients with chronic diseases such as asthma, type 2 diabetes and hypertension received recommended care. And as well as that, there was variation across the country. In NSW for example, the rate of hospitalisation for medical conditions such as asthma and diabetes between local government areas varies by nearly three times.
What is needed is a better understanding of the extent and reasons for this variation in care. The Australian Commission on Safety and Quality in Healthcare is leading Australia’s involvement with the OECD in a project to consider clinical variation within a number of countries for a range of conditions. The Commission is also working to understand further the degree of clinical variation experienced by patients across the country and plans to describe such variation in clinical care.
The next important step will be to understand how best to reduce any unwarranted variation. We know that when patients are given clear and accurate information about treatment, their choices begin to change.
Collaborative work is also underway through the Australian Primary Care Collaboratives, with participation by some 1100 GP practices Australia-wide. The Collaboratives have worked closely with divisions and now with Medicare Locals to look at continuous improvement in practices. That work includes reducing variation in key areas such as diabetes prevention and treatment, chronic obstructive pulmonary disease, and coronary heart disease.
It is important that the medical profession, and in particular the College, is given a leadership role in the work to understand the reasons for this variation in care, and in taking action to reduce unnecessary variation.
This will help to ensure that more people get the right care, at the right time and in the right place.


In closing, I want to take this opportunity, here, amongst her colleagues, to thank Professor Claire Jackson for her fine work as President of the RACGP over the past two years.
On Claire’s watch, the College’s membership has grown to an impressive record of 21,500 practitioners.
Claire has displayed great leadership on issues from eHealth, to general practice funding streams, chronic disease management, and after-hours arrangements.
Her work has also set the stage for the College to continue to develop and support the next generation of GPs.
And on a personal note, Claire, I want to thank you for your wise and honest counsel to me as Minister. I know you will continue to make a significant contribution to your profession, and to the Australian health sector.
Just as I know your successor, Dr Elizabeth Marles, will continue to represent the RACGP admirably.
I look forward to working with you, Dr Marles, to better support GPs, and to use the evidence about our performance to drive continuous improvement in the Australian primary healthcare system.
Thank you.
The text of the speech is found here:
I really wonder just how most GPs will see all this.
Consider this statement:
“The statistics tell me that in any week, one in three Australian GPs see a patient for whom they have no current information. And more than one in five GPs face this situation every day.”
Surely this means that, for the vast majority of patients GPs see, they do have information?
What I see in all this is an expanding set of requirements and demands for measurement and performance assessment of GPs from the Commonwealth Government and what I am not seeing is the evidence that the profession has decided that this is the way they want to profession to proceed.
It is also not entirely clear just how much evidence there is that such an approach - without a lot of support, education and clinical leadership - actually works.
What I find quite interesting is that there has been recognition for a very, very long time (going back to the work done at Intermountain Healthcare by Brent James (going back to 1988) of the importance of limiting variation in practice
See here:
In this paper the authors specifically say that they “did not try to control physicians’ practice behaviour by top down command and control...Instead we relied on solid process and outcome data, professional values that focused on patients’ needs and a shared culture of high quality”.
Brent James is widely recognised as probably the world expert in the area of clinical quality improvement so I hope the Ministerial Advisors are making sure they are going about their attempts to obtain quality improvement the right way that we know works and not just measuring for the sake of measuring without relevant clinical buy in and understanding. The information that will make a difference needs to be relevant and solid as well a locally credible.
The Collaboratives program mentioned later in the speech certainly seem to be heading in a sensible direction and by being more locally driven and clinically led. This program is, of course, hard work and needs continuing support to reach the wider clinical community.
Canberra bureaucrats can be a long way from the GP clinical work face!
Of course the best source of information on which to base quality improvement is that from local live systems used daily by GPs. Hardly what the NEHRS is providing sadly.


Anonymous said...

The program will employ around 30 GPs with expertise in the PCEHR to speak to their colleagues in around 200 locations across Australia.

One presumes the 200 locations are practices in each of the Wave 1 / Wave 2 Lead sites.

So each GP will speak with 6.5 colleagues ..... and they will all understand and the PCEHR will be embraced by them all and all will be well.

Anonymous said...

Presumably they will find plenty of GPs to take on this role - given the huge surplus of unemployed GPs with time on their hands, and their no doubt willingness to give up the care of patients to become glorified drug reps for the Feds.

Paul Karen said...

I'm not surprised how easily the RACGP has been paid off. Of course, now we'll hear the virtues of eHealth being sung from the rooftops of the college.
It will be interesting to see how the college accounts for the money. God forbid giving it directly to the grassroots GPs....

Anonymous said...

A good name for the implementation guide?

"how to get your PIP from the lemon"
"a lemon a day keeps the doctors in pay"

Bernard Robertson-Dunn said...

David quoted/said:

Consider this statement:
“The statistics tell me that in any week, one in three Australian GPs see a patient for whom they have no current information. And more than one in five GPs face this situation every day.”

Surely this means that, for the vast majority of patients GPs see, they do have information?

Spot on, David.

In order to solve the (relatively) small problem of few patients on whom the GP has no information, the GP (and all other health professionals) will have to enter full information on all patients and all incidents. (It has to be full information and all incidents, otherwise there will be uncertainty as to completeness and accuracy).

The cost of entering and managing all this information is likely to reduce the efficiency of health professionals. How much this might be is unclear.

The Deloitte eHealth strategy looked at the benefits of solving the problem and the costs of implementing the solution. What it did not look at was the impact on health professionals of entering and maintaining information.

As I've said before, implementing an eHealth solution will change the problem. Apart from the issue of controlling access to concentrated information, there is the impact on health work practices, potentially overall negative and probably significant.

Once again, I'd be interested in seeing any evidence that this issue has been analysed and what the conclusions were.

And while I'm at it, being negative and all, who is responsible for the consequences of incorrect information in the system? Will professional liability insurance increase? If so, have these cost been factored in?